主管:国家卫生健康委员会
主办:国家卫生健康委医院管理研究所
中国科技核心期刊(中国科技论文统计源期刊)
中国科学引文数据库(CSCD)核心库期刊
《中文核心期刊要目总览》核心期刊

中国护理管理 ›› 2025, Vol. 25 ›› Issue (7): 961-965.doi: 10.3969/j.issn.1672-1756.2025.07.001

• 特别策划·老年人整合照护模式 • 上一篇    下一篇

社区老年人主动健康整合照护模式的构建与实践

孙柳 王菡婷 王尊 王艳玲 肖树芹 景丽伟 孙久视 平学慧 徐静 毕宪国 刘均娥   

  1. 首都医科大学护理学院/首都健康老龄化创新研究中心,100069 北京市(孙柳,王菡婷,王艳玲,肖树芹,景丽伟,刘均娥);北京市丰台区右安门社区卫生服务中心(王尊);北京市密云区高岭镇社区卫生服务中心(孙久视);北京市通州区潞城社区卫生服务中心(平学慧);北京市西城区白纸坊社区卫生服务中心(徐静);北京市卫生健康委老龄健康处(毕宪国)
  • 出版日期:2025-07-15 发布日期:2025-07-15
  • 通讯作者: 刘均娥,博士,教授,博士生导师,院长,E-mail:liujune66@163.com E-mail:E-mail:sunliuccmu@163.com
  • 作者简介:孙柳,博士,副教授,硕士生导师,E-mail:sunliuccmu@163.com
  • 基金资助:
    北京市卫生健康委员会委托课题项目(老龄健康处202316号,202403号);北京市社会科学基金项目(23SRB007)

The construction and practice of an integrated active health care model for community-dwelling older adults

SUN Liu, WANG Hanting, WANG Zun, WANG Yanling, XIAO Shuqin, JING Liwei, SUN Jiushi, PING Xuehui, XU Jing, BI Xianguo, LIU Jun'e   

  1. School of Nursing, Capital Medical University, Chinese Institute for Health Ageing, Beijing, 100069, China
  • Online:2025-07-15 Published:2025-07-15
  • Contact: E-mail:liujune66@163.com E-mail:E-mail:sunliuccmu@163.com

摘要: 目的:构建本土化的社区老年人整合照护模式并实施,为促进老年人健康水平提供依据。方法:以《Integrated Care for Older People(ICOPE):初级卫生保健中以人为本的评估与照护路径指南》为指导,从主动健康视角出发,采用行动研究法构建面向北京市社区老年人的主动健康整合照护模式。2024年6月,选取北京市中心城区、近郊和远郊区域的7家社区卫生服务中心为试点运行该模式,在实践中不断修订和优化模式。通过调查服务人次及培训人次评价初步效果。结果:初步形成了社区老年人主动健康整合照护模式,并在7家社区卫生服务中心运行。截至2025年6月,已完成社区老年人内在能力筛查8 663人,深入评估和实施健康干预1 697人,累计培训社区医护人员约300人。结论:本研究构建的社区老年人主动健康整合照护模式展现出良好的可行性与推广前景,可为推进ICOPE模式在我国的本土化发展和实践推广提供参考。

关键词: 老年人整合照护; 主动健康;社区老年人;多学科团队;护理

Abstract: Objective: To develop an integrated active health care model for community-dwelling older adults and to apply the model in this population, in order to provide a reference for improving the health of older adults. Methods: Guided by the Integrated Care for Older People (ICOPE): guidelines on person-centred assessment and care pathways in primary care, this study adopted an action research approach to develop an integrated active health care model for community-dwelling older adults in Beijing from the perspective of proactive health management. The model was piloted in seven community health centers across urban, peri-urban, and rural areas of Beijing in June 2024. Iterative refinement and optimization of the model were conducted. The effects of this model was preliminarily evaluated by the number of service recipients and training participants. Results: The model was initially established and implemented in 7 community health centers. To June 2025, 8663 older adults have undergone intrinsic capacity screening, 1697 have received in-depth assessment and integrated health interventions, and approximately 300 community healthcare professionals have been trained. Conclusion: This model has demonstrated strong adaptability and potential. It provides a reference for promoting the localized development and practice of the ICOPE model in China.

Key words: Integrated Care for Older People; active health; community-dwelling older adults; multidisciplinary team; nursing

中图分类号:  R47;R197