《中国康复理论与实践》

《中国康复理论与实践》 ›› 2026, Vol. 32 ›› Issue (1): 90-100.doi: 10.3969/j.issn.1006-9771.2026.01.010

• 社区康复 • 上一篇    下一篇

基于老年人整合照护框架构建老年人轻度认知功能障碍社区-家庭管理模式

陈俊利1, 张晗2, 张叶凡3, 张艳秋3, 高润国1,4, 高倩倩3,4, 蔡伟芹3,4, 李海燕3, 嵇丽红1, 董志伟3(), 井淇3,4()   

  1. 1.山东第二医科大学公共卫生学院，山东潍坊市 261053
    2.西安交通大学公共政策与管理学院，陕西西安市 710049
    3.山东第二医科大学管理学院/ICF研究院/康复健康研究院，山东潍坊市 261053
    4.“健康山东”重大社会风险预测与治理协同创新中心，山东潍坊市 261053
  • 收稿日期:2025-06-26 修回日期:2025-10-11 出版日期:2026-01-25 发布日期:2026-01-28
  • 通讯作者: 井淇(1988-)，男，汉族，山东临朐县人，博士，教授，主要研究方向：卫生健康政策与管理。E-mail： jingq@sdsmu.edu.cn；董志伟(1989-)，男，汉族，山东寿光市人，博士，讲师，主要研究方向：卫生事业管理。E-mail： dongzhiwei1989@outlook.com
  • 作者简介:陈俊利(1998-)，女，汉族，山东莱州市人，博士研究生，主要研究方向：公共卫生政策与管理。
  • 基金资助:
    1.国家自然科学基金青年科学基金项目(72004165);2.山东省高等学校"青创团队计划"团队研究课题(2022RW075)

Construction of a community-family management model for older adults with mild cognitive impairment

CHEN Junli1, ZHANG Han2, ZHANG Yefan3, ZHANG Yanqiu3, GAO Runguo1,4, GAO Qianqian3,4, CAI Weiqin3,4, LI Haiyan3, JI Lihong1, DONG Zhiwei3(), JING Qi3,4()   

  1. 1. School of Public Health, Shandong Second Medical University, Weifang, Shandong 261053, China
    2. School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
    3. School of Management/China Academy of ICF/China Rehabilitation and Health Research Institute, Shandong Second Medical University, Weifang, Shandong 261053, China
    4. Healthy Shandong Collaborative Innovation Center for Major Social Risk Prediction and Management, Weifang, Shandong 261053, China
  • Received:2025-06-26 Revised:2025-10-11 Published:2026-01-25 Online:2026-01-28
  • Contact: JING Qi, E-mail: jingq@sdsmu.edu.cn; DONG Zhiwei, E-mail: dongzhiwei1989@outlook.com
  • Supported by:
    National Natural Science Foundation of China (Youth)(72004165);Shandong Province Higher Education Institutions "Youth Creative Team Program" Team Research Project(2022RW075)

RichHTML

PDF (PC)

摘要：

目的 构建老年人轻度认知功能障碍(MCI)社区-家庭管理模式，并制定详细的应用规范，在有限资源条件下，充分发挥社区和家庭的主动性，实现老年MCI社区早发现、早干预。

方法 采用文献研究法，筛选相关文献，结合语料库研究方法，提炼、删减、整合、归纳管理要素，形成管理模式各阶段具体内容和服务流程，并基于5W2H分析法，明确各阶段管理主体、管理对象、管理内容、管理方式等要素，最后经过专家咨询论证形成老年人MCI社区-家庭管理模式和应用规范。

结果 管理模式在认可度、可行性和系统性的得分为4.84分、4.32分和4.84分。老年人MCI社区-家庭管理模式包括筛查识别、综合评估、制定干预计划、保障管理模式实施的监测和转诊路径、加强社区和家庭成员及照护者的支持5个阶段和18条应用规范。

结论 老年MCI管理模式理论上可能有助于延缓认知功能下降，可能改善认知功能，实现认知状态的逆转，帮助老年人和家庭增强对MCI的认知和应对能力，提升社区卫生专业人员对老年人MCI的识别与管理能力。

关键词: 轻度认知障碍, 社区康复, 老年人整合照护理念, 管理模式, 老年人

Abstract:

Objective To develop a community-family management model for older adults with mild cognitive impairment (MCI) and to formulate detailed application specifications, and to fully leverage the initiative of communities and families under limited resource conditions, for achieving community-based early detection and early intervention for older adults with MCI.

Methods A systematic literature review was conducted to identify pertinent publications. Corpus-based research methodologies were employed to extract, refine, integrate and synthesize management elements, thereby establishing the specific content and service processes for each stage of the management model. Utilizing the 5W2H analytical framework, essential elements such as management stakeholders, target populations, content and methods for each stage were delineated. The model and its application guidelines were finalized through expert consultation and demonstration.

Results An expert evaluation of the management model yielded mean scores of 4.84, 4.32 and 4.84 for acceptability, feasibility and systematicity, respectively. By integrating the identified core elements with expert ratings and feedback, the final iteration of the community-family management model for older adults with MCI was formulated. This model comprised of five stages: screening and identification, comprehensive assessment, intervention planning, monitoring and referral pathways to ensure implementation, and enhanced support for communities, family members and caregivers. Additionally, it included 18 specific application guidelines.

Conclusion The proposed management model may theoretically help delay cognitive decline, improve cognitive function and potentially promote reversal from MCI to normal cognition. It may also enhance the awareness and coping capacity of older adults and their families, strengthen community healthcare professionals' ability to early identify and manage MCI.

Key words: mild cognitive impairment, community-based rehabilitation, integrated care for older people, management model, older adults

中图分类号: