基于“互联网+”基层地区老年慢性病患者延续护理模式构建与实践探索

Construction and Practical Exploration of a Continuous Nursing Model for Elderly Patients with Chronic Diseases Based on “Internet+”

摘要: 基于“互联网+”技术背景，结合老年慢性病患者长期健康管理需求，构建覆盖院内、院外及家庭多场景衔接的延续护理模式，为老年慢性病患者连续健康管理及护理服务模式优化提供理论参考与实践依据。以延续性护理理论、慢病健康管理理念及智慧医疗发展要求为理论基础，围绕出院准备、健康档案建立、互联网健康管理平台建设、远程健康教育、在线护理咨询、健康监测、风险评估、多学科协同管理及质量评价等关键环节，系统构建互联网延续护理服务流程，并提出模式运行保障措施。构建了以三级医院为主导、互联网平台支撑、家庭参与、患者主动配合的老年慢性病患者延续护理模式，实现患者住院、出院及居家康复阶段护理服务的连续衔接，形成涵盖健康评估、健康教育、护理随访、健康监测、风险管理及多学科协同的综合健康管理体系。

Abstract: Against the background of “Internet+” technology and in response to the long-term health management needs of older adults with chronic diseases, a transitional care model integrating multiple care settings, including inpatient, outpatient, and home-based care, was developed to provide theoretical and practical evidence for continuous health management and the optimization of nursing service delivery for older adults with chronic diseases. Based on transitional care theory, chronic disease health management concepts, and the development requirements of smart healthcare, the model focused on key components, including discharge preparation, establishment of health records, development of an Internet-based health management platform, remote health education, online nursing consultation, health monitoring, risk assessment, multidisciplinary collaborative management, and quality evaluation. An Internet-based transitional care service process was systematically established, and measures to ensure the effective implementation of the model were proposed. A transitional care model for older adults with chronic diseases was established, with tertiary hospitals serving as the primary coordinators, an Internet-based platform providing technical support, family members participating in care, and patients actively engaging in health management. The model facilitates the continuity and coordination of nursing services throughout hospitalization, the post-discharge period, and home-based rehabilitation, thereby establishing an integrated health management system encompassing health assessment, health education, nursing follow-up, health monitoring, risk management, and multidisciplinary collaboration.