心衰患者出院后30天再入院率可达21.7%，研究发现25%的患者出院后30天非计划再入院可通过早期风险识别和及时干预避免。国内关于建立多变量心衰患者再入院风险评估模型研究较少，缺乏对心衰患者再入院风险的预测。因此本研究拟构建再入院风险评估模型和多学科全程康复管理策略以降低老年慢性心衰患者再入院率。项目组以干预映射为理论指导，首先组建多学科团队，构建基于安德森行为模型的“老年慢性心衰患者再入院风险评估体系”，探索从医院到社区影响老年慢性心衰患者再入院的危险因素；进一步采用Cox比例风险回归模型构建老年慢性心衰患者再入院风险评估模型，及时准确预测再入院风险；最后基于“JBI循证卫生保健模式”，构建从医院到社区的科学、全程、多学科式康复管理策略，并通过随机对照试验和焦点小组访谈验证和优化管理策略。研究结果可为降低老年慢性心衰患者非计划再入院率提供理论参考，促进我国慢性心衰规范防控和循证决策开展。

The readmission rate of patients with heart failure can reach 21.7% within 30 days after discharge. It has been found that 25% of patients’ unplanned readmission of 30 days after discharge can be avoided by early risk identification and timely intervention. There are fewer researches on multivariate risk assessment model for readmission of heart failure in China, and lack of prediction for readmission risk of heart failure patients. Therefore, this study will construct a risk assessment model for readmission and a multidisciplinary rehabilitation management strategy to reduce the readmission rate of elderly patients with chronic heart failure. Guided by the theory of intervention mapping, a multidisciplinary team will be set up first to construct a "risk assessment system for readmission of elderly patients with chronic heart failure" based on Andersen’s behavioral model, and to explore the risk factors affecting readmission of elderly patients with chronic heart failure from hospital to community. And further construct a readmission risk assessment model for elderly patients with chronic heart failure by Cox proportional risk regression model. Finally, based on "JBI Evidence-based Health Care Model", a scientific, whole-course and multidisciplinary rehabilitation management strategy from hospital to community was constructed. The management strategy was validated and optimized through a randomized controlled trial and focus group interviews. The results can provide theoretical reference to reduce the unplanned readmission rate of elderly patients with chronic heart failure, and promote the development of normative prevention and control and evidence-based decision-making of chronic heart failure in China.