河北省失能老年人“互联网+”慢病康养全流程融合管理体系的构建-中华老年骨科与康复电子杂志

文章信息/Info

Title:: Construction of integrated management system of informationalized chronic disease rehabilitation for the disabled elderly in Hebei Province

Author(s):: Kang Yingxian1; Liu Yuehua2; Geng Jie1; Liu Xuewen1; Sun Yanrong1.; 1Qinghe Central Hospital, Qinghe 054800, China; 2Vanke School of Public Health and Wellness, Tsinghua University, Beijing 100084, China

Keywords:: Disabled elderly; Chronic rehabilitation; Informatization; Whole process; Integration

摘要:: 随着我国老龄化社会的到来，老年人成为慢病康养的重点目标人群。其中，失能老年人患有慢性病的概率远高于普通老年人且数量日益增多，对慢病康养服务需求更加迫切。然而，在当前医养结合、资源下沉的大背景下，基层失能老年人慢病康养管理体系尚未完善，在部门融合协作、机构融合管理、平台融合对接、人才融合培养等方面均面临困境和阻碍。为此，寻求整合多部门、机构有效资源，利用信息化和智能化手段，搭建集线上与线下为一体的服务平台，探索以县级医院为核心的“医院—社区—居家”失能老年人慢病康养全流程融合管理模式，将有利于缓解社会和家庭压力。本文以河北省清河县为例，阐述失能老年人“互联网+”慢病康养全流程融合管理体系的运行机制，为河北省失能老年人慢病康养的管理提出政策性建议。

Abstract:: With the arrival of aging society in China, the elderly have become the key target population of chronic disease rehabilitation. Among them, the probability of the disabled elderly suffering from chronic diseases is much higher than ordinary elderly and the number is increasing, and the demand for chronic disease rehabilitation services is more urgent. However, under the background of the combination of medical care and nursing and the sinking of resources, the management system of chronic disease rehabilitation for the disabled elderly at grassroots level has not been perfected, and it faces difficulties and obstacles in the aspects of department collaboration, hospital integration, platform docking, and talent training. Therefore, with the help of intelligent means, to seek integrate multiple departments and hospitals effective resources, and to establish the platform of both online and offline services, we explore a whole process integration management mode and hospital to community to home chronic disease rehabilitation integrated management system for the disabled elderly, which makes county-level hospital as the core. The system helps relieve social and family pressure. Taking Qinghe County of Hebei Province as an example, this paper expounds the operation mechanism of the informationalized whole-process integrated management system of chronic disease rehabilitation for the disabled elderly, and puts forward policy suggestions for Hebei Province.