社区老年人高血压“四位一体”管理的探索与实践

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。

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

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.