关键词: 老年人；整合照护；居家护理；智慧化；非接触；健康老龄化

Abstract: Objective: To develop a smart integrated care model for older people at home and to verify its effectiveness, providing a reference for optimizing elderly health management and improving home-bound elderly care service systems. Methods: A smart integrated care model was constructed using literature review and expert consultation. Sixteen communities were selected by convenience sampling from January to June 2024 in Hangzhou. These 16 communities were randomly assigned to the intervention group or the control group through a random number table. One hundred and one older adults were further recruited in each group using convenience sampling. Older adults in the control group received traditional home care and community management services, while older adults in the intervention group were managed through the smart integrated care model, both groups were intervened for 3 months. The intrinsic ability, social support and care between the two groups, the differences in gait scores of the intervention group before and after intervention were compared, and the user acceptance of the intelligent management platform was investigated. Results: The smart integrated care model covered the whole process of "screening-assessment-planning-implementation-monitoring-evaluation". After the intervention, older adults in the intervention group showed significantly better cognitive function and motor ability than those of the control group (both P<0.05). The psychological state and gait score of participants in the intervention group were improved after the intervention (both P<0.05). 93.3% of the older adults and 85.0% of the healthcare professionals were satisfied or very satisfied with the platform. Conclusion: The smart integrated care model can improve the intrinsic abilities and gait of the older adults, and has achieved high user acceptance. The model can provide a scientific basis and a practical path for promoting healthy aging.

Key words: older adults; integrated care; home care; intelligentization; contactless; healthy aging