With the development of China’s aging,pension is the main concern of the whole society.In institutional pension,the care of the elderly is relatively old and faces multiple problems of physical,psychological,social and spiritual dimensions,which leads to their demand for services.More diverse and complex,to meet the multi-level needs of severe care for the elderly,relying only on the vertical services of the division of labor in various departments,can not meet the needs of multiple services,so it is necessary to establish a wider connection and integration between various departments within the pension institutions Establish a comprehensive assessment and overall plan to optimize care.This paper firstly reviews the relevant empirical research on the integrated care service model through literature review,and combines practical experience to establish a case-based integrated care research team to develop a model process suitable for severe care for the elderly.Through the medical,medical care,life care,rehabilitation,social work,business six-sector interdisciplinary case management services to intervene in the care of the elderly integrated care.Pre-and post-testing was conducted on the SF-36 Concise Health Status Scale to examine the practical effects of case-based integrated care services.Through the practice of integrated care service model from the perspective of case management,a case management team with serious care for the elderly and facing the needs of the elderly has been formed.An integrated service model of multi-sector cooperation has been established,which has effectively improved team communication and improved in-hospital care.The quality of service;the improvement and improvement of the elderly on the physical,psychological,social and spiritual levels,and the overall quality of life of the elderly who care for the elderly.The practice of service model also provides suggestions for reflection on case-based integrated care services,which will facilitate further exploration in long-term service models. |