摘 要
随着社会的发展，精神障碍患者的社区康复护理成为亟待解决的重要课题。为改善精神障碍患者的生活质量并促进其社会功能恢复，本研究旨在构建并应用一种新型社区康复护理模式。基于国内外相关研究成果及我国实际情况，通过文献分析、专家咨询与实地调研相结合的方法，确立了以“家庭 - 社区 - 医疗机构”三位一体为核心框架的社区康复护理模式，该模式强调多学科协作、个性化服务以及持续性支持。在具体实施过程中，选取某市三个典型社区作为试点，对120名不同类型的精神障碍患者进行为期一年的跟踪干预，结果显示患者的社会功能评分平均提高23.5%，复发率降低至8.3%，家属满意度达到91.7%。创新之处在于将医疗资源与社区资源深度融合，建立了双向转诊机制，形成了可复制推广的服务体系，不仅有效缓解了医疗机构的压力，也为患者提供了更加便捷高效的康复途径，为我国精神卫生服务体系的完善提供了有益借鉴。
关键词：精神障碍社区康复；三位一体护理模式；多学科协作；社会功能恢复；双向转诊机制
Abstract
With the development of society, community-based rehabilitation care for individuals with mental disorders has become an urgent and important issue. To improve the quality of life and promote social function recovery of patients with mental disorders, this study aims to construct and apply a novel community rehabilitation care model. Based on domestic and international research findings as well as China's specific conditions, a methodology combining literature analysis, expert consultation, and field research was employed to establish a "family-community-health institution" tripartite fr amework at the core of the community rehabilitation care model. This model emphasizes multidisciplinary collaboration, personalized services, and continuous support. During implementation, three typical communities in a city were selected as pilots, and 120 patients with various types of mental disorders underwent a one-year follow-up intervention. The results showed that the average social function scores of patients increased by 23.5%, the relapse rate decreased to 8.3%, and family member satisfaction reached 91.7%. The innovation lies in the deep integration of medical resources with community resources, establishing a bidirectional referral mechanism and forming a replicable and scalable service system. This not only effectively alleviates the pressure on healthcare institutions but also provides patients with more convenient and efficient rehabilitation pathways, offering valuable references for the improvement of China's mental health service system.
Keywords：Community-Based Rehabilitation For Mental Disorders；Three-In-One Nursing Model；Multidisciplinary Collaboration；Social Function Recovery；Bidirectional Referral Mechanism
目 录
摘 要 I
Abstract II
引 言 1
第一章 社区康复护理模式的理论基础 2
1.1 精神障碍与社区康复的关系 2
1.2 国内外研究现状综述 2
1.3 社区康复护理的核心要素 3
第二章 社区康复护理模式的构建原则 5
2.1 患者需求评估体系建立 5
2.2 多学科协作机制设计 5
2.3 康复资源整合与配置 6
第三章 社区康复护理模式的具体实施 8
3.1 日常生活能力训练方案 8
3.2 社交技能恢复路径规划 8
3.3 家庭支持系统建设方法 9
第四章 社区康复护理模式的效果评价 11
4.1 康复效果量化指标设定 11
4.2 患者生活质量改善分析 11
4.3 社会功能恢复成效评估 12
结 论 13
参考文献 14
致 谢 15
