关键词: 慢性病管理；三级甲等医院；护士；社区；护理门诊

Abstract: Objective: To evaluate the effectiveness of chronic disease management with tertiary grade A hospital nurses providing service at community health service centers, so as to provide reference for promoting the sinking of high-quality nursing resources. Methods: A tertiary grade A hospital in Hefei selected nurses to work in four community service centers affiliated with a medical consortium. A "1+1+1+N" management team model was implemented for chronic disease management, and specialist nursing clinics were opened to standardize the management of patients with hypertension, diabetes and stroke. Totally 513 patients who were first filed after the opening of specialist nursing clinics were selected, and the blood pressure control, blood glucose control, quality of life, self-management behavior, self-efficacy and patient satisfaction rates were compared before and after the implementation. Results: After the involvement of tertiary grade A hospital nurses, improvements were observed in blood pressure and blood glucose control rates, quality of life, self-management behaviors, self-efficacy and patient satisfaction, the differences were statistically significant (all P<0.05). Conclusion: The practice of tertiary grade A hospital nurses providing chronic disease management service in community health service centers can enhance the quality of chronic disease management, improve patients' quality of life and self-efficacy.

Key words: chronic disease management; tertiary grade A hospital; nurse; community; nurse-led clinics