全-专联合模式下农村社区家庭医生对2型糖尿病优化管理的实践与评估

目的：探讨全-专联合模式下家庭医生对2型糖尿病优化管理的实践与效果评估。方法：在马陆镇实施全-专联合模式对社区2型糖尿病患者进行优化管理，评估全-专联合优化管理模式对入组患者管理前后的临床指标效果、区域医疗协作情况、家庭医生服务能力和患者满意度变化的情况。结果：在全-专联合模式下管理12个月后，患者临床管理效果提升显著，区域医疗协作机制建立，家庭医生服务能力明显提升，患者满意度明显提升。结论：全-专联合模式对社区2型糖尿病优化管理提升了慢性病管理质量，梳理明确了社区与三级医院之间的分级诊疗内容与秩序，推动了社区家庭医生制服务的发展，提升了社区卫生服务的内涵。

Practice and evaluation of the optimal management of type 2 diabetes by the family doctors under the family doctor-specialist federation pattern in the rural community

Objective:To discuss the practice and effective evaluation of the optimal management of type 2 diabetes by the family doctors under the family doctor-specialist federation pattern in the rural community. Methods:The family doctor-specialist federation pattern was carried out for the optimal management of type 2 diabetes in Malu Town, and under the family doctor-specialist federation pattern, the changes of the clinical indicators of the enrolled patients before and after the management, regional medical cooperation, family doctor service ability and the patients’ satisfaction were evaluated. Results:After one year of the management of the family doctor-specialist federation pattern, clinical management effect of patients was signiifcantly improved, the regional medical cooperation mechanism was established, the family doctor service capacity was obviously improved, and the patients’ satisfaction was significantly improved. Conclusion: The family doctor-specialist federation pattern for the optimal management of type 2 diabetes improves the quality of chronic disease management clearly, deifnes the contents and orders of the tiered medical service between the community and tertiary hospital, promotes the development of the community family doctor system service, and enhances the connotation of community health services.