提升糖尿病及初期慢性腎臟病照護整合率

Improve the Integration Rate of Diabetes and Early Chronic Kidney Disease Care

糖尿病腎病變(Diabetic Kidney Disease, DKD)是糖尿病病人常見併發症，故健保署於2022年推動「糖尿病及初期慢性腎臟病照護整合方案」，以延緩疾病進入末期腎病變。本院初期推動成效不佳，分析原因為無DKD個案管理系統、檢驗項目不符合DKD照護整合(健保新制)申報規範、醫護人員認知不足、疾病衛教師業務未整合與政策無監督機制。解決方案包括DKD照護整合政策宣導、疾病衛教師業務重整、制定DKD檢驗套餐、品質指標列入院層級會議追蹤與優化糖尿病個管作業系統。專案實施後，DKD照護整合率由改善前19.3%提升至85.4%，成效顯著，建議醫院未來投注更多資訊科技輔助，提升工作效能，落實以病人為中心的整合照護。

Diabetic Kidney Disease (DKD) is a common complication among diabetic patients. In 2022, the Health Insurance Administration initiated the ''Integrated Care Program for Diabetes and Early Chronic Kidney Disease'' to delay the progression of the disease to end-stage renal disease. Initially, our hospital's implementation was ineffective, attributed to the lack of a DKD case management system, insufficient laboratory tests, inadequate healthcare staff’s awareness, uncoordinated disease education efforts, and the absence of a supervisory mechanism for policies. Solutions included promoting DKD care integration policies, restructuring disease education tasks, establishing DKD test packages, incorporating quality indicators into hospital-level meetings for tracking, and optimizing diabetes management systems. Following project implementation, the integration rate of DKD care improved significantly from 19.3% to 85.4%. It is recommended that hospitals invest more in information technology to enhance operational efficiency and implement patient-centered integrated care practices.