医院社区一体化管理流程在糖尿病患者治疗中的应用研究

tudy for the application of hospital community integrated management processes for diabetes patients

目的评价糖尿病医院社区一体化管理流程的推广应用效果。方法利用糖尿病健康网络教育平台将已出院的100例糖尿病患者的资料转交给社区卫生服务人员,由社区医务人员进行连续性的管理,当社区的病人出现急性并发症或应急情况也可通过该网络反馈到医院,从而达到医院与社区资源的共享。评估患者教育前糖尿病知识的知晓率、治疗控制的达标率及干预后2年糖尿病知识的知晓率、治疗控制的达标率。结果实施医院社区一体化管理后患者对糖尿病的知识知晓率明显提高(P<0.01),患者治疗控制达标率显著提高(P<0.01)。结论糖尿病医院社区一体化管理流程,使社区糖尿病防治系统化和规范化,提高糖尿病的防治水平,改善糖尿病患者对糖尿病知识的知晓率和治疗控制达标率。

Objective To evaluation the effect of hospital community integrated management processes for diabetes patients.Method Diabetes health network education platform was used for 100discharged diabetic patients with information to community health service personnel,from community medical personnel for continuity of management,when the community of patients with acute complications or emergency situation can also be accessed via the network feedback to hospitals,so as to achieve the hospital and community resource sharing.Patients education prediabetic knowledge of awareness,treatment and control of compliance rate and intervention after 2years of diabetes knowledge of awareness was evaluated before and after the study.Result The implementation of the integrated management of the hospital community on diabetes patients after treatment was significant（P0.01）.Conclusion Diabetic hospital community integrated management processes will improve the Community system standardization and to improve diabetes level,improve diabetic patients to diabetes awareness and knowledge of the treatment control compliance rate.