糖尿病個案管理

Diabetes Case Management

糖尿病個案管理及自我照護教育能有效改善病人臨床結果及生活品質。糖尿病個案管理應由一個跨專業團隊提供。糖尿病教育已經從以「教導正確內容」為導向轉變成現在以「病人結果」為導向，現在的衛教強調以病人為中心的目標，依據此目標來促進行為改變，經由行為改變達到成功的自我照護已經成為糖尿病個案管理的理想結果之一。美國糖尿病衛教師學會發展出七項糖尿病自我照護行為可以作為糖尿病教育的行為目標及評價指標。這七項行為是健康飲食、身體活動、監測、使用藥物、問題解決、壓力調適及減少風險。糖尿病個案管理的流程包括評估、訂定預期結果、計劃、執行、評值、紀錄。在臺灣，糖尿病共同照護網全面推動糖尿病個案管理，全民健保糖尿病醫療服務改善方案試辦計畫在此基礎上提供包裹式給付，要求優質的跨專業照護及個案管理。

Diabetes case management and self-care education can effectively improve patient clinical outcomes and quality of life. Diabetes case management should be provided by an interdisciplinary team. Diabetes education has evolved from its previous focus on ”teaching proper content” to ”achieving successful patient outcomes” in line with the current emphasis in health education on patient-centered goals. Behavioral changes are facilitated based on these goals. Behavioral change directed at successful diabetes self-care was adopted as one of the desired outcomes of diabetes case management. The American Association of Diabetes Educators developed seven diabetes self-care behaviors as behavior objectives and evaluation indicators of diabetes education. These indicators include healthy eating, being active, monitoring, taking medication, problem solving, healthy coping, and reducing risks. The process of diabetes case management includes assessment, expected outcome identification, planning, implementation, evaluation, and documentation. In Taiwan, the Diabetes Share Care Network has promoted the advantages and techniques of diabetes case management. Based on network recommendations, the improvement program of National Health Insurance payment for diabetes medical treatment under the Bureau of National Health Insurance now provides package payment and requires quality interdisciplinary care and case management.