关键词: 整合照护；老年人；家庭病床；多学科团队；服务模式

Abstract: Objective: To develop a five-dimension integrated home-based care service model for older adults, in order to provide a reference for enhancing the comprehensiveness and continuity of home care services. Methods: Using literature review and expert focus group guided by the integrated care theory, we developed a five-dimension integrated home-based care service model for older adults. The five dimensions included "patient-centered, community-based, institution-supported, information-linked, and family-partnered" components. This service model was implemented in 32 community health service institutions of Futian district, Shenzhen in June 2024. The effects of the model was evaluated by analyzing indicators including the number of established home-based healthcare units for older adults, health outcomes of older adults, and service satisfaction among older adults. Results: A total of 520 home-based healthcare units for older adults were established, completed and closed, among which hospice care-type units accounted for 1.5%. The average establishment duration of all home-based healthcare units was 58.5(13.0, 85.0) days. Among the participants, 49.6% of the older adults showed improvement or recovery, and 25.0% maintained stable conditions. Service satisfaction rate among older adults reached 100.0%. Conclusion: The home-based care service model for older adults based on the integrated care theory is feasible, enhances the establishment efficiency of home-based healthcare units, effectively improves health outcomes of older adults, and achieves high service satisfaction.

Key words: integrated care; the elderly; home-based healthcare units; multidisciplinary team; service model