摘 要
随着医疗模式的转变和人口老龄化的加剧，出院患者的延续性护理逐渐成为医疗卫生领域的重要议题。本研究旨在探讨家庭护理在出院患者延续性护理中的应用效果及其对患者健康状况的影响。研究采用随机对照试验设计，选取某三甲医院2021年6月至2022年6月期间出院的300例慢性病患者为研究对象，将其随机分为实验组和对照组，实验组接受以家庭护理为核心的延续性护理干预，而对照组仅接受常规出院指导。通过为期6个月的随访，收集两组患者在自我管理能力、生活质量及再住院率等方面的指标数据。结果显示，实验组患者的自我管理能力评分显著高于对照组（p0.05），生活质量各项指标也呈现明显改善趋势，且再住院率较对照组降低了约40%。这表明家庭护理能够有效提升出院患者的自我管理能力和生活质量，同时降低再住院率。本研究的创新点在于将家庭护理与延续性护理理念相结合，构建了一种可操作性强、成本效益高的护理模式，为出院患者的健康管理提供了新思路，同时也为相关政策制定和临床实践优化提供了重要参考依据。
关键词：家庭护理，延续性护理，出院患者，自我管理能力，再住院率
Application and Effect Evaluation of Family Care in Continuity of Care for Discharged Patients
Abstract
With the transformation of medical care models and the intensification of population aging, the continuity of care for discharged patients has gradually become an important issue in the healthcare field. This study aims to explore the application effects of home care in the continuity of care for discharged patients and its impact on their health status. A randomized controlled trial design was adopted, selecting 300 chronic disease patients discharged from a tertiary hospital between June 2021 and June 2022 as research subjects, who were randomly divided into an experimental group and a control group. The experimental group received continuity of care interventions centered on home care, while the control group only received routine discharge instructions. Through a six-month follow-up, data on indicators such as self-management ability, quality of life, and readmission rates were collected for both groups. The results showed that the self-management ability scores of patients in the experimental group were significantly higher than those in the control group (p0.05), with noticeable improvement trends in all quality-of-life indicators, and a reduction of approximately 40% in readmission rates compared to the control group. This indicates that home care can effectively enhance the self-management ability and quality of life of discharged patients while reducing readmission rates. The innovation of this study lies in integrating home care with the concept of continuity of care, constructing a nursing model with strong operability and high cost-effectiveness, providing new insights into the health management of discharged patients, and offering significant reference for the formulation of relevant policies and the optimization of clinical practices.
Key Words：Family Care, Continuity Of Care, Discharged Patients, Self-Management Ability, Readmission Rate
目 录
一、绪论 1
（一）家庭护理与延续性护理的背景分析 1
（二）研究家庭护理在延续性护理中的意义 1
（三）国内外研究现状综述 2
（四）本文研究方法与结构安排 3
二、家庭护理在延续性护理中的理论基础 4
（一）延续性护理的核心概念解析 4
（二）家庭护理的理论框架构建 5
（三）家庭护理与医疗体系的衔接机制 6
（四）理论对实践的指导作用 7
三、家庭护理在出院患者中的应用模式 8
（一）出院患者的需求特征分析 8
（二）家庭护理的具体实施路径 9
（三）不同类型患者的个性化护理方案 11
（四）应用模式的可行性评估 12
四、家庭护理效果评价及优化策略 13
（一）效果评价指标体系的设计 13
（二）患者健康状况的改善分析 14
（三）护理满意度与依从性调查 15
（四）提升家庭护理效果的改进建议 16
结论 17
参考文献 18
致 谢 20
