| Object:Construct a scientific and standardized diabetes continuation care plan with mobile medical App as the medium,in order to provide patients with comprehensive,professional,continuous and personalized continuation care services and promote patient recovery.Methods:The programme framework was initially developed through a literature review.Using a combination of qualitative and quantitative research methods,we conducted semi-structured interviews with 12 hospitals and community managers to understand the current status of diabetes linkage management,work content,team member composition,division of responsibilities,personnel access standards,training requirements,and the operation process of managing diabetes by App.A questionnaire survey was conducted on 268 diabetic patients through convenience sampling,to understand the needs of patients for the content,method,and time of diabetic continuation care,as well as the needs of using diabetes App for disease management.At the same time,15 patients were interviewed semi-structured.In-depth exploration of patients’ individual needs for continued nursing services and App management functions,supplementing the deficiencies of qualitative research.Improve the key links and measures of continued care,and initially build a continuous care plan for diabetic patients based on the linkage of the App "hospital-community-family".Two rounds of Delphi method were used to evaluate the plan,and the consultation results were revised and improved through the positive coefficient,authority coefficient,coefficient of variation,coordination coefficient and other indicators of expert consultation,and the final continued nursing plan was formed.Results:1.The medical and nursing interviews distilled six themes:(1)clarify the division of staff responsibilities;(2)set up extended care teams;(3)strengthen relevant training;(4)provide individualised services in response to patients’ needs;(5)build a simple,practical and functional information platform;(6)establish a complete discharge plan.2.The score of patients’ need for diabetes care(4.00±0.57)is higher than that of complication care(3.74±0.72)and health promotion(3.63±0.81).There is a high demand for health education on disease-related knowledge,regular inspections of various indicators,prevention and nursing guidance for diabetic eye disease,healthy behavior and lifestyle guidance,etc.(95.9%～81.0%);high demand for outpatient review Follow up by phone and online(74.63%,62.31%,49.63%);55.60% of patients want to carry out diabetes special activities and are willing to use the App to manage their condition;hope that the App has medication reminders,blood glucose monitoring,follow-up time,and provides diabetes-related knowledge and information,Online consultation,record related inspection indicators,provide personalized suggestions and other functions(89.93%～51.49%).Patients’ interviews distilled five themes:(1)hope to accept the "hospital-community-family" linkage model of extended care services;(2)hope to provide convenient,diverse and personalized access to information and follow-up;(3)expect to receive continuous,comprehensive and specialized health guidance;(4)expect to accept the hospital nurse-led,multidisciplinary team management of extended care services;(5)expect diabetes App easy and practical,to meet the needs of post-discharge monitoring,evaluation feedback,health education,health intervention care,to protect personal privacy,and free to use.3.The positive coefficients of experts in the two rounds of correspondence were 95.24% and 100%,respectively,and the authority coefficient of experts was 0.88.Finally,22 primary entries such as lead unit,linkage unit,staff composition,division of responsibilities,and nursing staff admission criteria,95 secondary entries such as education,title,and years of specialty work,and 106 tertiary entries such as diabetes specialist nurses,endocrinologists,and ophthalmologists and nurses were screened.The coefficients of expert opinion coordination were 0.412,0.386,and 0.389,respectively,and all were statistically significant(P < 0.01)as suggested by statistical hypothesis testing.The final establishment plan consists of four parts:(1)The organizational structure of diabetes continuation care(including 4first-level items and 10 second-level items);(2)Establishing a multidisciplinary team led by diabetes specialist nurses(including 3 first-level items,25 items)Second-level items,52 third-level items);(3)Carrying out special training for nurses to homogeneity(including 6 first-level items and 30 second-level items);(4)Continuing care of diabetic patients based on the linkage of App "hospital-community-family" Run the program(including 9 first-level items,30 second-level items,and 54 third-level items).Conclusion:1.Being guided by the actual needs of patients is the prerequisite for providing personalized continuous care services.Patients have high demand for convenient and personalized information access and follow-up methods,professional health guidance,hospital-community-family support,and multidisciplinary team management.They have a strong willingness to use the App while looking forward to its simplicity Practical,complete functions,to meet its individual needs.2.This continuous nursing care of diabetic patients is constructed based on the development status,existing problems of diabetes continuation care,and the actual needs of patients.Experts have demonstrated that this plan is scientific and feasible,including "diabetes continuation care organization structure" and "establishing a multidisciplinary team led by diabetes specialist nurses","developing nurses’ homogenization special training","App hospital-community-family linkage-based diabetic patients continued nursing operation procedures".It can provide guidance for the standard implementation of post-diabetes continuous care. |
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