摘 要
随着中国老龄化程度加深，社区老年人慢性病管理成为亟待解决的社会问题。本研究旨在探讨社会工作介入社区老年人慢性病管理的有效模式，通过整合多学科资源提升患者生活质量。研究采用混合研究方法，选取上海市三个典型社区作为样本点，运用问卷调查、深度访谈和案例分析相结合的方式，对320名患有高血压、糖尿病等常见慢性病的老年人及其家属进行为期一年的跟踪研究。研究发现，社会工作者在慢性病管理中发挥着协调者、支持者和倡导者的多重角色，能够有效促进医患沟通，提高患者治疗依从性。创新之处在于构建了“社工+医护+家庭”三位一体的服务模式，强调以患者为中心的整体关怀理念。该模式不仅改善了患者的生理健康状况，更在心理支持和社会融入方面取得显著成效。
关键词：社区老年人慢性病管理 社会工作介入 医患沟通
Abstract
With the deepening of aging in China, chronic disease management of the community elderly has become an urgent social problem to be solved. This study aimed to explore the effective model of social work involvement in chronic disease management in community elderly and improve the quality of life of patients by integrating multidisciplinary resources. Using mixed research methods, the three typical communities in Shanghai were selected as sample points, and a one-year tracking study of 320 elderly people and their families with common chronic diseases such as hypertension and diabetes was conducted by combining questionnaire survey, in-depth interview and case analysis. The study found that social workers play multiple roles as coordinator, supporter and advocate in chronic disease management, which can effectively promote doctor-patient communication and improve patient treatment compliance. The innovation lies in the construction of a trinity service mode of "social worker + medical care + family", emphasizing the overall concept of patient-centered care. This model not only improves the physical health status of patients, but also achieves remarkable results in psychological support and social integration.
Keyword:Community Elderly Chronic Disease Management Social Work Intervention Doctor-Patient Communication
目 录
1绪论 1
1.1研究背景与意义 1
1.2国内外研究现状 1
1.3研究方法与技术路线 1
2社区老年人慢性病管理需求分析 2
2.1慢性病对老年人生活质量的影响 2
2.2老年人慢性病管理的现状调查 2
2.3社区在慢性病管理中的作用 3
3社会工作介入模式探索 4
3.1社会工作的理论基础 4
3.2适合老年人的介入模式 4
3.3模式实施的具体路径 5
4实践案例与效果评估 6
4.1典型社区案例介绍 6
4.2干预措施及实施过程 6
4.3效果评估与经验总结 7
结论 8
参考文献 9
致谢 10
随着中国老龄化程度加深，社区老年人慢性病管理成为亟待解决的社会问题。本研究旨在探讨社会工作介入社区老年人慢性病管理的有效模式，通过整合多学科资源提升患者生活质量。研究采用混合研究方法，选取上海市三个典型社区作为样本点，运用问卷调查、深度访谈和案例分析相结合的方式，对320名患有高血压、糖尿病等常见慢性病的老年人及其家属进行为期一年的跟踪研究。研究发现，社会工作者在慢性病管理中发挥着协调者、支持者和倡导者的多重角色，能够有效促进医患沟通，提高患者治疗依从性。创新之处在于构建了“社工+医护+家庭”三位一体的服务模式，强调以患者为中心的整体关怀理念。该模式不仅改善了患者的生理健康状况，更在心理支持和社会融入方面取得显著成效。
关键词：社区老年人慢性病管理 社会工作介入 医患沟通
Abstract
With the deepening of aging in China, chronic disease management of the community elderly has become an urgent social problem to be solved. This study aimed to explore the effective model of social work involvement in chronic disease management in community elderly and improve the quality of life of patients by integrating multidisciplinary resources. Using mixed research methods, the three typical communities in Shanghai were selected as sample points, and a one-year tracking study of 320 elderly people and their families with common chronic diseases such as hypertension and diabetes was conducted by combining questionnaire survey, in-depth interview and case analysis. The study found that social workers play multiple roles as coordinator, supporter and advocate in chronic disease management, which can effectively promote doctor-patient communication and improve patient treatment compliance. The innovation lies in the construction of a trinity service mode of "social worker + medical care + family", emphasizing the overall concept of patient-centered care. This model not only improves the physical health status of patients, but also achieves remarkable results in psychological support and social integration.
Keyword:Community Elderly Chronic Disease Management Social Work Intervention Doctor-Patient Communication
目 录
1绪论 1
1.1研究背景与意义 1
1.2国内外研究现状 1
1.3研究方法与技术路线 1
2社区老年人慢性病管理需求分析 2
2.1慢性病对老年人生活质量的影响 2
2.2老年人慢性病管理的现状调查 2
2.3社区在慢性病管理中的作用 3
3社会工作介入模式探索 4
3.1社会工作的理论基础 4
3.2适合老年人的介入模式 4
3.3模式实施的具体路径 5
4实践案例与效果评估 6
4.1典型社区案例介绍 6
4.2干预措施及实施过程 6
4.3效果评估与经验总结 7
结论 8
参考文献 9
致谢 10
