衰弱是失能前的窗口期，可引发诸多不良临床结局。对衰弱老年人实施健康管理有利于提高其生活质量，降低死亡率。目前，国内外尚未发现针对社区衰弱老年人的健康管理模式。本研究首次采用国际居民评估体系中的家庭照护评估工具(International Resident Assessment Instrument Home Care, interRAI HC)构建衰弱老年人健康管理模式，包括：①实施老年综合评估；②明确健康问题；③确定照护目标；④制定个体化照护计划；⑤随访计划执行情况；⑥教育支持主要照顾者。该工具的使用可使衰弱老年人综合评估标准化，并聚焦于有改善潜能的健康问题，制定符合老年人生活方式和习惯的个体化照护计划，以期提高其健康行为依从性，达到照护目标，进而实现对衰弱老年人有效的健康管理。在此基础上，将该模式应用于实践，分析、比较其效果。经过验证的模式对完善我国老年人健康管理体系具有重要研究价值。

Frailty is the window phase of disability which could lead to many adverse clinical outcomes. Health management for the frail older people could improve their quality of life, and decrease the mortality. However, there is no specific model of health management for the frail older people in community both overseas and at home. Based on the International Resident Assessment Instrument Home Care (interRAI HC), we will construct a health management model for the frail older people, which including geriatric comprehensive assessment, identification of health problems, determining the goals of care, personalized care planning, monitoring of adherence, and support for the family caregivers. The use of interRAI HC could improve the standardized comprehensive assessment, focus on the health problems with improved potential, and make the personalized care plans meeting the lifestyle and habits of the frail older people, in order to improve the compliance to the health behavior and achieve care goals. Thus, we could manage the frail older people in the community effectively. Based on the formation of health management model for frail older people in the community, the effect of this model would be evaluated. The validated health management model for the frail older people would have economic and social significance for the improvement of the health management system of the older people in China.