面向老年人的社区慢性病管理服务设计研究

目的 探索如何为社区慢性病老人提供更好的健康管理服务,构建出本土化的社区慢性病管理服务模式.方法 首先通过文献分析了解国内外社区慢性病管理的研究现状,其次以一位老年慢性肾脏病患者为目标用户进行个案研究.运用半参与式观察、深度访谈等用户研究方法,理解与分析慢性病老人在社区慢性病管理活动中的外显行为与内隐需求,最后依据目标用户的主要需求与痛点,综合各方服务人员进行概念设计.结论 提出了5种面向老年人社区慢性病管理的功能服务模块:健康档案共享模块、协同诊疗服务模块、药物分装管理模块、药物配送服务模块和健康学习分享模块,构建了面向老年慢性肾脏病患者的综合护理服务系统,为应对我国老龄化和老年慢性病管理问题提供了新的思考与路径.

Designing and Studying of Community Chronic Disease Management Service for the Elderly

The paper aims to explore how to provide better health management services for the elderly with chronic diseases in the community and build a localized community chronic disease management service model. Firstly, the domestic and foreign research status of chronic disease management in community was understood through literature analysis. Secondly, a case study was conducted with an elderly patient with chronic kidney disease as the target user. User research methods such as semi-participatory observation and in-depth interview were used to understand and analyze the explicit behaviors and implicit needs of elderly people with chronic diseases in community chronic disease management activities. Finally, according to the main needs and pain points of target users, conceptual design was carried out by integrating all service personnel. This chronic disease management service system for the elderly community contains five functional service modules:health file sharing module, collaborativediagnosis and treatment service module, management module, drugs delivery service module, healthy share learning modules. Build the comprehensive nursing service for elderly patients with chronic kidney disease system. It provides a new thinking and new way to deal with the problem of aging and chronic disease management.