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