Nursing Professional Team Community Diabetes Case Management
2018年南通市卫生和计划生育委员会科研课题（WKZL 2018016）；南通市2020年度基层卫生健康研究立项课题（2020JCC010）
目的：探讨医联体护理专业小组社区糖尿病个案管理模式效果。方法：组建护理专业小组社区糖尿病护理志愿服务队，每月随机选取医联体社区4~8名糖尿病患者接受6个月糖尿病个案管理干预和随访，观察干预效果。结果：109例社区糖尿病患者个案管理半年后空腹血糖、早餐后2小时血糖、焦虑抑郁、糖尿病依从性、药物依从性、糖尿病自护行为、糖尿病自我效能、糖尿病痛苦等指标均有改善，差异有统计学意义；患者生活质量评价8个维度提升13.27%~42.43%。结论：医联体护理专业小组行社区糖尿病个案管理模式可有效改善糖尿病患者血糖代谢及自我管理效果，带动社区护理人员糖尿病规范化管理，提高个案管理能力。
Objective：To observe the effect of community-based diabetes case management model by Medical Union nursing professional team. Methods：The members of the nursing professional team were selected to form a community diabetes care volunteer service team. Randomly select 4 to 8 diabetic patients from the medical consortium community every month to receive 6-month diabetes case management intervention and follow-up，then to observe the effect of the intervention. Results：The fasting blood glucose，2 hours blood glucose after breakfast，anxiety and depression，diabetes compliance，drugs compliance，diabetes self-care behavior，diabetes self-efficacy and diabetes pain were all improved after half a year of community diabetes case management，the difference was statistically significant；The eight dimensions of patients’quality of life evaluation were improved 13.27%~42.43%. Conclusion：The community-based diabetes case management model of hospital nursing team can effectively improve glycemic control in patients with diabetes，the self-management effect of diabetic patients and promote the case management ability of community nursing staff.