香港医院开展老年社区外展服务模式介绍及启示

doi:10.3761/j.issn.1672-9234.2025.02.019

摘要/Abstract

摘要：

随着我国老龄化程度不断加深，老年人的健康问题日益引起重视。社区作为接纳老年人的主要场所，完善成熟的社区护理外展服务体系可以满足老年人的日常健康需求，减轻老龄化带来的医疗负担。该文总结了香港基督教联合医院老年社区外展服务模式，包括老年社区护理服务、社区老人评估小组、离院长者综合支援计划、护讯铃4种服务模式及服务范畴，并对照目前内地社区延续护理发展现状，提出完善建议，以期进一步推动社区延续护理快速发展。

关键词: 香港, 老年, 社区外展服务, 模式

Abstract:

As China’s aging population continues to accelerate，the health issues of the elderly are increasingly being taken seriously. As the main place for elderly care，a well-established and mature community nursing service system can meet the health needs of the elderly and reduce the medical burden caused by aging. This article summarizes the outreach service model of the Hong Kong Christian United Hospital’s elderly community，which includs four service models and service categories：elderly community nursing services，community geriatric assessment teams，integrated care and discharge support for elderly patients，and patient support call centre. Compared with the current development status of community continuity nursing in mainland China，suggestions for improvement are proposed in order to provide reference for the development of community continuity nursing in China.

Key words: Hong Kong, Old age, Community Outreach Services, Mode

常飞飞, Tam Yuen Yee, 吴晓冰, 曹迎春. 香港医院开展老年社区外展服务模式介绍及启示[J]. 中华护理教育, 2025, 22(2): 246-251.

CHANG Feifei, Tam Yuen Yee, WU Xiaobing, CAO Yingchun. Introduction and implications of elderly community outreach service model of hospitals in Hong Kong[J]. Chinese Journal of Nursing Education, 2025, 22(2): 246-251.

参考文献 18

[1]	国家统计局, 国务院第七次全国人口普查领导小组办公室. 第七次全国人口普查公报(第五号):人口年龄构成情况[J]. 中国统计, 2021(5):10-11.
[2]	陈营, 孙华君, 于文超, 等. 天津市老年护理服务需求调查及影响因素分析[J]. 中国护理管理, 2023, 23(5):691-697.
	Chen Y, Sun HJ, Yu WC, et al. Investigation on the demand of elderly nursing service in Tianjin and analysis of its influencing factors[J]. Chin Nurs Manag, 2023, 23(5):691-697.
[3]	彭鸿影, 陈在余. 健康老龄化背景下我国老龄人口养老脆弱性评估及相关因素研究[J]. 医学与社会, 2022, 35(11):50-54,60.
	Peng HY, Chen ZY. Research on the vulnerability and related factors of elderly care in China under the background of healthy aging[J]. Med Soc, 2022, 35(11):50-54,60.
[4]	香港政府统计处. 2021年人口普查简要结果[EB/OL].[2022-02-28]. https://www.censtatd.gov.hk/tc/press_release_detail.html?id=5156.
[5]	Roodenbeke ED, Lucas S, Rouzaut A, et al. Outreach services as a strategy to increase access to health workers in remote and rural areas:increasing access to health workers in rural and remote areas[M]. Geneva: World Health Organization, 2011.
[6]	香港医院管理局. Community Nursing Service 50th Anniversary Commemorative Book[M/OL]. Hong Kong,Hospital Authority, 2018. https://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=246340&Lang=ENG.
[7]	香港医院管理局. 社区医疗服务[EB/OL]. [2023-10-30]. https://www.ha.org.hk/visitor/ha_visitor_index.asp?Parent_ID=10089&Content_ID=10090&Ver=HTML.
[8]	戴利, 杨云智, 姚国仙, 等. 香港社区护士居家护理工作场所暴力预防[J]. 中国护理管理, 2019, 19(4):505-507.
	Dai L, Yang YZ, Yao GX, et al. The experience of workplace violence prevention of home care among Hong Kong community nurses[J]. Chin Nurs Manag, 2019, 19(4):505-507.
[9]	Leung DY, Lee DT, Lee IF, et al. The effect of a virtual ward program on emergency services utilization and quality of life in frail elderly patients after discharge:a pilot study[J]. Clin Interv Aging, 2015, 10:413-420.
[10]	香港医院管理局. 社区医疗服务[EB/OL].[2023-10-30]. https://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=10091&Lang=CHIGB&Dimension=100&Parent_ID=10089.
[11]	Lin FO, Luk JK, Chan TC, et al. Effectiveness of a discharge planning and community support programme in preventing readmission of high-risk older patients[J]. Hong Kong Med J, 2015, 21(3):208-216. doi: 10.12809/hkmj144304 pmid: 25904292
[12]	Leff B, Burton L, Mader SL, et al. Hospital at home:feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients[J]. Ann Intern Med, 2005, 143(11):798-808.
[13]	冯雪, 刘国莲, 马楠楠. 社区产后家庭访视护理质量评价指标体系的实证研究[J]. 中国全科医学, 2017, 20(10):1162-1167. doi: 10.3969/j.issn.1007-9572.2017.10.004
	Feng X, Liu GL, Ma NN. Empirical research on the evaluation index system of nursing quality of postpartum family visits by community medical workers[J]. Chin Gen Pract, 2017, 20(10):1162-1167. doi: 10.3969/j.issn.1007-9572.2017.10.004
[14]	王君, 王爱民, 叶洪江. 基于行为阶段理论的社区家庭访视对老年糖尿病患者服药依从性的影响[J]. 护理管理杂志, 2019, 19(4):293-296.
	Wang J, Wang AM, Ye HJ. The effect of community home visit based on the trans-theoretical model of change on drug compliance behavior of elderly diabetes patients[J]. J Nurs Adm, 2019, 19(4):293-296.
[15]	王桂梅, 谢红芬, 胡启梅, 等. 基于Peplau人际关系模式的家庭访视在抑郁症患者康复中的应用研究[J]. 护理管理杂志, 2020, 20(6):381-386.
	Wang GM, Xie HF, Hu QM, et al. Application of family visit based on Peplau interpersonal model in the rehabilitation of depression patients[J]. J Nurs Adm, 2020, 20(6):381-386.
[16]	杨平, 蹇泽英, 赵毅, 等. 初治肺结核患者实施延伸护理提高化疗依从性及效果观察[J]. 检验医学与临床, 2017, 14(9):1315-1316.
	Yang P, Jian ZY, Zhao Y, et al. Observation on the effect of implementing extended nursing care to improve the compliance of chemotherapy for newly diagnosed pulmonary tuberculosis patients[J]. Lab Med Clin, 2017, 14(9):1315-1316.
[17]	马楠楠, 刘国莲, 冯雪. 银川市社区家庭访视护理现状的质性研究[J]. 重庆医学, 2015, 44(31):4456-4459.
	Ma NN, Liu GL, Feng X. Qualitative study on the present situation of family visiting nursing in Yinchuan community[J]. Chongqing Med, 2015, 44(31):4456-4459.
[18]	汤育英. 社区老年慢性病家庭访视护理的研究进展[J]. 上海护理, 2016, 16(3):76-79.