A 15-year follow-up report of an elderly diabetic foot with multiple recurrences leading to toe amputation and thoughts on the model of care for diabetic foot ulcer.

Diabetic foot ulcer (DFU) is one of the most serious complications of diabetes. Elderly diabetic patients are a high prevalence of diabetic foot ulcers, and their high recurrence, disability, and mortality rates impose a heavy economic burden on families and society. This paper reports a case of an elderly patient with a diabetic foot ulcer who was admitted in April 2007 and discharged after recovery from comprehensive diabetic foot treatment. Due to intermittent foot care and lack of home care, the patient's foot ulcers recurred after repeated healing during home rehabilitation, eventually resulting in the amputation of the right bunion. After the patient was discharged from the hospital with an amputated toe, the whole-process seamless management model of "hospital - community - family" was implemented. The hospital provides specialized foot support and guidance, and the community is responsible for daily disease management and referrals. The family is responsible for the implementation of home rehabilitation programs, and family caregivers need to identify and provide feedback on foot abnormalities promptly. As of May 2022, the patient had not experienced ulcer recurrence. This paper reports the whole process of "ulcer development → ulcer healing → ulcer recurrence healing → toe amputation → continuous care management" experienced by the patient in 15 years, aiming to reflect on the significance of the whole-process seamless foot care management model of "hospital-community-family" for diabetic foot ulcer rehabilitation through the case.