【摘要】 目的 ：评价三级甲等医院护士坐诊社区卫生服务中心的慢性病管理实践效果，为促进优质护理资源下沉提供借鉴和参考。方法 ：合肥市某三级甲等医院选拔护士到医联体单位的4个社区服务中心，实施“1+1+1+N”管理团队的慢性病管理服务模式并开设专科护理门诊，对高血压、糖尿病、脑卒中3类慢性病患者进行规范管理。以开设专科护理门诊后第1次建档的513例患者为研究对象，比较实施前后患者的血压、血糖控制情况，生活质量，自我管理行为，自我效能和患者满意度。结果 ：三级甲等医院护士坐诊社区卫生服务中心后，患者的血压、血糖控制率，生活质量，自我管理行为，自我效能和满意度优于坐诊前，差异均有统计学意义（P<0.05）。结论 ：三级甲等医院护士坐诊社区服务中心的慢性病管理实践能够提高慢性病患者的管理质量，提高其生活质量和自我效能。更多还原

【Abstract】 Objective: To evaluate the effectiveness of chronic disease management with tertiary grade A hospital nurses providing service at community health service centers, so as to provide reference for promoting the sinking of high-quality nursing resources. Methods: A tertiary grade A hospital in Hefei selected nurses to work in four community service centers affiliated with a medical consortium. A "1+1+1+N" management team model was implemented for chronic disease management, and specialist nursing clinics were opened to standardize the management of patients with hypertension,diabetes and stroke. Totally 513 patients who were first filed after the opening of specialist nursing clinics were selected,and the blood pressure control, blood glucose control, quality of life, self-management behavior, self-efficacy and patient satisfaction rates were compared before and after the implementation. Results: After the involvement of tertiary grade A hospital nurses, improvements were observed in blood pressure and blood glucose control rates, quality of life, self-management behaviors, self-efficacy and patient satisfaction, the differences were statistically significant(all P<0.05). Conclusion: The practice of tertiary grade A hospital nurses providing chronic disease management service in community health service centers can enhance the quality of chronic disease management, improve patients’ quality of life and self-efficacy.更多还原