摘要共病患者有多种医疗需求,尤其是老年人共病,常有老年综合征,传统的专科诊疗模式不适合共病患者,需要多学科协同干预.文章介绍了以社区全科医生为主导的多学科团队服务模式,并通过1例老年共病患者的管理实践过程,介绍以该模式为老年共病患者提供全人管理的具体临床应用.

abstractsPatients with multiple diseases have a variety of medical needs,especially in elderly patients with senile syndrome.The conventional specialty care model is not suitable for patients with comorbidities and multidisciplinary intervention and management are required.The article introduces the concept and practice of a general practitioner (GP)-led multidisciplinary team in management of comorbidities in the community.Using one case of elderly patient with multiple diseases as example,the article shows how this model worked and how the patient benefited,and the related issues and reflections are also discussed in the article.