International Journal of Clinical Case Reports, 2025, Vol.15, No.1, 44-51 http://medscipublisher.com/index.php/ijccr 44 Feature Review Open Access Research on the Chronic Disease Management Model for the Elderly Based on a Community Health Assessment System Weiping Cai 1, Ziming Huang2, Qianxi Han 1, Yeli Huang3 1 Department of Geriatrics, The Sixth Medical Center, Chinese PLA General Hospital, Haidian, 10039, Beijing, China 2 Outpatient Department of LLQ, Southern Medical Branch of Chinese PLA General Hospital, Haidian, 10039, Beijing, China 3 Department of Nursing, The Sixth Medical Center, Chinese PLA General Hospital, Haidian, 10039, Beijing, China Corresponding author: huangyeli88@163.com International Journal of Clinical Case Reports 2025, Vol.15, No.1 doi: 10.5376/ijccr.2025.15.0005 Received: 22 Dec, 2024 Accepted: 05 Feb., 2025 Published: 22 Feb., 2025 Copyright © 2025 Cai et al., This is an open access article published under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Preferred citation for this article: Cai W.P., Huang Z.M., Han Q.X., and Huang Y.L., 2025, Research on the chronic disease management model for the elderly based on a community health assessment system, International Journal of Clinical Case Reports, 15(1): 44-51 (doi: 10.5376/ijccr.2025.15.0005) Abstract Chronic diseases (such as hypertension, diabetes, and cardiovascular conditions) are highly prevalent among the global elderly population, posing significant challenges to public health systems. This study explores the role of community health assessment systems in optimizing chronic disease management for the elderly. Community health assessment systems offer continuous health monitoring, promoting early disease detection and intervention, thereby reducing complications and improving patient quality of life. These systems support the development of personalized care plans through data analysis, enhancing patient adherence to treatments and alleviating pressure on healthcare resources. The study also discusses the importance of community caregiver involvement and its impact on the effectiveness of chronic disease management. With the continuous development of innovative technologies (such as telemedicine and mobile health applications), community health assessment systems hold promise for further enhancing chronic disease management in the future. This research provides a foundation for the sustainable and effective management of chronic diseases and has significant implications for public health systems in the context of an aging population. Keywords Chronic disease management; Community health assessment system; Elderly care; Personalized health management; Technological innovation 1 Introduction Chronic diseases, such as hypertension, diabetes, and cardiovascular conditions, are highly prevalent among the elderly population worldwide. The increasing rate of these conditions poses significant challenges to public health systems, including higher healthcare costs and the need for comprehensive, continuous care. The growth of the aging population further amplifies these issues, making it essential for healthcare systems to adopt sustainable and effective management strategies (Drouin et al., 2015). In developing countries, this situation is exacerbated by limited medical resources and uneven access to care, highlighting the necessity for innovative solutions (Wu et al., 2021). Community health assessment systems play a crucial role in chronic disease management by supporting tailored healthcare interventions and promoting the integration of healthcare services. These systems enable continuous monitoring and proactive disease management, which can reduce complications and improve patient outcomes (Waters et al., 2021). Studies have shown that models involving community-based health assessments contribute to better disease self-management, reduced mental health issues, and overall enhanced quality of life (Wu et al., 2023). They facilitate seamless transitions between different levels of care, benefiting older adults who often require multifaceted care approaches (Sendall et al., 2016). The rapid aging of populations has underscored the need for innovative approaches in healthcare, particularly for managing chronic diseases (Buco et al., 2018). Community-based models that incorporate health assessment systems have emerged as effective tools to address this challenge (Mason, 2024). These systems not only focus on treatment but also emphasize preventive measures and continuous patient engagement. Research indicates that integrating community health resources with systematic assessments can improve compliance, reduce anxiety, and elevate the overall health status of elderly patients (Liu and Wu, 2023).
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