基于 PDSA 理论构建医联体下老年共病整合管理模式构建

he continuous increase in the prevalence of comorbidities has severe challenges to population health managementand the World Health OrganizationWHO recommends the development of integrated medical care models to cope with the pressure of health management of patients with comorbidities. In this paperwe constructed an integrated management model for geriatric comorbidities under medical association based on PDSA theoryin order to continuously improve the management ability and effect in the reciprocal cycle of "plan-execute-research-act". The model consists of four key elementsincluding management teammanagement processmanagement tools and management effect. Based on previous intervention researchthe model integrates patient-centeredmultidisciplinary teampatient self-management and other intervention methodsand relies on big data technology to establish a decision support platformthus realizing the whole life cycle health management of patients with comorbidities.