基于社区护理干预的老年慢性病服务模式研究进展

Research Progress of Elderly Chronic Disease Service Model Based on Community Nursing Intervention

摘要: 老年人易患慢性病，慢性病具有潜伏期长、病程长、治疗复杂等特点，为预防、控制慢性病，降低其对老年人生活的影响，需要对患者进行长期监督，给予持续观察、护理以及康复指导。本文对社区护理干预的概念、国内外老年慢性病患者护理服务模式进行阐述，旨在为我国推进老年慢性病患者延续性护理提供参考。本文明确我国老年慢性病护理发展限制，提出我国应制定延续性护理质量评价标准，探索更多适合我国国情的老年慢性病护理服务模式，充分发挥社区护士在延续性护理中的主导作用，重视对老年护理人才的培养，组建多学科协作团队，提供以患者为中心的护理，建设从医院过渡到社区或家庭的中间机构，确保护理的连续性。

Abstract: Older adults are prone to chronic diseases, which have long latent periods, long disease courses, and complex treatments. To prevent and control chronic diseases and reduce their impact on older adults’ lives, it is necessary to provide long-term monitoring, continuous observation, nursing care, and rehabilitation guidance for patients. This paper describes the concept of community nursing intervention and the nursing service models for chronic disease patients in the elderly at home and abroad, aiming to provide reference for China’s promotion of chronic disease care for the elderly. This paper clarifies the limitations of chronic disease care for the elderly in China and proposes that China should establish quality evaluation standards for continuity of care, explore more suitable nursing service models for the elderly with chronic diseases in China, fully play the leading role of community nurses in continuity of care, pay attention to the training of elderly care personnel, form a multidisciplinary team, provide patient-centered nursing, and build intermediate institutions that transition from hospitals to communities or homes to ensure the continuity of care.