留言板

尊敬的读者、作者、审稿人, 关于本刊的投稿、审稿、编辑和出版的任何问题, 您可以本页添加留言。我们将尽快给您答复。谢谢您的支持!

姓名
邮箱
手机号码
标题
留言内容
验证码

老年人医养康一体化康复服务体系建设的专家共识

国家重点研发计划《智慧医养康服务一体化技术与应用研究》项目组

国家重点研发计划《智慧医养康服务一体化技术与应用研究》项目组. 老年人医养康一体化康复服务体系建设的专家共识[J]. 中华全科医学, 2025, 23(10): 1636-1642. doi: 10.16766/j.cnki.issn.1674-4152.004194
引用本文: 国家重点研发计划《智慧医养康服务一体化技术与应用研究》项目组. 老年人医养康一体化康复服务体系建设的专家共识[J]. 中华全科医学, 2025, 23(10): 1636-1642. doi: 10.16766/j.cnki.issn.1674-4152.004194
Project Team of the National Key R&D Program 'Integrated Technologies and Applications for Smart Healthcare and Elderly Care Services'. Expert consensus on the development integrated medical-nursing-rehabilitation service system for older adults[J]. Chinese Journal of General Practice, 2025, 23(10): 1636-1642. doi: 10.16766/j.cnki.issn.1674-4152.004194
Citation: Project Team of the National Key R&D Program "Integrated Technologies and Applications for Smart Healthcare and Elderly Care Services". Expert consensus on the development integrated medical-nursing-rehabilitation service system for older adults[J]. Chinese Journal of General Practice, 2025, 23(10): 1636-1642. doi: 10.16766/j.cnki.issn.1674-4152.004194

老年人医养康一体化康复服务体系建设的专家共识

doi: 10.16766/j.cnki.issn.1674-4152.004194
基金项目: 

国家重点研发计划项目 2022YFC3601605

详细信息

    马迎春,E-mail:mych323@163.com

  • 中图分类号: R197.1 R492

Expert consensus on the development integrated medical-nursing-rehabilitation service system for older adults

  • 摘要: 伴随着人口老龄化、高龄化的日益加剧,我国老年人医疗、康复护理以及养老等健康问题将面临重大挑战。如何更有效地整合医疗、康复、养老资源,统筹居家社区养老、机构养老等模式,并依托社区医院、康复机构等医疗康复资源,实现为老年人提供全生命周期的整合性养老和健康管理,进而实现健康老龄化,是我国当前亟须解决的问题。因此,依托于国家重点研发计划项目《智慧医养康服务一体化技术与应用研究》,由中国康复研究中心牵头起草,联合广东省人民医院、中南大学、中国老龄科学研究中心等12家单位的专家学者,就构建老年人医养康一体化服务体系建设制订本专家共识,在医养康一体化的内涵、服务原则、功能评估等7个方面形成了专家共识,以期为我国老年人医养康一体化服务建设提供科学参考。

     

  • 图  1  2015年世界卫生组织(WHO)的健康老龄化公共卫生框架

    注:来源于2015年WHO《老龄化与健康全球报告》。

    Figure  1.  The World Health Organization' s (WHO) 2015 policy framework, "A Framework for Healthy Ageing"

  • [1] 国务院第七次全国人口普查领导小组办公室编. 2020年第七次全国人口普查主要数据[R]. 北京: 中国统计出版社, 2021.

    Leading Group Office of the State Council for the Seventh National Population Census. Key data of the seventh national population census 2020[R]. Beijing: China Statistics Press, 2021.
    [2] United Nations. World population prospects 2024[EB/OL]. (2024-01-01)[2024-06-14]. https://population.un.org/wpp/.
    [3] 杨哲. "医养融合"养老服务: 概念内涵、掣肘因素及推动路径[J]. 现代经济探讨, 2016(10): 25-29.

    YANG Z. "Medical-nursing integration" elderly care service: conceptual connotation, constraints and promotion paths[J]. Modern Economic Research, 2016(10): 25-29.
    [4] 孙鹃娟, 蒋炜康, 陈雨欣. 医养康养相结合的养老服务体系: 政策意涵与实践路径[J]. 北京行政学院学报, 2023(2): 109-118.

    SUN J J, JIANG W K., CHEN Y X. The policy implication and practice path of the chinese system of elderly care service with the integration of medical & elderly care and convalescent & elderly care[J]. Journal of Beijing Administrative College, 2023(2): 109-118.
    [5] World Health Organization. World report on ageing and health[EB/OL]. (2015-09-29)[2024-06-19]. https://apps.who.int/iris/handle/10665/186463.
    [6] World Health Organization. Integrated care for older people (ICOPE) implementation pilot programme: findings from the'ready'phase[EB/OL]. (2022-04-25)[2024-06-20]. https://www.who.int/publications/i/item/9789240048355.
    [7] YAN W N, LIU X, KONG X, et al. Implementation and impact of the World Health Organization integrated care for older people (ICOPE) program in China: a randomised controlled trial[J]. Age Ageing, 2024, 53(1): afad249. DOI: 10.1093/ageing/afad249.
    [8] 国家标准化管理委员会国家市场监督管理总局. 老年人能力评估规范: GB/T 42195-2022[S]. 北京: 中国标准出版社, 2022.

    Standardization Administration of China & State Administration for Market Regulation. Specification for ability assessment of older adults: GB/T 42195-2022[S]. Beijing: Standards Press of China, 2022.
    [9] World Health Organization. Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care, 2nd ed[EB/OL]. (2024-12-29)[2025-02-08]. https://iris.who.int/handle/10665/380175.
    [10] 路菲. 高龄社区居民内在能力评估及其对不良结局预测价值的研究[D]. 北京: 北京协和医学院, 2023.

    LU F. Intrinsic capacity assessment in advanced-age community-dwelling older adults and its predictive value for adverse outcomes[D]. Beijing: Peking Union Medical College, 2023.
    [11] GIUDICI K V, DE SOUTO BARRETO P, GUYONNET S, et al. Predictive capacity of the integrated care for older people screening tool for intrinsic capacity impairments: results from the INSPIRE-T cohort[J]. J Gerontol A Biol Sci Med Sci, 2024, 79(7): glae112. DOI: 10.1093/gerona/glae112.
    [12] LEUNG A, SU J J, LEE E, et al. Intrinsic capacity of older people in the community using WHO integrated care for older people (ICOPE) framework: a cross-sectional study[J]. BMC Geriatr, 2022, 22(1): 304. DOI: 10.1186/s12877-022-02980-1.
    [13] 国家卫生健康委员会. 护理需求等级评定表: 国卫发〔2019〕48号[Z]. 北京: 国家卫生健康委员会, 2019.

    National Health Commission of the People' s Republic of China. Rating scale for nursing care needs: Guo Wei Fa〔2019〕No. 48[Z]. Beijing: National Health Commission, 2019.
    [14] 刘铭玥. 我国长期护理保险定价研究: 基于《护理需求等级评定表(试行)》[D]. 上海: 上海财经大学, 2020.

    LIU M Y. Pricing of long-term care insurance based on <nursing needs rating form (trial)>[D]. Shanghai: Shanghai University of Finance and Economics, 2020.
    [15] 许文丽. 社区老年人医养康护一体化服务需求问卷的编制及初步应用[D]. 泰安: 泰山医学院, 2018.

    XU W L. Development and preliminary application of a needs questionnaire for integrated medical, nursing, rehabilitation and care services among community-dwelling older adults[D]. Tai'an, China: Taishan Medical College, 2018.
    [16] 李芳, 黄伟红, 胡建中, 等. 老年人医养服务需求量化评估指标体系的构建与验证[J]. 中南大学学报(医学版), 2023, 48(2): 231-241.

    LI F, HUANG W H, HU J Z, et al. Construction and verification of a quantitative index system to evaluate the medical and nursing care for the elderly service needs[J]. J Cent South Univ (Med Sci), 2023, 48(2): 231-241.
    [17] 国卫办老龄发. 关于印发医养结合机构服务指南(试行)的通知[EB/OL]. (2019-12-23)[2024-07-27]. https://www.gov.cn/zhengce/zhengceku/2020-01/01/content_5465777.htm.

    National Health Commission. Notice on issuing the service guidelines for medical-nursing integrated institutions (Trial Version)[EB/OL]. (2019-12-23)[2024-07-27]. https://www.gov.cn/zhengce/zhengceku/2020-01/01/content_5465777.htm.
    [18] 国卫办老龄发. 关于印发居家和社区医养结合服务指南(试行)的通知[EB/OL]. (2023-11-01)[2024-07-26]. https://www.gov.cn/zhengce/zhengceku/202311/content_6914596.htm.

    National Health Commission. Notice on issuing the operational guidelines for home- and community-based medical-nursing integrated services (Trial Version)[EB/OL]. (2023-11-01)[2024-07-26]. https://www.gov.cn/zhengce/zhengceku/202311/content_6914596.htm.
    [19] 宋应诺. 基于医疗信息技术构建区域协同医养一体化居家养老服务平台的探索[D]. 广州: 南方医科大学, 2015.

    SONG Y N. Exploration of constructing a regional collaborative medical-elderly care integrated home-based service platform based on health information technology[D]. Guangzhou: Southern Medical University, 2015.
    [20] GOMEZ-SORIA I, IGUACEL I, CUENCA-ZALDIVAR J N, et al. Cognitive stimulation and psychosocial results in older adults: a systematic review and meta-analysis[J]. Arch Gerontol Geriatr, 2023, 115: 105114. DOI: 10.1016/j.archger.2023.105114.
    [21] WANG W T, WANG H. Effects of Tai Chi Chuan on cognitive function in adults 60 years or older with mild cognitive impairment: a systematic review and meta-analysis[J]. Front Physiol, 2025, 16: 1556622. DOI: 10.3389/fphys.2025.1556622.
    [22] LIANG J H, SHEN W T, LI J Y, et al. The optimal treatment for improving cognitive function in elder people with mild cognitive impairment incorporating Bayesian network meta-analysis and systematic review[J]. Ageing Res Rev, 2019, 51: 85-96. doi: 10.1016/j.arr.2019.01.009
    [23] ZHOU M, KUANG L, HU N. The association between physical activity and intrinsic capacity in chinese older adults and its connection to primary care: China health and retirement longitudinal study (CHARLS)[J]. Int J Environ Res Public Health, 2023, 20(7): 5361. DOI: 10.3390/ijerph20075361.
    [24] 魏媛媛, 马迎春. 老年慢性肾脏病患者的康复治疗[J]. 中国临床保健杂志, 2020, 23(6): 743-748.

    WEI Y Y, MA Y C. Rehabilitation strategy for elderly patients with chronic kidney disease[J]. Chinese Journal of Clinical Healthcare, 2020, 23(6): 743-748.
    [25] IZQUIERDO M, DE SOUTO B P, ARAI H, et al. Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR)[J]. J Nutr Health Aging, 2025, 29(1): 100401. DOI: 10.1016/j.jnha.2024.100401.
    [26] O'BRYAN S J, GIULIANO C, WOESSNER M N, et al. Progressive resistance training for concomitant increases in muscle strength and bone mineral density in older adults: a systematic review and meta-analysis[J]. Sports Med, 2022, 52(8): 1939-1960. doi: 10.1007/s40279-022-01675-2
    [27] IZQUIERDO M, CADORE E L. Multicomponent exercise with power training: a vital intervention for frail older adults[J]. J Nutr Health Aging, 2024, 28(4): 100008. DOI: 10.1016/j.jnha.2023.100008.
    [28] EL-KHOURY F, CASSOU B, LATOUCHE A, et al. Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossebo randomised controlled trial[J]. BMJ, 2015, 351: h3830. DOI: 10.1136/bmj.h3830.
    [29] CHEN W, LI M, LI H, et al. Tai Chi for fall prevention and balance improvement in older adults: a systematic review and meta-analysis of randomized controlled trials[J]. Front Public Health, 2023, 11: 1236050. DOI: 10.3389/fpubh.2023.1236050.
    [30] 段蕾蕾, 赵玉斌, 耳玉亮, 等. 八段锦对社区老年人平衡功能影响效果的整群随机对照试验研究[J]. 中华流行病学杂志, 2024, 45(2): 250-256.

    DUAN L L, ZHAO Y B, ER Y L, et al. The effect of Ba Duan Jin on the balance of community-dwelling older adults: a cluster randomized control trial[J]. Chinese Journal of Epidemiology, 2024, 45(2): 250-256.
    [31] VOLKERT D, BECK A M, CEDERHOLM T, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics[J]. Geriatr Psychol Neuropsychiatr Vieil, 2024, 22(3): 273-315.
    [32] KHOR P Y, VEARING R M, CHARLTON K E. The effectiveness of nutrition interventions in improving frailty and its associated constructs related to malnutrition and functional decline among community-dwelling older adults: a systematic review[J]. J Hum Nutr Diet, 2022, 35(3): 566-582. doi: 10.1111/jhn.12943
    [33] VOLKERT D, BECK A M, CEDERHOLM T, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics[J]. Clin Nutr, 2019, 38(1): 10-47. doi: 10.1016/j.clnu.2018.05.024
    [34] DEUTZ N E, BAUER J M, BARAZZONI R, et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group[J]. Clin Nutr, 2014, 33(6): 929-936. doi: 10.1016/j.clnu.2014.04.007
    [35] 国家重点研发计划2020YFC2008200项目组, 中华医学会眼科学分会眼视光学组, 中国医师协会眼科医师分会眼视光专业委员会, 等. 中国低视力康复临床指南(2021)[J]. 中华眼视光学与视觉科学杂志, 2021, 23(3): 161-170.

    Research Panel of the National Key R&D Project 2020YFC2008200; Chinese Optometric Association of Chinese Ophthalmological Society; Optometry Committee of Chinese Ophthalmologists Association, et al. Chinese low vision rehabilitation clinical guideline (2021)[J]. Chin J Optom Ophthalmol Vis Sci, 2021, 23(3): 161-170.
    [36] World Health Organization. Package of eye care interventions[EB/OL]. [2025-01-28]. https://iris.who.int/handle/10665/354256.
    [37] KALDENBERG J, SMALLFIELD S. Occupational therapy practice guidelines for older adults with low vision[J]. Am J Occup Ther, 2020, 74(2). DOI: 10.5014/ajot.2020.742003.
    [38] GOLDSTEIN J E, JACKSON M L, FOX S M, et al. Clinically meaningful rehabilitation outcomes of low vision patients served by outpatient clinical centers[J]. JAMA Ophthalmol, 2015, 133(7): 762-769. doi: 10.1001/jamaophthalmol.2015.0693
    [39] 全国防聋治聋技术指导组, 中华医学会耳鼻咽喉头颈外科学分会, 中华耳鼻咽喉头颈外科杂志编辑委员会, 等. 老年听力损失诊断与干预专家共识(2019)[J]. 中华耳鼻咽喉头颈外科杂志, 2019, 54(3): 166-173.

    National Committee for the Prevention of Hearing Loss, National Health Commission of the People' s Republic of China Society of Otorhinolaryngology Head and Neck Surgery, Chinese Medical Association Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery, et al. Expert consensus on diagnosis and intervention of hearing loss in the elderly(2019)[J]. Chin J Otorhinolaryngol Head Neck Surg, 2019, 54(3): 166-173.
    [40] ZHENG Q, XU Z, LI N, et al. Age-related hearing loss in older adults: etiology and rehabilitation strategies[J]. Front Neurosci, 2024, 18: 1428564. DOI: 10.3389/fnins.2024.1428564.
    [41] YE X, ZHU D, CHEN S, et al. Effects of providing free hearing aids on multiple health outcomes among middle-aged and older adults with hearing loss in rural China: a randomized controlled trial[J]. BMC Med, 2022, 20(1): 124. DOI: 10.1186/s12916-022-02323-2.
    [42] 中华医学会精神医学分会老年精神医学组. 老年期抑郁障碍诊疗专家共识[J]. 中华精神科杂志, 2017, 50(5): 329-334.

    Geriatric Psychiatry Group of Chinese Society of Psychiatry. Expert consensus on diagnosis and treatment of depressive disorders in older adults[J]. Chin J Psychiatry, 2017, 50(5): 329-334.
    [43] SIMON S S, CORDAS T A, BOTTINO C M. Cognitive behavioral therapies in older adults with depression and cognitive deficits: a systematic review[J]. Int J Geriatr Psychiatry, 2015, 30(3): 223-233. doi: 10.1002/gps.4239
    [44] HEISSEL A, HEINEN D, BROKMEIER L L, et al. Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression[J]. Br J Sports Med, 2023, 57(16): 1049-1057. doi: 10.1136/bjsports-2022-106282
    [45] LIU C J, CHANG W P, CHANG M C. Occupational therapy interventions to improve activities of daily living for community-dwelling older adults: a systematic review[J]. Am J Occup Ther, 2018, 72(4): 7204190060p1-7204190060p11. DOI: 10.5014/ajot.2018.031252.
    [46] 国务院. 国务院关于印发"十四五"国家老龄事业发展和养老服务体系规划的通知[EB/OL]. (2022-02-21)[2024-08-18]. https://www.gov.cn/zhengce/content/2022-02/21/content_5674844.htm.

    State Council of the People' s Republic of China. Notice on issuing the "14th Five-Year Plan" national aging affairs development and elderly care service system plan[EB/OL]. (2022-02-21)[2024-08-18]. https://www.gov.cn/zhengce/content/2022-02/21/content_5674844.htm.
    [47] FISCHER S H, DAVID D, CROTTY B H, et al. Acceptance and use of health information technology by community-dwelling elders[J]. Int J Med Inform, 2014, 83(9): 624-635. doi: 10.1016/j.ijmedinf.2014.06.005
    [48] ZHANG Q, GUO X, VOGEL D. Information and communication technology use for life satisfaction among the elderly: a motivation perspective[J]. Am J Health Behav, 2021, 45(4): 701-710. doi: 10.5993/AJHB.45.4.9
    [49] CHEN H, HAGEDORN A, AN N. The development of smart eldercare in China[J]. Lancet Reg Health West Pac, 2023, 35: 100547. DOI: 10.1016/j.lanwpc.2022.100547.
    [50] 梁铭标, 梁会营, 李丹, 等. 智慧医养康服务一体化应用新模式构建与研究[J]. 中国卫生信息管理杂志, 2024, 21(1): 25-31.

    LIANG M B, LIANG HY, LI D, et al. Construction and research on new model of the integrated application of smart medical-elderly-rehabilitation services[J]. Chinese Journal of Health Informatics and Management, 2024, 21(1): 25-31.
  • 加载中
图(1)
计量
  • 文章访问数:  2
  • HTML全文浏览量:  4
  • PDF下载量:  0
  • 被引次数: 0
出版历程
  • 收稿日期:  2025-04-15

目录

    /

    返回文章
    返回