糖尿病整合照護之概論

Introduction to Integrated Diabetes Care

林俐伶(Li-Ling Lin) ； 林秋菊(Chiu-Chu Lin)

《護理雜誌》 63卷5期 (2016/10) Pp. 115-120

https://doi.org/10.6224/JN.63.5.115

摘要

糖尿病的照護問題已被多數國家公認為重要的國安議題，除影響病人的身心健康外，醫療支出也相當可觀，未妥善解決甚至會動搖國本，因此歐美各國均積極發展整合照護模式，來協助糖尿病病人複雜的照護需求。實證研究顯示，糖尿病整合照護確實能有效減少併發症發生、提升病人的健康素養及降低醫療花費。利用整合照護的概念，讓病人在醫院療養時，能接受跨團隊、跨領域的整合照護，出院返回社區後，也能受到持續性的醫療服務，來達到疾病控制及預防的目的。目前，我國在糖尿病整合照護之相關論述較欠缺，故本文將針對糖尿病整合照護之概念，及進階護理師於整合照護模式中扮演的角色與職責進行介紹，期此引發健康專業人員有更寬廣之照護觀。

關鍵字

整合照護 ； 糖尿病管理 ； 進階護理師

並列摘要

Diabetes is a huge problem that has been recognized as an important healthcare issue by most national governments. Diabetes affects patients not only in terms of physical health but also in terms of mental health. Furthermore, the medical costs that are associated with diabetes are considerable. Many countries have developed integrated care models for the treatment of diabetes and pay particular attention to assisting patients that require complicated care. Evidence from empirical studies shows that the integrated care of diabetes reduces complications, increases patients' health literacy, and decreases medical costs. Accordingly, integrated care has been applied to the treatment and care of diabetes patients. In the integrated care model, patients not only receive multidisciplinary care during hospitalization but also receive medical services after their return to the community. There has been a dearth of scholarly discussions in Taiwan related to the integrated care of diabetes. Therefore, we present in this paper the concept of integrated diabetes care and the role of the advanced practice nurse (APN) in the multidisciplinary model. It is hoped that this introduction provides practical insights for healthcare professionals into the essence of integrated care.

並列關鍵字

integrated care ； diabetes management ； advanced practice nurse (APN)

參考文獻

郝立智、趙建剛、趙海倫、洪靜如、王瑞祥、吳達仁…馬彌嘉（2010）．某榮民醫院糖尿病患者代謝指標改善程度與認知行為關係之研究．中華民國糖尿病衛教協會會訊，6（3），11–20。[Hao, L. Z., Zhao, J. G., Zhao, H. L., Hong, J. R., Wang, R. X., Wu, T. R., ... Ma, M. J. (2010). The relationship between metabolic outcome and cognitive behavior in a patient with diabetes: An example from a veterans general hospital in Taiwan. Newsletter of the Taiwanese Association of Diabetes Educators, 6(3), 11–20.] doi:10.6583/TADE.2010.6(3).5

陳惠姿（2007）．整合性照顧系統．護理雜誌，54（5），5–10。[Chen, H. T. (2007). Integrated care systems. The Journal of Nursing, 54(5), 5–10.] doi:10.6224/JN.54.5.5

蔡姈砡、林秋菊（2015）．運用共享決策於一位腎癌病併皮下轉移病人之照護經驗．護理雜誌，62（3），89–94。[Tsai, L. Y., & Lin, C. C. (2015). Using shared decision-making on a patient with renal cell carcinoma and subcutaneous metastasis: A care experience. The Journal of Nursing, 62(3), 89–94.] doi:10.6224/JN.62.3.89

譚建民（2011）．2011年美國糖尿病協會（ADA）糖尿病診療標準指引摘要．臺灣醫界，54（3），128–136。[Tan, J. M. (2011). The abstracted standards of diabetes care—ADA (2011 version). Taiwan Medical Journal, 54(3), 128–136.]

American Diabetes Association. (2015). Standards of medical care in diabetes—2015. Diabetes Care: The Journal of Clinical and Applied Research and Education, 38(1, Suppl.), S1–S93. Retrieved from http://www.slideshare.net/UtaiSukviwatsirikul/standards-of-medical-care-in-diabetes-2015