基于PDCA理论的医联体内老年共病整合管理模式构建及效果评价研究

随着我国人口老龄化程度的逐步深入，老年共病问题日益严峻，如何为老年共病患者提供连续高效的医疗与健康管理服务是至关重要的问题。目前我国尚未完善老年共病的管理模式，仍以专科诊疗为主，共病患者多点就诊，各医疗机构以及学科之间缺乏信息互通机制，容易造成共病患者多重用药、过度医疗等问题。因此，本研究拟在调查和分析社区老年共病患者的现况及影响因素的基础上，坚持以患者为中心，以PDCA理论为引导，在医联体框架下构建老年共病整合管理模式，包括以社区全科医生团队为核心的GIT团队、基于PDCA的老年共病患者的闭环管理流程与原则、患者评估与管理系统、患者自主管理方式等要点。最后，通过实证研究和随机对照实验法评价整合管理模式的实施效果，进一步优化和完善模式，为社区老年共病患者的管理策略提供依据。整合管理模式有助于改善老年共病患者的健康结局，提高全科医生团队的服务能力，助力家庭医生签约制度与分级诊疗制度的实施。

With the gradual deepening of the population aging in China, the burden of multimorbidity in the elderly is becoming increasingly prominent. It is a crucial issue to provide continuous and efficient healthcare services for elderly with multimorbidity. Currently, there is no well-established management model for the elderly with multimorbidity in China, with specialized diagnosis and treatment as the main approaches. The lack of information communication mechanisms between different medical institutions and disciplines can cause issues of polypharmacy and excessive medical treatment. Therefore, based on the investigation and analysis of the current status, characteristics and influencing factors of elderly with multimorbidity in communities, this study aims to build an integrated management model for elderly with multimorbidity, which.adheres to the concept of patient-centered care and the PDCA theory. This model consists of the following key components: the geriatric interdisciplinary team (GIT) with community GP team as the core, PDCA-based management process and principles, patient assessment and management system, and patient self-management. Finally, empirical studies and randomised clinical trials are carried out to evaluate the implementation of the model, so as to further optimize and improve the management mechanism and provide evidences for the management strategy for elderly with multimorbidity in communities. The integrated management model will improve the health outcomes of elderly with multimorbidity, improve the service capabilities of general practitioner teams, further promote the contracting service of GPs, and promote the establishment of the referral system.