社区老年人高血压“四位一体”管理的探索与实践  

The exploration and practice of the “four in one” management of the elderly hypertension in the community

作　　者：钟丽霞[1] 陈志刚[1] 张家驹[1] 朱莉珍[1] 易春涛[1] 

机构地区：[1]上海市徐汇区康健街道社区卫生服务中心,上海200233

出　　处：《上海医药》2012年第10期41-44,共4页Shanghai Medical & Pharmaceutical Journal

摘　　要：目的:探索社区"四位一体"老年高血压管理模式的实施效果。方法:通过慢性病关爱家园建立的平台,从患者、志愿者、全科医生、专家4个层面对社区老年高血压患者进行自我管理、心理干预、知己健康管理和群组干预,对平均血压值、规范管理率、控制率及满意度与传统高血压管理进行比较。结果:经过3年的干预,管理组高血压患者血压平均值从146/94mmHg下降到134/86mmHg(P<0.01)。高血压规范管理率从管理前的71.3%上升到83.8%(P<0.01),血压控制率从管理前的63.3%上升到76.6%(P<0.01),患者满意度从67.0%上升到86.0%。结论:社区老年人高血压"四位一体"管理可以充分发挥社区高血压管理各个层面人员的作用,增加高血压患者的依从性,提高社区高血压规范管理率及控制率,是社区老年人高血压管理新模式的有益探索。Objective：To explore the practice effect of the new management model of the elderly with hypertension in community.Methods：With the foundation of ＂home care for the chronic diseases＂,before and after the community elderly hypertension patients were under the premise of the standard four-in-one management of the self-management,chronic psychological intervention,the self health management and group intervention of the patients,volunteers,general practitioners and experts involvement,their average blood pressure,rate of standard management,control and satisfaction rates were compared.Results：Through 3 years management in this mode,the average blood pressure of the hypertension patients decreased from 146/94 mmHg to 134/86 mmHg（P〈0.01）.The control rate significantly increased from 63.3% to 76.6%（P〈0.05）,The patient’s satisfaction increased from 67% to 86%.Conclusion：The management of the elderly hypertension in community in four-in-one mode can give full play to the roles of different levels of personnel to increase the patients’ compliance,and enhance the community hypertension management and control rates,which is a benefit exploration of the new community elderly hypertension management model.

关 键 词：老年人 高血压 四位一体管理 

分 类 号：R473.2[医药卫生—护理学]