Background: Longer average life expectancies have caused the rapid growth of the elderly as a percentage of Taiwan's population and, as a result of the number of elders with chronic diseases and disability. Providing continuing-care services in community settings for elderly with multiple chronic conditions has become an urgent need.
Purpose: To review the nurse-led care models that are currently practiced among elders with chronic disease in the community and to further examine the effectiveness and essential components of these models using a systematic review method.
Methods: Twelve original articles on chronic disease-care planning for the elderly or on nurse-led care management interventions that were published between 2000 and 2015 in any of five electronic databases: MEDLINE, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus with Full Text, Cochrane Library, and CEPS (Chinese Electronic Periodicals Service）were selected and analyzed systematically.
Results: Four types of nurse-led community care models, including primary healthcare, secondary prevention care, cross-boundary models, and case management, were identified. Chronic disease-care planning, case management, and disease self-management were found to be the essential components of the services that were provided. The care models used systematic processes to conduct assessment, planning, implementation, coordination, and follow-up activities as well as to deliver services and to evaluate disease status. The results revealed that providing continuing-care services through the nurse-led community chronic disease-care model and cross-boundary model enhanced the ability of the elderly to self-manage their chronic diseases, improved healthcare referrals, provided holistic care, and maximized resource utilization efficacy.
Conclusions / implications for practice: The present study cross-referenced all reviewed articles in terms of target clients, content, intervention, measurements, and outcome indicators. Study results may be referenced in future implementations of nurse-led community care models as well as in future research.
Title: 護理人員引領社區老人慢性病照護管理模式—系統性文獻回顧探討.
背景: 隨著老年人口劇增及平均餘命延長，慢性病與失能照護之需求提升，社區護理人員如何滿足老人慢性病之照顧，值得進一步探討。.
目的: 透過系統性文獻回顧，探討護理人員引領的社區老人慢性病照護模式、服務內容及其角色功能。.
方法: 搜尋2000至2015年在MEDLINE、PubMed、CINAHL（Cumulative Index to Nursing and Allied Health Literature）、Plus with Full Text、Cochrane Library與CEPS（Chinese Electronic Periodicals Service）中文電子期刊服務之中英文資料庫，找出以護理師於社區老人慢性病照護模式為主要介入措施之研究文獻，萃取12篇研究進行評讀。.
結果: 護理師引領的社區老人慢性病照護模式主要分為四類：基層保健醫療服務、次段預防照護、跨領域合作模式及個案管理。照護內涵包括：慢性病照護計劃、個案疾病管理和自我管理，在慢性病護理照護過程中，進行評估、規劃、措施、協調、追蹤、評價。透過護理師連續性照護合併跨團隊合作模式，除提升社區老年個案在慢性病自我照顧管理能力、健康照護連結正面成效，亦能減少住院與急診服務使用率，進而改善其生活品質。.
結論／實務應用: 我國護理師在社區發展現況仍有許多限制，本研究凸顯護理師在社區老人慢性病照護中之互補與替代醫療服務角色之重要性，期能提供政府相關單位及健康照護專業團隊之參考，透過護理師或個案管理師及跨團隊合作模式，在社區中提供適當、有效率、有品質的老人慢性病照護。.
Keywords: care effect; chronic disease; community elders; nursing care.