Clinical follow-up study on diabetes patients participating in a health management plan.

Abstract

The "Health Management Plan"(HMP) for caring diabetic patient was begun by the National Health Insurance (NHI) in Taiwan in order to maximize the effectiveness of limited medical resources. This study describes the clinical experience of the nurse-directed diabetic HMP program and analyzes factors associated with the outcome. One hundred and thirty-six patients, all of whom had participated in the diabetic HMP program at least 5 times, were enrolled in the study. The effect of the HMP was evaluated by comparing hemoglobin A1C status before and after %) maintained their hemoglobin A1C status over the course of HMP participation. Diabetic patients with regular exercise habits showed a 2.8-fold increased chance of outcome improvement compared with those who did not exercise regularly. The chance of outcome improvement in patients with complications was found to be one-third that of patients who had no complications (Odds ratio: 0.3, 95% CI: 0.1-1.0). This study found that specially trained nurses, following agreed upon protocols and algorithms and collaborating with medical team members, can effectively concentrate on providing comprehensive and effective diabetes care.