关键词: 慢性病管理；社区护理；居家护理；能力提升；护理门诊

Abstract: Objective: To construct a chronic disease community nursing model in Shanghai, explore the development path of homogeneous nursing in Shanghai community health service centers, in order to improve the nursing quality of chronic disease in the community. Methods: A three-dimensional linkage integrated sharing platform was constructed to train the community nurses with multi-skills. The role of community nurse for chronic diseases was clarified by qualitative research and other methods. The training results of nurses with multi-skills and the effectiveness of community nursing practice for chronic diseases were evaluated. Results: Community health service centers have been in long-term and orderly connection with higher-level medical institutions. By the end of 2023, a total of 4435 multi-skilled community nurses have been trained, and 137 (55.5%) community health service centers have opened 337 specialized nursing clinics. The ability of community nurses to care for chronic diseases has been improved. From January to December 2023, 1.512 million patients in Shanghai received homogeneous specialized nursing services at community health service centers, and the continuous care needs of chronic disease patients have been met to a certain extent. Conclusion: The application of community nursing model for chronic disease in Shanghai has enhanced the specialized nursing abilities of community nurses, promoted the standardization of chronic disease nursing practices, and enabled community residents to enjoy effective, convenient, and high-quality continuous nursing.

Key words: chronic disease management; community care; home care; capacity building; nurse-led clinic