臺北市立聯合醫院的糖尿病整合照護之成效

The Outcomes of Integrated Diabetic Care Service in Taipei City Hospital

劉聿芬(Yu-Fen Liu) ； 陳盈均(Ying-Chun Chen) ； 翁林仲(Lin-Chung Woung) ； 廖國盟(Kuo-Meng Liao) ； 葉豪(Hao Yeh) ； 鄭筆聳(Pi-Sung Cheng) ； 侯冠廷(Kuan-Ting Hou) ； 張家萍(Chia-Ping Chang) ； 陳春森(Chung-Sen Chen)

《北市醫學雜誌》 16卷附冊 (2019/10) Pp. 1-9

https://doi.org/10.6200/TCMJ.201910/SP_16.0001

摘要

目的：糖尿病管理及整合性照護等措施是有效協助糖尿病照護的解決方案，有效且持續的疾病管理計畫可以改善患者的健康狀況並節省醫療成本。我們開發以患者為中心的照護方式，評估措施對照護品質的影響。方法：以標竿院區為首，橫向整合六大院區的糖尿病衛教中心，並使用六種策略：簡化流程採取一站式照護，全面性併發症篩檢，線上醫病互動諮詢，強化資訊系統開發品質管理監測系統，多專科整合照護的整合性門診，強化醫病關係的感動服務。結果：2016到2018年，過程指標的糖尿病照護率從75.6%到81.5%，結果指標之HbA1c良率從50.3%到56%，照護過程與結果兩者品質高於國家平均值。結論：我們的策略確實改善了糖尿病照護過程與照護品質，也促進各院區之照護品質一致化與提升，也獲得更多的品質獎勵與認證。

關鍵字

糖尿病併發症 ； 整合照護 ； 糖尿病 ； 慢性病

並列摘要

Objective: Diabetes management and integrated care is a solution that effectively helps diabetes care. An effective and persistent disease management plan can improve patient health and save medical costs. We developed a patient-centered care system and assessed its influences on care quality. Methods: Leaded by the Zhongxiao branch of the Taipei City hospital, the system integrated diabetes care centers of the six hospital branches in the different areas, horizontally by using six strategies: one-stop service to simplify the management workflow processes, comprehensive complications screening, online interactive consulting instructions, strengthened medical information system and development quality monitoring system, integrated clinic with multidisciplinary integrated care, and enhanced service of touched care for doctor-patient relationship. Results: The diabetes care rate increased from 75.6% in 2016 to 81.5% in 2018. During the same period, the ideal level of HbA1c (less than 7.0%) increased from 50.3% to 56%, indicating that the quality of process outcome and result were higher than average of national means.Conclusion: Our Integrated Diabetic Care System approach improved the process outcome and quality of care and elevated the care quality and consistency across branches. As a result, we attained even more quality awards and certifications.

並列關鍵字

diabetic complications of management ； integrated care coordination ； diabetes mellitus ； chronic disease