運用個案管理模式提升糖尿病病患自我照顧能力之專案

Applying a Case Management Model to Improve Self-care Ability for Diabetic Patients

本專案旨在改善糖尿病病患之個案管理後，除了提升收案率外，更改善病患的自我照顧能力與臨床檢驗值，有助於增進照護品質與降低醫療成本。改善前接受本院糖尿病個案管理收案率僅達73.9%，且透過問卷發現未收案管理之糖尿病病患之自我照護能力得分達80分者僅27.9%，分析原因發現：病患自我照護認知不足、缺乏後續追蹤管理、病患拒絕收案管理、缺乏資訊提示系統。針對以上原因並運用個案管理模式提出解決辦法：1.增加診間外衛教掛圖2.製作多媒體衛教影片3.製作已收案病患經驗分享影片4.新增電腦提示系統5.新增檢驗值異常警示系統6.訂定血糖值異常病患治療目標7.新增個案管理監測系統。結果發現病患收案率提升為91.2％，自我照護能力得分達80分者提昇至61.2%，同時亦改善病患的收案率及臨床檢驗值，顯示專案措施之介入有顯著成效。

The aims of this project were to increase the participation rate in case management and to improve the self-care ability as well as values of clinical diagnostic tests for patients with diabetes, consequently improving quality of care and reducing health care costs. Before the implementation of this project, only 73.9% of the patients were involved in case management. It was found that only 27.9% of the excluded cases achieved more than 80 points through questionnaires. By means of analysis, the possible reasons to explain why the excluded cases got such low scores could be the lack of self-care cognition, a lack of follow-up management, unwillingness of the patient to participate in case management, and the lack of the reminder system for recruiting participants. The following approaches based on case-management models were presented to solve these problems: 1) Increasing use of health education charts outside the clinic; 2) Creating multimedia health education videos; 3) Making the patient experience shared videos; 4) Setting up computerized reminder systems; 5) Setting a warning system for patient’s values of clinical diagnostic tests; 6) Setting up treatment goals for the patient with abnormal blood glucose; and 7) Setting up a monitoring system for case management. The authors conducted the case-management model and found that 91.2% of the patients with diabetes in the hospital were involved in case management and 61.2% of the excluded cases achieved more than 80 points after this intervention. Furthermore, project participation rate and the values of clinical diagnostic tests for the patients were improved. As a result, the implementation effectiveness of this project for improving self-care ability and follow-up efficiency of diabetic patient was validated.