关键词: 专科护士；社区护理门诊； 三级医院；慢性病

Abstract: Objective: To analyze the effects of setting up chronic diseases nursing clinic in community health centers by specialist nurses from tertiary hospital. Methods: Established hypertension and diabetes nursing clinic in community health center, and established the working system for community chronic disease nursing clinic. The general working indicators of the community chronic disease nursing clinic from September 2017 to February 2018, and the outcomes of patients with hypertension and diabetes after 3 and 6 months of the intervention were collected. Results: There were 86 and 95 patients signed up for hypertension and diabetes nursing care clinic, respectively. After 3 months and 6 months of intervention, the achieved rate of the main indicators for hypertension management was 70.93% and 87.20% respectively, and 23.15% and 40.00% for diabetes respectively. Conclusion: Setting up chronic disease nursing clinic in community health centers is benefit to improve the chronic disease management level, the implementation of tiered medical consultation system and the patients' satisfaction. In the future, policy supports and scientific management system are needed for the long-term implementation of the community chronic disease nursing clinic.

Key words: specialist nurses; community nursing clinic; tertiary hospital; chronic disease