以人為中心第二型糖尿病個案六層全人照護圈

Holistic Person-Centered Care for Individuals With Type 2 Diabetes Mellitus

2022年美國糖尿病學會（American Diabetes Association）及歐洲糖尿病研究學會（European Association for the Study of Diabetes）強調第二型糖尿病照護是以人為中心（person centered）之全人照護概念，本文綜合整理第二型糖尿病照護相關文獻，提出「第二型糖尿病個人六層全人照護圈」的模式。此模式將第二型糖尿病個人處於照護核心，除考量到其需求、偏好及價值觀，並以六層照護圈為基礎，以達到優化個案生活品質並避免及延緩併發症產生的總體照顧目標。第一層強調照護提供者須列入家庭與社區。第二層為在照護團隊須為多專業、跨科別的醫療團隊照護，透過資訊平台溝通形成在個案照護過程中的後盾。第三層強調在照護上仍須透過合併症的監控及篩檢、健康行為修正、監測及持續評估、減少低血糖風險、有效的實踐及照護組織、考量潛在的生理狀況、避免治療惰性、考量健康的社會決定因素、心理因素、糖尿病結構化的教育、語言方式、共享決策及考量區域內醫療機構及相關資源等十三項原則的運用。第四層則強調運用照護決策循環原則，持續性、動態性的進行個案管理。第五層強調照護網絡的整合，根據個人終生的健康需求適當轉介醫院、長期照護或基層診所／醫療群，以達到良好的照護。第六層則強調健康照護系統的建置須基於慢性病照護模式中的社區資源及政策、健康照護系統組織、自我管理支持、設計傳輸系統、臨床資訊系統以及決策資源的有效性整合，以建立支持性的健康照護系統，達到以人為中心的預防併發症及優化生活品質的核心目標。希望此模式可做為台灣地區未來在規畫第二型糖尿病健康照護體系的參考。

In 2022, the American Diabetes Association and the European Association for the Study of Diabetes emphasized that type 2 diabetes care is a person-centered holistic care concept. This article summarizes the concepts of holistic care for individuals with type 2 diabetes and proposes a complete model of the six-layer whole-person care circle for individuals with type 2 diabetes. This model treats individuals with type 2 diabetes as the core of care and adopts their specific needs, preferences, and values to design individualized care plans. The overall goal of care is to maintain quality of life and to avoid or delay complications. Management methods must be holistic. Based on people and comprehensive considerations, six circles of care are listed. The first layer is caregivers, taking into account the influence of the family and the community on the individual. The second layer is multiprofessional and multi-disciplinary team care, which provides support to individuals with diabetes. The third layer emphasizes the need for the following thirteen principles in diabetes care: monitoring and screening for complications, behavior modification for healthy habits, monitoring and continuous assessment, reducing the risk of hypoglycemia, effective implementation and care organization, considering underlying physiological conditions, avoiding therapeutic inertia, considering social determinants of health, psychological factors, structured diabetes education, language proficiency, shared decision-making, and considering regional healthcare institutions and related resources. The fourth layer is the decision cycle of care, which applies the principles of care and conducts continuous and dynamic case management based on the decision cycle. The fifth layer is the healthcare network through which health providers provide hospital, long-term care, and primary clinics/ primary network care referrals based on the needs of individual with diabetes. The sixth layer leverages the chronic care model to construct a supportive healthcare system comprising organizational support, clinical information systems, delivery system design, decision support, self-management support, and community resources. This proposed model may provide a reference for constructing healthcare systems to care for patients with type 2 diabetes.