关键词: 慢性病, 老年人, 延续性健康管理, 健康管理, 影响因素分析, 上海

Abstract: Background　Chronic disease among elderly patients usually has characteristic of long course，wide prevalence，high cost and high rates of disability and fatality. The application of transitional health management services to the post-discharge community follow-up of these patients is conducive to rational allocation of medical resources and substantial reduction of medical costs. Objective　To investigate the demands and influencing factors of transitional health management among elderly patients with chronic disease in Shanghai. Methods　From July to September in 2019，600 discharged elderly patients with chronic diseases from two grade A tertiary hospitals in Shanghai were investigated with a self-made health management needs questionnaire consisting of demographic information，needs of transitional health management（including treatment needs and health promotion needs） and preferred services of transitional health management. Pearson correlation analysis was used to explore the correlation of the above-mentioned factors with the needs of transitional health management. Multiple linear regression analysis was used to explore the associated factors of the overall needs of transitional health management and of treatment needs and health promotion needs. Results　A total 587 cases of 600 returned responsive questionnaires，achieving a survey response rate of 97.8%. The average score of the scale was （3.3±0.5）. And the average scores of treatment and health promotion needs dimensions were （3.8±0.3） and （2.9±0.8），respectively. The top three treatment needs were guidance for medication safety，disease monitoring and follow-up guidance，with corresponding average scores of （4.6±0.1），（4.5±0.2），（3.8±0.5）；the top three health promotion needs were guidance for reasonable exercise guidance，dietary nutrition guidance and psychological counseling（3.4±0.2），（3.4±0.2），（2.8±0.4），respectively. The results of multiple linear regression analysis showed that age and education level were the influencing factors of treatment needs，while relevant socio-economic factors had no influence on health promotion needs. Age，education level and disease were the influencing factors of the overall needs of transitional health management. Conclusion　The demands of transitional health management of elderly patients with chronic diseases is widespread but the cognition of transitional health management is not comprehensive enough. Patients' age and education level positively affected total demand demand. It is necessary to stimulate and guide the patients' needs through multiple channels，rationally allocate medical resources，and bring the transitional health management of chronic diseases to the community. The related policies，systems and evaluation standards of transitional health management should be further studied and introduced.

Key words: Chronic disease, Aged, Transitional health management, Health management, Root cause analysis, Shanghai