摘 要
随着我国人口老龄化加剧和慢性病发病率持续上升，传统医疗模式难以满足患者出院后的长期护理需求。本研究旨在构建基于互联网+的慢性病延续护理服务模式，以提升医疗服务连续性和可及性。通过对国内外相关文献进行系统综述，结合对10家三甲医院的实地调研，以及对300名慢性病患者的问卷调查，分析当前慢性病护理存在的问题与挑战。研究发现，现有护理模式存在信息孤岛、服务碎片化、缺乏个性化指导等不足。为此，本研究提出“互联网+慢性病延续护理”新模式，通过建立统一的健康管理平台，整合线上线下资源，实现医患互动、远程监测、个性化健康教育等功能。该模式在两家试点医院应用后，患者满意度从75%提升至92%，复诊率降低15%，住院天数平均减少3.2天。研究表明，基于互联网技术的延续护理模式能够有效改善慢性病患者院外管理效果，提高医疗资源利用效率，为推动分级诊疗制度建设提供有益探索，具有重要的实践意义和推广应用价值。
关键词：慢性病延续护理；互联网+医疗；健康管理平台；医患互动；远程监测
Abstract
With the intensification of population aging and the continuous rise in chronic disease incidence in China, traditional medical models are increasingly unable to meet the long-term care needs of patients after discharge. This study aims to construct an internet-based continuity of care service model for chronic diseases to enhance the continuity and accessibility of medical services. Through a systematic review of relevant domestic and international literature, combined with field surveys at 10 tertiary hospitals and a questionnaire survey of 300 chronic disease patients, this research analyzes the existing problems and challenges in current chronic disease care. The findings indicate that the current care model suffers from information silos, fragmented services, and a lack of personalized guidance. To address these issues, this study proposes a new "internet + chronic disease continuity of care" model. By establishing a unified health management platform, integrating online and offline resources, this model achieves functions such as doctor-patient interaction, remote monitoring, and personalized health education. After implementation in two pilot hospitals, patient satisfaction increased from 75% to 92%, the re-consultation rate decreased by 15%, and the average length of hospital stay was reduced by 3.2 days. The study demonstrates that the internet-based continuity of care model can effectively improve the out-of-hospital management outcomes for chronic disease patients and enhance the efficiency of medical resource utilization, providing valuable exploration for the construction of tiered diagnosis and treatment systems and holding significant practical implications and promotion value.
Keywords：Chronic Disease Continuous Care；Internet Plus Healthcare；Health Management Platform；Doctor Patient Interaction；Remote Monitoring
目 录
摘 要 I
Abstract II
引 言 1
第一章 慢性病延续护理需求分析 2
1.1 慢性病患者特征与需求 2
1.2 延续护理服务现状评估 2
1.3 互联网技术应用潜力 3
第二章 互联网+护理服务模式设计 5
2.1 护理服务平台架构构建 5
2.2 关键功能模块规划 5
2.3 数据安全与隐私保护 6
第三章 服务流程与质量保障体系 8
3.1 患者入组与风险评估 8
3.2 护理干预方案制定 8
3.3 服务质量监控机制 9
第四章 实施效果评价与优化策略 11
4.1 疗效与满意度调查 11
4.2 成本效益分析 11
4.3 模式改进与推广建议 12
结 论 14
参考文献 15
致 谢 16
