基于家庭医生签约服务的专科护士跟踪式个案管理对社区居家T2DM患者的影响  

Effect of follow-up case management of specialist nurses based on family doctor contract service on community home T2DM patients

作　　者：徐祁新 钟嘉炜 林瑞钦 XU Qixin;ZHONG Jiawei;LIN Ruiqin(Outpatient Department of General Practice,Panyu District Shiqi Town Community Health Service Center,Guangzhou,Guangdong 510000,China)

机构地区：[1]番禺区石碁镇社区卫生服务中心全科门诊,广东广州510000

出　　处：《医药前沿》2025年第5期117-120,共4页Journal of Frontiers of Medicine

摘　　要：目的观察基于家庭医生签约服务的专科护士跟踪式个案管理对社区居家2型糖尿病患者(T2DM)的影响。方法选取2023年9月—2024年2月在番禺区石碁镇社区卫生服务中心接受糖尿病随访的40例居家T2DM患者。其中,2023年9—11月随访的20例居家T2DM患者纳入对照组;2023年12月开始全面实施基于家庭医生签约服务的专科护士跟踪式个案管理,将2023年12月—2024年2月随访的20例居家T2DM患者纳入个案管理组。比较两组患者的自我管理能力和空腹血糖水平。结果干预后,个案管理组自我管理行为各维度评分均高于对照组(P<0.05);个案管理组空腹血糖水平低于对照组(P<0.05)。结论基于家庭医生签约服务的专科护士跟踪式个案管理可提高居家T2DM患者的自我管理能力,降低其空腹血糖水平。Objective To observe the effect of follow-up case management of specialist nurses based on family doctor contract service on community home diabetes mellitus type 2(T2DM)patients.Methods A total of 40 community home T2DM patients who received diabetes follow-up in Panyu District Shiqi Town Community Health Service Center from September 2023 to February 2024 were selected.Among them,20 patients who were followed up from September to November 2023 were included in the control group;in December 2023,the full implementation of follow-up case management of specialist nurses based on family doctor contract service began,and 20 patients who were followed up from December 2023 to February 2024 were included in the case management group.The self-management ability and fasting blood glucose level of the two groups before and after intervention were compared.Results After intervention,the scores of each dimension of self-management behavior score in the case management group were higher than those in the control group,and the differences were statistically significant(P<0.05);the fasting blood glucose level in the case management group was lower than that in the control group(P<0.05).Conclusions Follow-up case management of specialist nurses based on family doctor contract service can improve the self-management ability of community home T2DM patients and reduce their fasting blood glucose level.

关 键 词：2型糖尿病 专科护士 家庭医生签约服务 跟踪式个案管理 社区 空腹血糖 

分 类 号：R473[医药卫生—护理学]