关键词: 糖尿病；个案管理；个案管理师；护理工作室；专科护理门诊

Abstract: Objective: To construct a case management studio for diabetes and evaluate its effects in order to provide reference for advanced nursing practice in diabetes management. Methods: The case management studio is led by a specialist nurse in diabetes. Multidisciplinary professionals are included in the studio. The hospital provides supports from the aspects of policy, setting and equipment, talent training and information construction. The team members work together to develop the rules and regulations, service contents and process, case management program, and quality evaluation index system. The studio aimed to provide patients with systematic and professional care to paitents with diabetes. Besides, the talent cultivation schedule and research plan are also developed. Results: For two years since the studio established, the number of outpatients increased by 28.3%, the number of cases receiving care from the studio increased by 47.4%, and the number of patients serviced increased by 29.0%. A total of 621 individual management files have been established, and the detection rate of HbA1c and the good control rate of HbA1c have been significantly increased. The defective rate of HbA1c control has been significantly decreased, and the satisfaction level with medical service has been increased (P<0.05). Diabetes case managers have been cultivated for the hospital, medical consortium community and all provinces and cities across the country. The teaching achievements and academic research output have been improved based on the data from the studio. Conclusion: The case management studio for diabetes can meet the needs of patients with diabetes and effectively improve the medical quality and satisfaction of patients. It is conducive to the cultivation of advanced practice nurse and the development of academic research. It can promote the nursing disciplines development, and provide a new direction for the career development of nursing staff. The studio is worth of promotion in diabetes management.

Key words: diabetes mellitus; case management; case manager; nursing studio; nurse-led clinic