부산대학교 도서관

Objective: This study aimed to develop a community health care-based integrated care model for older patients to limit the occurrence of disability in this group and promote healthy aging in Taiwan. Methods: Ten primary care group practices participated in this study. The primary care doctors and staff were trained to conduct a brief comprehensive assessment and management of older people. Patients eligible for evaluation were those aged ≥65 years with at least one of the following diseases: hypertension, diabetes mellitus, and hyperlipidemia. The assessment included a 10-minute comprehensive screening test, a frailty examination, and a medication review. A care plan was developed based on the results. Patients were followed-up after 60 days. Results: In total, 12,506 participants were enrolled; their mean age was 74.6 ± 6.9 years, 61.9% were female, and 66.7% had at least one abnormal assessment. After suitable intervention, 6,247 participants were followed-up in 60 days. The data revealed that after intervention, the condition of 43.4% of the patients improved, 25.16% remained abnormal, and 22.39% remained normal; only 9.0% of the patients experienced a deterioration of their condition. Conclusions: Our results indicate that comprehensive geriatric assessment and care planning delivered by primary health care providers is effective and practicable.