摘要目的:构建以三级医院为主导互联网为核心的居家延续护理服务模式，为老年居家患者实施个性化的护理服务提供一定参考。方法:回顾性研究，选取2021年12月至2022年11月在汉中市人民医院接受“互联网+”及“医养结合居家养老”护理模式的居家老年患者60例作为研究对象，其中男35例、女25例，年龄（70.34±3.57）岁。平台注册护士共125例，其中男8例、女117例，年龄（34.12±3.23）岁。主要照顾者60例，其中男15例、女45例，年龄（45.23±5.51）岁。统计完成居家护理服务项目的结果，并对患者满意度进行调查，对比实施护理模式前后患者主要照顾者负担评分及护士职业认同感评分。统计学方法采用 t检验、 χ2检验。 结果:共服务老年居家患者60例，完成居家护理155次，无不满意评价，各项满意度均为100.00%。实施“互联网+”及“医养结合居家养老”延续性护理模式后，患者主要照顾者责任负担、个人负担及总分均低于实施前［（12.12±2.28）分比（15.23±3.23）分、（22.34±4.78）分比（27.22±5.23）分、（35.17±6.23）分比（43.21±6.56）分］，差异均有统计学意义（ t=4.975、4.356、5.621，均 P<0.05）；实施后，护士职业认知评价、职业社会支持、职业社会交往技能、职业挫折应对、职业自我反思及总分均高于实施前［（33.24±3.12）分比（30.23±3.23）分、（24.24±2.67）分比（20.23±3.11）分、（25.45±2.56）分比（21.12±3.11）分、（24.34±2.56）分比（21.23±2.89）分、（13.68±1.67）分比（10.23±1.89）分、（120.56±5.56）分比（112.23±4.87）分］，差异均有统计学意义（ t=3.671、5.358、5.888、4.412、7.492、6.173，均 P<0.05）。 结论:在医养结合政策背景下，开展“互联网+”及“医养结合居家养老”护理模式可提升老年居家患者满意度，同时减轻照顾者的负担，并提升护士职业认同感，推动护理服务业向更高层次发展。

abstractsObjective:To construct a home extended care service mode leaded by tertiary hospitals and with internet as the core, and to provide references for the implementation of personalized nursing service for elderly homebound patients.Methods:This was a retrospective study. Sixty patients taking the "internet+" and "combining medical care with home care" nursing mode in Hanzhong People's Hospital from December 2021 to November 2022 were selected as the research objects, including 35 males and 25 females who were (70.34±3.57) years old. There were 125 registered nurses on the platform, including 8 males and 117 females who were (34.12±3.23) years old. There were 60 main caregivers for the patients, including 15 males and 45 females who were (45.23±5.51) years old. The results of completed home care projects were statistically calculated. The patients' satisfaction was investigated. The burden scores of the caregivers and the scores of professional identity of the nurses before and after the implementation of this service were compared. t and χ2 tests were applied. Results:A total of 60 elderly homebound patients were served, with a total of 155 cases and a patient satisfaction rate of 100.00%. The scores of responsibility burden and personal burden and total score of the patients' primary caregivers were lower after than before the implementation of the "internet+" and "combining medical care with home care" continuous nursing mode [(12.12±2.28) vs. (15.23±3.23), (22.34±4.78) vs. (27.22±5.23), and (35.17±6.23) vs. (43.21±6.56)], with statistical differences ( t=4.975, 4.356, and 5.621; all P<0.05). The scores of professional cognition, social support, social communication skills, frustration coping, and self-reflection and total score of the nurses were higher after than before the implementation [(33.24±3.12) vs. (30.23±3.23), (24.24±2.67) vs. (20.23±3.11), (25.45±2.56) vs. (21.12±3.11), (24.34±2.56) vs. (21.23±2.89), (13.68±1.67) vs. (10.23±1.89), and (120.56±5.56) vs. (112.23±4.87)], with statistical differences ( t=3.671, 5.358, 5.888, 4.412, 7.492, and 6.173; all P<0.05). Conclusions:Under the policy background of medical and nursing integration, the implementation of the "internet+" and "combining medical care with home care" nursing mode can improve the satisfaction of elderly homebound patients, reduce the burden of caregivers, and improve the professional identity of nurses. It can promote the development of the nursing service industry to a higher level.