摘要目的：了解社区慢性病患者对三元联动延续护理服务的真实需求。方法自行设计调查表，采用便利抽样法选取5家社区的200例慢性病患者进行调查。结果共发放问卷200份，回收有效问卷178份，有效率为89％。对延续护理服务项目非常了解的慢性病患者仅占21．4％（38/178）；希望出院后继续接受医护照护的慢性病患者占80．9％（144/178）；38．2％（68/178）的慢性病患者“不确定”延续护理服务对疾病疗效的影响；77．5％（138/178）的慢性病患者担心延续护理服务的自费比例问题。社区慢性病患者对延续护理服务的需求包括安全用药知识、血压控制及自我监测、饮食指导、疾病相关知识、血脂及血糖控制与监测、康复锻炼方法等。希望由社区护士提供院外护理服务的慢性病患者仅占8．4％（15/178）。结论社区慢性病患者对延续护理服务内容的需求量比较大，但是尚存在一些瓶颈，因此要充分利用社区护士人力资源，有效开展医院-社区-家庭三元联动延续护理服务。

abstractsObjective To study the demands among community patients with chronic diseases for continuing nursing care .Methods Totals of 200 patients from five community health service centers were recruited into the study and investigated with self-designed questionnaire .Results Out 200 questionnaires , totals of 178 questionnaires were taken back , with effective rate of 89%.Among 178 patients, 21.4%(38/178) of patients chose “good understanding of continuing nursing care”, 80.9%(144/178) of patients chose“hoping to continue to receive care after discharge”;38.2%(68/178) of patients were “not sure the effect of continuing nursing care”;77.5%(138/178) of patients worried about their own expense for continuing nursing care .The demands for continuing nursing care included knowledge of safe medication and diseases , blood pressure control and self-monitoring, dietary guidelines, knowledge related to the disease , blood lipid and blood glucose control and monitoring, rehabilitation exercise and so on .Only 8.4%(15/178) of patients hoped that nursing care after discharge was provided by community nurses .Conclusions Community patients have a high demand for continuing nursing care , while difficulties exist in implementing of continuing nursing care at present .It is necessary to make fully use community nursing human resources to develop continuing nursing care model of hospital-community-family.