Geriatrics
Conditions
Interventions
Intervention group :Multidisciplinary team management
Group 2:No
Sponsors
Gaobeidian Community Health Service Center, Chaoyang District, Beijing
Eligibility
Sex/Gender
All
Age
65 Years to 90 Years
Inclusion criteria
Inclusion criteria: 1. Aged = 65 years old or older residents of the community, type 2 diabetes mainly and coexisting chronic coexisting patients with hypertension, coronary heart disease, stroke, chronic obstructive pulmonary disease; 2. ADL (Barthel Scale) score below 95 points; 3. taking 5 or more drugs at the same time; 4. The subject or subject's legal representative (LAR) voluntarily signed an informed consent form approved by the independent ethics committee.
Exclusion criteria
Exclusion criteria: 1. The patient is diagnosed by a doctor and needs to be transferred to an acutely treated patient, such as an acute complication of acute illness or chronic disease; 2. combined with serious chronic diseases: such as cardiovascular disease (NYHA = 3), nervous system diseases (moderate and severe dementia), liver disease (active hepatitis, decompensated chronic liver disease such as cirrhosis, ascites, etc.), kidney (e -GFR<30ml/min) and serious primary diseases such as hematological malignancies, AIDS or mental patients; 3. can not adhere to patients who have been administered by multidisciplinary teams for more than 6 months; 4. refusal to sign multi-disciplinary team management informed consent; 5. There are any other conditions or events that the primary investigator or research doctor considers to be excluded.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Satisfaction; | — |
Countries
China
Contacts
Public ContactFuying Zhao
Gaobeidian Community Health Service Center, Chaoyang District, Beijing
Outcome results
None listed