医养结合-四元联动整合照护模型的实践

The building of the “treatment-care and four linkage combination” integrated care model

本研究通过探索医养结合-四元联动运行机制和分级管理工作模式,建立"医养结合-四元联动"整合照护模型,形成医院-护理院-社区-家庭全流程闭环管理,解决医养结合实践中老年人医疗和延续照护中存在的问题,为医养结合服务实践提供方法和思路。经过1年多的前期准备与实践探索,初步建成了以社会服务部为中心的医养结合-四元联动信息化平台,实现了医院、护理院、社区及家庭之间的线上和线下的医养结合照护服务。"医养结合-四元联动"整合照护模型的构建是解决当前国情下老年人医疗和延续照护双重需求的有效途径,是实现"小病在社区、大病进医院、照护在机构、养老在家庭"的可行方法。

The aim is to explore and build the ＂treatment-care and four linkage combination＂ integrated care model,so as to provide methods and ideas for the medical service practice. By exploring the mechanism and hier- archical management mode of the ＂treatment-care and four linkage combination＂ integrated care model,we have set up a whole process management closed loop in four combined linkage,including hospital,medical care,community and family,raised to solve the medical combination of acute medical treatment and the problems existing in the continuing care. After more than a year of preparation and practice,we have build the social service centered med- ical combined with four linkage information platform,and have realized the online and offline medical combination of care services in hospital,medical care,community and family. Based on Internet technology,the building of the ＂treatment-care and four linkage combination＂ integrated care model is the efficient method to solve the difficulties and problems of the health care and the continuation demands among elderly under the current conditions,and the fea- sible way to realize the＂slight illness in the community,disease the hospital,care in institutions,pension in the family＂.