Boult C, Pualwan T F, Fox P D, Pacala J T
University of Minnesota Medical School, Minneapolis, MN, USA.
Am J Manag Care. 1998 Aug;4(8):1137-46.
Many older adults with chronic illnesses and multidimensional needs are at high risk of adverse health outcomes, poor quality of life, and heavy use of health-related services. Modern proactive care of older populations includes identification of such high-risk individuals, assessment of their health-related needs, and interventions designed both to meet those needs and to prevent undesirable outcomes.
This paper outlines an approach to the tasks of identifying and assessing high-risk seniors. Intervention identification of high-risk seniors (also called case finding) is accomplished through a combination of periodic screening, recognition of high-risk seniors by clinicians, and analysis of administrative databases. Once identified, potentially high-risk individuals undergo on initial assessment in eight domains: cognition, medical conditions, medications, access to care, functional status, social situation, nutrition, and emotional status. The initial assessment is accomplished in a 30- to 45-minute interview conducted by a skilled professional--usually one with a background in nursing. The data are used to link some high-risk persons with appropriate services and to identify others who require more detailed assessments. Detailed assessment is often performed by interdisciplinary teams of various compositions and methods of operation, depending on local circumstances.
The rapid growth in Medicare managed care is presenting many opportunities for developing more effective strategies for the proactive care for older populations. Identification and assessment of high-risk individuals are important initial steps in this process, paving the way for testing of interventions designed to reduce adverse health consequences and to improve the quality of life.
许多患有慢性病且有多种需求的老年人面临着不良健康后果、生活质量低下以及大量使用与健康相关服务的高风险。现代针对老年人群体的积极护理包括识别此类高风险个体、评估他们与健康相关的需求，以及设计既能满足这些需求又能预防不良后果的干预措施。
本文概述了一种识别和评估高风险老年人的方法。通过定期筛查、临床医生对高风险老年人的识别以及行政数据库分析相结合的方式来完成对高风险老年人的干预识别（也称为病例发现）。一旦确定，潜在的高风险个体将在八个领域接受初步评估：认知、医疗状况、药物、就医机会、功能状态、社会状况、营养和情绪状态。初步评估通过由熟练专业人员（通常是有护理背景的人员）进行的30至45分钟访谈来完成。这些数据用于将一些高风险人员与适当的服务联系起来，并识别其他需要更详细评估的人员。详细评估通常由跨学科团队根据当地情况采用不同的组成和操作方法进行。
医疗保险管理式医疗的快速发展为制定更有效的老年人群体积极护理策略提供了许多机会。识别和评估高风险个体是这一过程中的重要初始步骤，为测试旨在减少不良健康后果和提高生活质量的干预措施铺平了道路。
