Exploration of continuous nursing services in outpatient chronic disease management practice
延续性护理服务在门诊慢病管理中的实践探索

摘要

目的 探索延续性护理服务在门诊慢病管理中的应用模式，评估其对患者疾病控制、自我管理能力及就医体验的影响，为优化门诊慢病管理体系提供科学依据。方法 采用前瞻性随机对照研究，选取2023年1月-2024年12月于我院门诊就诊的100例慢病患者，随机分为对照组（50例）与实验组（50例）。对照组接受常规门诊诊疗服务，实验组在常规诊疗基础上，构建基于“互联网+多学科协作”的延续性护理服务模式。结果 实验组患者疾病指标控制率（86.0%）显著高于对照组（62.0%）（P<0.01）；自我管理能力评分（82.5±6.3）分高于对照组（68.2±5.8）分（P<0.001）；患者满意度（94.0%）显著高于对照组（72.0%）（P<0.001）。结论 延续性护理服务通过整合线上线下资源，实现了门诊慢病管理从碎片化诊疗向全程化照护的转变，有效提升患者疾病控制水平与自我管理能力，显著改善就医体验。

Abstract

Objective To explore the application mode of continuity of care services in outpatient chronic disease management, evaluate its impact on patients' disease control, self-management ability, and medical experience, and provide scientific basis for optimizing the outpatient chronic disease management system.
Methods A prospective randomized controlled study was conducted, selecting 100 chronic disease patients who visited our outpatient department from January 2023 to December 2024.They were randomly divided into a control group(50 cases)and an experimental group(50 cases).The control group received routine outpatient diagnosis and treatment services, while the experimental group built a continuous nursing service model based on "Internet plus multidisciplinary cooperation" on the basis of routine diagnosis and treatment.
Results The control rate of disease indicators in the experimental group(86.0%)was significantly higher than that in the control group(62.0%) (P<0.01); The self-management ability score(82.5±6.3)was higher than that of the control group (68.2±5.8) (P<0.001); Patient satisfaction (94.0%) was significantly higher than that of the control group (72.0%) (P<0.001).
Conclusion   Continuity of care services have achieved the transformation of outpatient chronic disease management from fragmented diagnosis and treatment to full process care by integrating online and offline resources, effectively improving patients' disease control level and self-management ability, and significantly improving the medical experience.