基于“医养结合”的老年慢性病健康照护模式构建研究

With the rapid increase of the aging population in China, we are facing the dual challenges of daily pension and long-term health care for the elderly with chronic diseases. Under the influence of welfare pluralism, the concept of “medical-nursing combined” (MNC) care has gained much more attention. It is a big struggle for health care system to realize the effective integration with pension system to provide the elderly with systematic health management and care. To balance the clinical treatment and disease prevention, and to improve humanistic care are also two important issues. But the relevant researches are inadequate. This study intends to draw lessons from the Chronic Care Model (CCM) and the domestic or international experience, and analyze the demand of health care services by the elderly population. We will use the theoretical research methods in combination with empirical research to construct a new MNC based health care model. The reasonable health care items and service forms will be systematically developed. By adopting the RE-AIM implementation evaluation framework on the exemplary pilot cases, the theoretical model will be modified. Findings of this study are expected to provide strategies for better basic public health services improving health management and care for the elderly with chronic diseases, and to provide scientific evidence for effectively implementing the MNC model in China. The final aim of the study is to meet the health needs by the elderly population and to improve their quality of life.

我国人口老龄化形势日益严峻，面临日常养老和长期慢病照护需求的双重挑战。受福利多元主义的影响，“医养结合”的概念已成为关注的焦点。卫生系统在这样的契机下如何实现有效“融合”，突破过去重治疗轻预防和缺乏人文关怀的不足，为老年人提供系统的健康管理和照护是亟待解决的问题，但相关研究仍很匮乏。本研究拟借鉴慢性病照护模型(CCM)和国内外发展经验，从我国不同养老方式下的慢性病防治服务需求出发，采用规范研究和实证研究相结合的思路，构建基于“医养结合”的老年慢性病健康照护模式，规划合理的照护服务内容和服务形式。对现有典型“医养结合”试点案例开展RE-AIM框架的实施性评价，以修正理论模型，并提出在此模式下基本公共卫生服务加强老年慢性病管理和照护的发展策略，为我国推广实施“医养结合”提供科学证据。最终目标是满足老年人口的卫生服务需要，提高生活质量。

随着我国老龄化程度的加深，为现代不同养老方式下老年慢性病患者提供更好的长期健康照护已成为亟待解决的问题。近年来各地加快推进“医养结合”的试点和推广，为了促进“医养结合”制度的良性发展进行了本课题研究。本研究通过整理分析近几年国家、省级老年健康相关数据库、开展不同特征老年人群的现场定性与定量研究，明确我国老年慢性病患者的健康照护需求和服务利用现状。通过循证综述与专家咨询，确定常见慢性病老年患者“医养结合”医疗照护服务、日常生活照护、心理照护服务和社会服务等四个维度的健康照护服务项目。运用RE-AIM实施性评估框架，进行护理院、医院和社区“医养结合”试点运行典型案例的初步评价，总结建设经验与存在问题，构建与修正强调全生命周期与全病程、系统协同的老年慢性病健康照护模式。提出“医”和“养”的结合需要改革一定生态环境下筹资支付、人力开发、信息共享、服务提供和协同治理等系统要素与机制，提出全面构建协同的“医养结合”服务体系，加快健全各类制度规范，加强医保和长期照护险对养老服务的支持，着力打造老年照护人才队伍与加快 “医养结合”信息化与智能化建设的具体政策建议。