目的：通过对养老机构老年人开展全科团队综合健康干预，为提高老年人健康状态提供指导依据。方法采用队列研究法，对两家城乡结合部养老机构随机分组，对干预组老年人实施团队综合健康干预，对照组开展常规健康宣教及随访措施。分别于1年后再次以生活质量评价表（SF-36）、老年简易营养评估量表（MNA）进行评价，从而评估干预效果。结果干预组进行团队健康干预1年后，除了情感职能（RE）无统计学差异(P>0.05)，SF-36总均分及其他维度得分干预后高于干预前(P>0.001)；而对照组SF-36总均分及各维度评分1年前后比较无差异(P>0.05)；干预组老人干预后营养状态得到改善(P>0.05)，而对照组无统计学差异(P>0.05)。结论开展全科团队的综合性、持续性健康管理，能有效地提高养老机构老年人的生活质量和营养状况，也是“医养融合”的一种具体实施方法。%Objective In order to provide guidance basis for improving the health status in elderly by carrying out commu-nity general physician team comprehensive health intervention for old people in the senior care organization. Methods The two senior care organizations in rural-urban fringe zone were randomly divided into groups by the cohort study method, the intervention group adopted team comprehensive health intervention, the control group carried out the conventional health propaganda and education and follow-up measures, and both groups were evaluated again by the life quality assessment scale (SF-36) and brief nutrition evaluation scale (MNA) after 1 year thus the intervention effect was evaluated. Results There was no statistical difference in the emotional function after 1 year's team health intervention in the intervention group,(P>0.05), the total mean score of SF-36 and other demission scores after intervention were higher than those before intervention,(P<0.001); but there was no difference in the total mean score of SF-36 and other demission scores in the control group before and after 1 year by comparison (P>0.05), the nutrition state in intervention group was improved,(P<0.05), but there was no statistical difference in the control group(P>0.05). Conclusion Carrying out the community general physician team comprehensive and continuous health management can effectively improve the quality of life and nutrition state in old people in senior care organization, and it is also one of the specific implementation methods of “combination of medical care and pension”.
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