我国城镇老年群体健康管理与长期照护模式研究

Study on health management and long-term nurse model of the aged group in China cities

通过对国内外老年人健康管理、长期照护模式的总结分析,结合我国实际设计一套以社区为中心,针对我国城镇老年人群体的慢病预防、慢病管理、失能与半失能老人日常照护等方面的整合性健康管理与长期照护模式。通过构建健康档案、健康评估、干预以及体检四大部分,形成一个有机的循环的健康管理模式,并在健康评估有风险时直接把这部分人群无缝对接到长期照护体系中来,使得我国老年人健康状况有科学的管理,降低向失能和半失能转化的风险,提高老年人的生活质量。

Through summarizing and analyzing health management and long - term nurse model of the elderly at home and abroad. Combines with the actual to design a set of of a conformability health management and long - term nurse model to cities＇ elderly that takes communities as the center, and aims to daily nurse of the aged group＇s chronic disease prevention, chronic disease management, disability and semi - disability. Through setting up health records, health assessment, intervention and physical examination to form an organic cyclic health management model, and seamless connects to long - term nurse system when they have the risk in health assessment. So, the elderly people have scientific health management, reduce the risk of disabihty and semi - disability, improve the life quality of the elderly.