A Study on Optimising Family Doctors’ Health Management Services for Chronic Diseases in the Elderly within the Community-Based Home Care Model

Vollständiger Abstract

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Against the backdrop of community-based home care for the elderly, family doctors are key service providers in the health management of chronic diseases among the elderly. Taking the Pujin Community Health Service Centre in Shanghai as a case study, this paper adopts a combination of literature review, case analysis and interviews to examine the current status and challenges of family doctors’ involvement in the management of chronic diseases among the elderly. The study found that whilst family doctors are already capable of carrying out basic health management, they face issues such as high work pressure, a lack of precision in chronic disease management, low levels of active participation among elderly patients, and limited IT support capabilities. Based on these findings, the study proposes optimisation pathways including improving the development of family doctor teams, advancing the precision management of chronic diseases, strengthening health education for the elderly, and promoting IT integration and community collaboration. This research provides practical guidance for the management of chronic diseases among the elderly in primary care communities.