关键词: 慢性病；医院-社区-家庭；延续性护理；政策引导

Abstract: Objective: To construct and promote the three-way linkage and continuous care model for chronic diseases, and to provide a basis for the formulation of relevant policies for chronic disease prevention and control. Methods: Based on WHO's innovative nursing model for chronic diseases, a three-way linkage and continuous nursing model of "hospital, community and family" was constructed with "hospital, community and family" as the three interfaces and "information, management and relationship" as the core elements. Innovative promotion mechanisms such as "high-quality nursing resources radiating to the grassroots, case management, Internet + nursing services, and chronic health science popularization" have been put forward to break the operation barriers of the model. Based on "structure-process-outcome", an evaluation index system for the quality of continuous care for stroke patients was established to provide an evaluation tool for the effective implementation of standardized continuous care for chronic diseases. Results: Through the operation of the model, it guided the formulation of policies such as the sinking of high quality nursing resources, multi-point practice of nurses, construction of community nursing centers and popularization of science into the evaluation of professional titles, optimized the allocation of medical resources and enhanced the ability of community nursing service. It also improved the health outcome and self-management ability of chronic disease patients. Conclusion: The construction and operation of the "hospital-community-family" three-way linkage and continuous care model for chronic diseases plays an important role in guiding the formulation of chronic disease policies, optimizing the allocation of medical resources, improving community nursing capacity and improving the health outcomes of patients, etc. The government, hospitals, communities, families and patients need to work together to truly achieve continuous and whole-process care for patients after discharge.

Key words: chronic disease; hospital-community-family; continuous care; policy guidance