社区老年高血压患者的健康管理模式和效果评价

目的探索基于健康管理的社区老年高血压患者综合干预模式,并对干预效果进行评价,为制定高血压病防控对策提供依据。方法以海淀区双榆树社区卫生服务中心系统管理1年的181例高血压患者为研究对象,进行生物学-心理学-行为学-社会学模式的综合干预,并对干预前后患者对高血压知识知晓率、服药依从率、管理人群控制率、患者满意度等指标进行评价。结果目标样本181例,实际完成全程健康管理者181例,男女比例为1∶1.105,平均年龄（70.3±3.3）岁。管理前后患者对高血压知识的知晓率、管理人群的控制率、服药依从率及患者对健康管理团队的满意度变化情况比较,差异有统计学意义（P〈0.05）。结论基于社区健康管理的老年高血压患者的综合干预是一种新型管理模式,它不仅在提高患者对高血压知识知晓率、服药依从率、控制率、满意度等方面具有重要意义,而且在提高患者生活质量,充分合理利用医疗资源,降低医疗费用方面有着广阔前景

Health Management Model and Performance Evaluation of Senior Hypertensive Patients in Community

Objective To explore the comprehensive intervention model based on community health care management,evaluate its intervention effectiveness for the strategy development of hypertension prevention and provide a basis for the control measures.Methods The approach was to establish biology-psychology-behavior-sociology comprehensive intervention model,and to evaluate the awareness rate of hypertension,medication compliance rates,crowd-control rate,patient satisfaction,and other indicators of patients before and after intervention,based on the system management of 181 hypertensive patients at Shuangyushu Community Health Service Center in Haidian District.Results The sample cases were 181,and the actual completion of the whole health management was 181 patients,with a male to female ratio of 1∶1.105 and an average age of 70.3±3.3 years.The change of hypertensive patients’ knowledge awareness,crowd-control rate,medication compliance rate and patient satisfaction with health management team before and after management was statistically significance（P〈0.05）.Conclusion The community-based health management intervention in senior hypertensive patients is a new integrated management model.It can not only improve the patients’ awareness knowledge of hypertension,treatment compliance rate,control rate and satisfaction,but also improves patients’ quality of life,full and reasonable use of medical resources and reduce medical costs