医疗服务共同体模式下专科护士为主导的社区糖尿病患者个案管理实践

Community case management practice of diabetes patients led by specialist nurses under the medical service community model

目的探讨以医疗服务共同体糖尿病专科护士为主导的管理团队在社区糖尿病个案管理中的成效。方法以医疗服务共同体专科护士为主导组建社区糖尿病个案管理团队,选取专科护士服务的3个社区糖尿病患者作为研究对象,通过抽签法分为实验组150例与对照组164例。对照组由家庭医生签约团队服务社区糖尿病患者,实验组在对照组基础上采取以专科护士为主导的社区个案管理方法,比较干预6个月后的效果。结果干预6个月后,实验组自我管理行为量表评分、医学应对评分、空腹血糖、总胆固醇、甘油三酯等指标均有改善,差异有统计学意义(P<0.01或P<0.05),血压指标改善不明显(P>0.05)。结论以医疗服务共同体专科护士为主导的个案管理团队,能有效提高糖尿病患者自我管理行为、提高医学应对能力、改善代谢指标,促进社区进行糖尿病规范化管理和提高个案管理能力。

Objective To explore the effectiveness of management team led by diabetes specialist nurses in the management of community diabetes patients in the medical community model.Methods A community diabetes case management team led by specialized nurses was established in the medical service community.A total of cases of diabetes patients from 3 communities who were served by specialist nurses were selected as the research object,and they were divided into an experimental group(n=150)and a control group(n=164).The control group was served by a team of family doctors for community diabetes.Based on the control group,the experimental group adopted the community case management method led by specialist nurses.The effects of the intervention were compared after 6 months.Results The Summary of Diabetes Self-Care Activities score,Medical Coping Modes Questionnaire score,fasting blood glucose,total cholesterol and triglyceride were all improved after 6 months of community diabetes case management,the difference were statistically significant(P<0.01 or P<0.05).Blood pressure was not improved(P>0.05).Conclusion The case management team led by specialized nurses in the medical service community model can effectively improve diabetic patients'self-management behavior,improve medical coping ability,improve metabolic indexes,promote standardized diabetes management in the community,and improve case management capability.