Discussion on the Transformation Path of Chronic Disease Health Management Model for the Elderly from the Perspective of Evidence-Based Medicine
Download PDF

Keywords

Chronic diseases in the elderly
Health management model
Evidence-based practice

DOI

10.26689/ijgpn.v3iSpecial.13920

Submitted : 2026-01-25
Accepted : 2026-02-09
Published : 2026-02-24

Abstract

The intensification of global population aging has made the high incidence of chronic diseases among the elderly a major public health challenge. Traditional management models centered on disease treatment have limitations such as high costs, fragmented services, and delayed interventions. This paper compares the differences between China’s “integration of medical care and elderly care” and Australia’s “Aged Care System,” finding that both face common issues such as uneven distribution of service resources, a shortage of professional talent, and insufficient interdepartmental collaboration. Based on the principles of evidence-based medicine, the paper proposes a systematic transformation path from four aspects: building an early intervention system with prevention as the priority, integrating resources to improve collaborative management mechanisms, empowering management efficiency through technology, and strengthening policy guarantees to promote transformation. It also analyzes the applications and development directions of wearable devices, AI risk assessment, and smart health management platforms. The study aims to shift the management of chronic diseases among the elderly from “disease treatment” to “health promotion and early prevention,” providing theoretical and practical references for improving management levels and addressing the challenges of aging.

References

Chen Y, Zhu G, Xue F, 2024, Analysis of the Current Status and Influencing Factors of Medication Adherence Among the Elderly in Shandong Province Under the Active Health Management Model. Chinese General Practice, 27(10): 120–125.

Ryan F, Otto B, Khan A, et al., 2017, A Cross-Sectional Study of Work-Related and Lifestyle Factors Associated with Health in Australian Long-Distance Commuters and Residential Miners, World Physiotherapy, viewed October 28, 2025, https://world.physio/zh-TW/congress-proceeding/cross-sectional-study-work-related-and-lifestyle-factors-associated-health

Shen Y, Li L, Wang C, et al., 2024, Research on the Socio-Economic Impact of Physical Training for the Elderly in the Context of “Integration of Sports and Medicine,” Chinese Association of Sport Science - Strength and Conditioning Branch, Proceedings of the 2024 Second Belt and Road Initiative Summit Forum on Strength and Conditioning & Second National Annual Conference on Strength and Conditioning. Graduate School of Harbin Sport University; School of Sports Human Science, Harbin Sport University; Henan University of Chinese Medicine, 67.

Shi X, Long L, Luo X, 2023, Research on the Development Strategy of Health Management Models for Chronic Diseases in the Elderly Promoted by the Integration of Sports and Medicine, Jiangxi Society of Sports Science, National School Sports Alliance Jiangxi Branch, Jiangxi Sports Discipline Alliance, School of Physical Education & Health, East China Jiaotong University, Proceedings of the Fourth “National Fitness & Scientific Exercise” Academic Exchange Conference and International Forum on Sports and Health. School of Physical Education, Weinan Normal University; School of Physical Education, East China University of Technology, 121–122.

Sharman JE, 2023, Improving the Delivery of Cardiovascular Disease Care in Australia: A Cluster Randomized Controlled Trial (The IDEAL Study), viewed October 28, 2025, https://ichgcp.net/zh/clinical-trials-registry/NCT04896021

Xue Y, 2023, Research on Risk Behaviors and Health Management Pathways of Elderly Patients with Multiple Chronic Conditions from the Perspective of Health Ecology, dissertation, Southern Medical University.

Dong B, Bu X, Song Y, 2021, Construction of a “Hospital-Community-Family” Trinity Information Management Model for Elderly COPD Patients. Chinese Journal of Geriatric Care, 19(06): 161–162 + 165.

Huang R, 2021, Research on Community Elderly Chronic Disease Health Management Based on the ICCC Perspective, dissertation, Dongbei University of Finance and Economics.

Lin H, 2024, Research on the Active Health Management Model for Community Elderly Based on the Advocacy Catalyst Theory, dissertation, Southern Medical University.

Chen B, Hu Q, Sun M, et al., 2020, Construction and Effect Evaluation of a “Three-Teacher Co-management” Community Elderly Chronic Disease Health Management Model by Family Doctor Teams. Chinese Journal of Medical Innovation, 17(15): 164–168.

Ying L, Yang H, 2019, Australian Chronic Disease Management Plan and Its Enlightenment to China. Chin Gen Pract, 22(34): 4184–4189.

Wickramasinghe LK, Schattner P, Hibbert ME, et al., 2013, Impact on Diabetes Management of General Practice Management Plans, Team Care Arrangements and Reviews. Med J Aust, 199(4): 261–265.

Wang L, Li J, 2023, Challenges and Strategies of Chronic Disease Management for Rural Elderly in China. Chinese Journal of Public Health, 40(2): 45–51.

Liu X, Zhang Y, Chen Z, et al., 2024, Integrated Health Management for Special Elderly Groups: Focusing on Disabled and Solo-living Older Adults. Geriatrics & Gerontology International, 24(1): 10–20.

Jones KM, Dunning T, Costa B, et al., 2012, The CDM-Net Project: The Development, Implementation and Evaluation of a Broadband-Based Network for Managing Chronic Disease. Int J Family Med, 2012: 453450.

Australian Nursing and Midwifery Federation, 2025, Pulse Check of the Aged Care Sector: The Real Impact of Reforms, viewed October 28, 2025, https://anmj.org.au/pulse-check-of-the-aged-care-sector-the-real-impact-of-reforms/

The West Australian, n.d., Minister’s Warning to Aged-Care Providers Ahead of Changes, viewed October 28, 2025, https://thewest.com.au/politics/federal-politics/aged-care-sam-rae-warns-aged-care-providers-theyve-got-no-excuses-ahead-of-new-regime-kicking-off-c-20454117