Abstract:

With the accelerating ageing of China’s population and the growing burden of chronic diseases，multimorbidity has become a common challenge for population health and nursing care. Traditional disease-specific and specialty-centred nursing models are increasingly inadequate for meeting the complex，continuous，and integrated care needs of patients with multimorbidity. This paper analyzes the challenges of multimorbidity nursing care from 3 dimensions—“disease-patient-system”—and proposes recommendations such as advancing integrated care，enhancing holistic management of patients with multimorbidity and reducing treatment burdens；reinforcing health goal-oriented patient care to establish a personalized nursing and self-management loop；improving continuous care，data standards，and talent development systems to strengthen the support framework for multimorbidity nursing care. These measures aim to deepen multimorbidity nursing research，promote the transformation of nursing models，and build a multimorbidity nursing theory and service system tailored to China’s national conditions.

Key words: Population Ageing, Multimorbidity Nursing, Integrated Care, Nursing Models, Coping Strategies

摘要：

随着我国人口老龄化加速和慢性病负担持续增加，共病已成为居民健康与护理服务面临的常态化挑战，传统单病种、单专科护理模式已难以满足复杂、连续、整合的照护需求。该文从“疾病-患者-系统”3个层面解析共病护理挑战，提出推进整合照护，强化共病患者的整体管理，减轻治疗负担；强化患者健康目标导向，构建个体化护理与自我管理闭环；完善连续照护、数据标准与人才培养体系，夯实共病护理系统支撑等建议，以深化共病护理研究，推动护理模式转型，构建符合国情的共病护理理论与服务体系。

关键词: 人口老龄化, 共病护理, 整合护理, 护理模式, 应对策略