A Study on Optimising Family Doctors’ Health Management Services for Chronic Diseases in the Elderly within the Community-Based Home Care Model
-- Taking the Pujin Community Health Service Centre in Shanghai as a Case Study
DOI:
https://doi.org/10.54097/ea6bfa81Keywords:
Community-based Home Care, Family Doctors, Chronic Disease Management in the Elderly, Pujin CommunityAbstract
Against the backdrop of community-based home care for the elderly, family doctors are key service providers in the health management of chronic diseases among the elderly. Taking the Pujin Community Health Service Centre in Shanghai as a case study, this paper adopts a combination of literature review, case analysis and interviews to examine the current status and challenges of family doctors’ involvement in the management of chronic diseases among the elderly. The study found that whilst family doctors are already capable of carrying out basic health management, they face issues such as high work pressure, a lack of precision in chronic disease management, low levels of active participation among elderly patients, and limited IT support capabilities. Based on these findings, the study proposes optimisation pathways including improving the development of family doctor teams, advancing the precision management of chronic diseases, strengthening health education for the elderly, and promoting IT integration and community collaboration. This research provides practical guidance for the management of chronic diseases among the elderly in primary care communities.
Downloads
References
[1] World Health Organization. (2017). Integrated care for older people: guidelines on community level interventions to manage declines in intrinsic capacity. https://www. who.int/ publications/ i/item/9789241550101.
[2] Li, Z. J., & Li, M. H. (2025). The impact of family and community support on older adults’ choices of care arrangements. Chinese Rural Health Service Administration, 45(3), 214 220.
[3] State Council Office of Health System Reform. (2016). Guidelines on promoting family doctor contract services. https://www.nhc.gov.cn/tigs/c100053/201606/a2f65c166d5b438f8abb684d3a8c13d0.shtml.
[4] Zhang, F., & Wang, L. Y. (2020). Community prevention, control and health management of chronic diseases. Chemical Industry Press.
[5] Li, J. X., & Li, L. (2026). A study on the impact of comorbidity patterns of chronic diseases in older adults on the burden of healthcare. Journal of Hunan University of Chinese Medicine, 46(1), 190 199.
[6] Tencent News. (2025, April 25). Minhang family doctor facilitates ‘seamless’ referrals between primary and secondary care; Her practice serves over 10,000 patients annually. https:// news. qq.com/rain/a/20250425A05XWQ00.
[7] Xu, J. X., Dai, Y. L., Wang, T. Y., et al. (2025). Analysis of health education needs and influencing factors among residents in a community in Minhang District, Shanghai. Health Research, 45(6), 669 673.
[8] Gao, P., & Yang, C. Y. (2026). Policy evolution and implications of China’s family doctor system: An analysis based on the initiative alliance framework. Journal of Northeastern University (Social Sciences Edition). https://doi. Org / 10.15936/j.cnki.1008 3758.2022.03.010.
[9] Huang, J. L., Kang, L., Ge, M., et al. (2026). Fifteen years of development and future prospects of family doctor contract services in China. Chinese General Practice, 29(17), 2296 2302. https://doi.org/10. 12114/j.issn. 1007 9572. 2025. 0369.
[10] Wang, L. P., & Guo, X. L. (2025). Analysis of factors affecting the effectiveness of chronic disease management in community based public health services. Frontiers in Medicine, 15(13), 143 146.
[11] Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1(1), 2 4. https://doi.org/10.1007/BF03256731.
[12] Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness: The chronic care model, Part 2. JAMA, 288(15), 1909 1914. https://doi.org/10.1001/jama.288.15.1909.
[13] Yang, S. H. (2026). A study on health literacy among older adults in the context of active aging: Based on a sample survey of health literacy among older adults in five Chinese provinces and cities [Master’s thesis]. Nanjing University of Posts and Telecommunications.
[14] Liu, Q. Y. (2025). A study on the computerized management of archives in community health service centers. Heilongjiang Archives, (2).
[15] Han, Y. L., Ding, Y., Wan, H. P., Zhang, J. Y., & Zhang, X. Y. (2026, April 12). Analysis of the challenges and pathways for effective contract fulfilment by family doctors in Shanghai from an information technology perspective. Shanghai Journal of Preventive Medicine.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Academic Journal of Management and Social Sciences
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
