关键词: 高年资护士;糖尿病;社区;医联体

Abstract: Objective: To evaluate the effect of arranging senior nurses from tertiary hospital in communities and their suitable roles to serve in health alliance. Methods: Based on the platform of innovative health alliance of Anhui medical reform office, the effect of senior nurses' work was evaluated in the process of the management of "three people and four diseases" in the community. Individualized interventions were implemented by senior diabetes nurse in the community nursing clinic, and integrated care mode of diabetes "treatment-care, three sections, four linkage and five circles combination" was established. Home visits were provided by senior nurses together with the family doctor team. And the patients' satisfaction, fasting glucose, and senior nurse's self-value experience were compared before and after the intervention 3 months later. Results: Patients' satisfaction, fasting glucose, and senior nurse's self-value experience were significantly improved after intervention. Conclusion: Arranging senior nurses to serve in communities is worth considering in hierarchical diagnosis system and developing the community nurse practitioner.

Key words: senior nurse; diabetes mellitus; community; health alliance