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中文摘要: 目的 研究多学科参与的延续性护理服务团队对老年慢性病患者出院后生活质量、日常生活活动能力和抑郁状况的影响，从而探讨建立适合老年慢性病患者出院后居家介护式护理模式。方法 采用简明健康状况调查表、老年抑郁量表和日常生活能力调查表对107名出院老年慢性病患者进行调查，随后按社区随机分为干预组和对照组，干预组人数为56名，对照组人数为51名，对干预组老进行居家介护护理康复干预，干预1年后再次进行测评，评价护理康复模式效果。结果 经过1年的干预，两组老人干预随访前后差值除生理性日常生活能力评分外均有统计学意义(P<0.01)，干预组老人干预后生活质量各维度得分、抑郁分值和工能性日常生活能力评分与活动能力总分明显好于对照组老人。结论 全科医生、中医医生、护理和公卫等多学科参与的延续性护理服务团队切实可行，能有效提高慢性病出院老人的生活质量、日常生活活动能力，降低抑郁状况。
Abstract:OBJECTIVE Study on the influence of subject participation of continuing care services team for discharged elderly patients in improving the quality of life, activities of daily,depression and to explore a home care nursing mode of discharged elderly patients with chronic diseases．METHODS A set of questionnaires,including general information questionnaire,36-item Short Form Health Survey, Geriatric Depression Scale and Activities of Daily Living were sent to 107 elderly patients with chronic diseases discharged. and were randomly divided into the experimental group (56) treated with the comprehensive intervention and the control group (51) with the traditional community follow-up without any intervention. RESULTS After one year intervention，there were significant differences in quality of life，depression status，in-strumental activities of daily living and totel activities of daily the two groups. (P<0.01). The conditions of the elderly in intervention group were better than those in control group in every aspect. CONCLUSION General practitioner,doctor of Chinese medicine, nursing, public health doctor and other disciplines involved in the continuing care team is feasible.It can effectively improve the quality of life，activities of daily and reduce depression of discharged elderly patients with chronic diseases
文章编号：3201902031 中图分类号：R1-9 文献标志码：
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