医联体模式下团队服务在社区糖尿病管理中的实践探索  

Practice and Exploration of Team Service in Community Diabetes Management under the Medical Consortium Model

作　　者：桑圣梅[1] 缪慧英 徐赟 赵丽华[1] SANG Shengmei;MIAO Huiying;XU Yun;ZHAO Lihua(Internal Medicine Department,Nantong First People’s Hospital,Nantong,Jiangsu,226001)

机构地区：[1]南通市第一人民医院内科,江苏南通226001

出　　处：《江苏卫生事业管理》2022年第11期1569-1572,共4页Jiangsu Health System Management

基　　金：南通市卫生健康委员会科研课题(MB2021012);南通市卫生健康委员会基层课题(2020JCC010)。

摘　　要：目的:探索医联体模式下,在社区糖尿病管理中实施团队服务并分析其成效。方法:选取2021年1月~2021年5月社区糖尿病患者120例,随机分为2组,每组各60例。对照组实施常规管理,观察组实施医联体团队服务联合分层管理。三级医院选派医疗护理专家驻点帮扶指导,对基层医疗机构人员开展系列培训。比较两组患者血糖控制水平、患者满意度、规范用药依从性。结果:观察组患者空腹血糖和餐后2 h血糖控制优于对照组;患者满意度和规范用药依从性高于对照组,差异均有统计学意义(P<0.05)。结论:医联体模式下社区糖尿病患者管理实施团队服务,可有效改善患者血糖水平,增加规范用药依从性,提高患者满意度。依托医联体提高基层社区慢病管理能力,为患者提供规范、连续、多元化、多层次医疗服务,对实现全程健康服务和健康保障,应用效果显著。Objective:To explore the implementation and analysis of team services in community diabetes management under the medical consortium model.Methods:A total of 120 community diabetes patients from January 2021 to May 2021 were randomly divid⁃ed into 2 groups of 60 patients in each group.The control group was under routine management,and the observation group was under joint hierarchical management.The tertiaryhospitals send medical and nursingexperts to help and guide them,and carry out series of training for the staff of the basic-level medical institutions.The level of blood glucose control,patient satisfaction and compliance of standardized medication were compared between the two groups.Results:The fasting blood glucose and 2h after meal blood glucose control rate of the observation group exceeded the control group.Patient satisfaction and compliance with standardized medication were higher than those in the control group,which was significant(P<0.05).Conclusion:The team serving the management of diabetes pa⁃tients in the community under the medical consortium mode can effectively regulate patients’blood sugar level,increase standardized medication compliance,and improve patient satisfaction.Relying on the medical consortium to improve the ability of chronic disease management in the grassroots community,and to provide standardized,continuous,diversified and multi-level medical services for pa⁃tients,which has a significant application effect on realizing the whole-process health services and health security.The application ef⁃fect is remarkable.

关 键 词：医联体 团队服务 糖尿病管理 社区 

分 类 号：R197.32[医药卫生—卫生事业管理]