基于CCM模式的糖尿病移动健康管理平台的研发及应用  

Development and Application of Mobile Platform for Diabetes Healthcare Management Based on Chronic Care Model

作　　者：王莉[1] 付阿丹[1] 曾倩姣 丁胜[2] 付莎莉 易兰 唐莎 杨静 WANG Li;FU Adan;ZENG Qianjiao;DING Sheng;FU Shali;YI Lan;TANG Sha;YANG Jing(Department of Nursing,The Central Hospital of Wuhan,Affiliated to Tongji Medical College of Huazhong University of Science and Technology,Wuhan Hubei 430014,China;Department of Endocrinology,The Central Hospital of Wuhan,Affiliated to Tongji Medical College of Huazhong University of Science and Technology,Wuhan Hubei 430014,China)

机构地区：[1]华中科技大学同济医学院附属武汉中心医院护理部,湖北武汉430014 [2]华中科技大学同济医学院附属武汉中心医院内分泌科,湖北武汉430014

出　　处：《中国医疗设备》2023年第10期90-95,共6页China Medical Devices

基　　金：中华护理学会2021年立项科研课题(ZHKY202105);湖北省自然科学基金项目(2023AFC041);武汉市科技局知识创新专项项目(2023020201010188)。

摘　　要：目的 为实现院内规范、高效的血糖管理,构建基于慢性病管理模型(Chronic Care Model,CCM)模式的糖尿病移动健康管理平台,并评价其应用效果。方法 结合CCM模式六要素,明确关键指标,研发与院内各信息系统互联互通、涵盖九大功能的糖尿病移动健康管理平台,并启用以内分泌科室为主导的专业团队进行全院糖尿病患者的血糖管理。结果 平台上线后,共服务95个病区,纳入患者管理6217例、纳入管理比例95.46%、预警人数53790人次、胰岛素泵强化治疗324例、持续动态血糖监测400例。平台应用后,医护及患者对平台满意率较高(均达90%以上),且预警响应时间和处置单响应时间明显缩短(P<0.05)。结论 基于CCM模式的糖尿病移动健康管理平台实现了院内血糖管理的全天多点、持续、规范高效的血糖管理,为糖尿病健康管理提供新思路。Objective To develop a mobile healthcare management platform for diabetes based on the chronic care model(CCM)and evaluate its application effect,so as to achieve standardized and efficient blood glucose management in the hospital.Methods In combination with the six elements of CCM mode,the key indicators were identified,and a mobile health management platform for diabetes interlinked with various information systems in the hospital and covering nine functions was developed.A professional team led by the Endocrine Department was implemented to manage the blood glucose of diabetes patients in the hospital.Results After the launch of the platform,a total of 95 wards were served,with 6217 patients under management accounting for 95.46%,53790 times of early warning,324 patients receiving intensive insulin pump treatment,and 400 patients receiving continuous dynamic blood glucose monitoring.After the application of the platform,the satisfaction rate of nurses and patients with the platform was relatively high(both reaching over 90%),and the response time of early warning and disposal order was significantly shortened(P<0.05).Conclusion The mobile healthcare management platform for diabetes based on CCM mode has realized the continuous,standardized and efficient blood glucose management at multiple points throughout the day,provides new ideas for diabetes healthcare management.

关 键 词：慢性病管理模型 糖尿病 移动健康管理 血糖管理 

分 类 号：R197.324[医药卫生—卫生事业管理]