襄阳职业技术学院学报

目的 探讨“医院—家庭”赋能教育模式对老年慢性病患者自我管理能力及健康结局的影响。方法 选取2021年1月至2024年1月航空工业襄阳医院收治的218例老年慢病患者，随机分为实验组与对照组，各109例。对照组接受常规出院指导与随访，实验组在此基础上实施“医院—家庭”过渡期赋能教育。分别于干预前、干预后1个月及3个月评估两组自我管理行为、自我效能、服药依从性及生活质量，并比较再入院率。结果 干预后，实验组的自我管理行为、自我效能、服药依从性、生活质量各维度得分及总分均显著高于对照组，再入院率显著低于对照组（均P<0.05）。结论 基于“医院—家庭”过渡期赋能教育可有效提升老年慢病患者的自我管理能力与自我效能，改善服药依从性与生活质量，降低再入院风险，是践行“互联网+护理服务”与“慢性病五大处方”理念的创新实践策略。

Objective: To explore the effect of the "hospital-family" empowerment education model on selfmanagement ability and health outcomes in elderly patients with chronic diseases. Methods: A total of 218 elderly patients with chronic diseases admitted to our hospital from January 2021 to January 2024 were randomly allocated to an intervention group and a control group, with 109 cases in each. The control group received routine discharge guidance and follow-up, while the intervention group was provided with additional "hospital-family" transitional empowerment education. Self-management behaviors, self-efficacy, medication adherence, and quality of life were assessed at baseline, 1 month, and 3 months post-intervention. The readmission rate was compared between the two groups. Results: After intervention, the scores of all dimensions and total scores of self-management behaviors, self-efficacy, medication adherence, and quality of life in the intervention group were significantly higher than those in the control group, and the readmission rate was significantly lower(all P<0.05). Conclusion: The "hospital-family" transitional empowerment education can effectively enhance selfmanagement ability and self-efficacy, improve medication adherence and quality of life, and reduce the risk of readmission in elderly patients with chronic diseases. It serves as an innovative practical strategy for implementing the concepts of "Internet + Nursing Services" and "Five Prescriptions for Chronic Diseases".