The Whole Course Management of Diabetic Foot Based on the Co-care Model of "Specialist-General Practitioner" Family Medicine Team Contractual Services: a Case Report and Literature Review

doi:10.12114/j.issn.1007-9572.2024.0435

Abstract

Abstract:

Background

As one of the serious chronic complications of diabetes, diabetic foot is characterized by high rate of disability and high burden of diseases. which require multi-disciplinary collaboration and long-term standardized management in the prevention and treatment of diseases. At present, there are many difficulties during the management of diabetic foot in all community-level medical and health care institutions, such as insufficient specialized resources and lack of continuous care.Through the analysis of a successful management path in diagnoses and treatments process of a case of type 2 diabetes patient complicated with diabetic foot, to investigate the feasibility of promoting the co-care management model based on the"Specialist-General Practitioner" family medicine team contractual services in the management of diabetic complications in community health service center.

Methods

Through combing and analyzing the whole treatment and management pathway of a diabetes foot patient under the new model of "Specialist-General Practitioner"family medicine team contractual services. we searched for relevant literature from 2004 to 2024 in the full-text journal of CNKI, Wanfang data, Vip and PubMed with the key words of "Diabetic foot, Community"in Chinese and"Diabetic foot and Management, Diabetic foot and Administration, Community diabetic foot"in English. The results showed that the new model for co-care management in diabetic foot had more obvious advantage and widespread concern than the existing community management models and contents.

Results

Under the new model of "Specialist-General Practitioner"family medicine team contractual services, the patient's gangrenous toes linked to his diabetes were preserved and the foot infection associated with diabetes was cured. Meanwhile, the patient's blood sugar, blood lipids, and blood pressure gradually reached the standard of good control. According to the document retrieval results, it is found that most of the management models for community diabetes foot at home and abroad are still in the primary stage, including community-based management model, hospital-community linkage management model, hospital-community-family management model, Internet plus hospital-community-family intelligent nursing model, self-management model, multidisciplinary teams management, telemedicine model by using computer software, smartphones, apps running on tablets, network camera and other devices, artificial intelligence prediction model for diabetes foot ulcers and multi-disciplinary integration of diabetes foot management team.

Conclusion

The co-care model based on "Specialist-General Practitioner"family medicine team contractual services got remarkable effect on the management of diabetes foot in the community. Compared to the similar models in China and abroad, this model has a simple team structure, clear division of labor among members, emphasis on individualization of services, and work more efficiently, which is worth spreading and applying in the community health service center.

Key words: Diabetic foot, Diabetes complications, Health services of community family physician, Diabetes joint care, Community management, Case reports

摘要：

背景

糖尿病足作为糖尿病严重的慢性并发症之一，具有高致残率、高疾病负担的特点，其防治需要多学科协作与长期规范化管理。当前，我国基层医疗卫生机构在糖尿病足管理中常面临专科资源不足、连续性照护欠缺等问题。

目的

本文通过对1例首诊社区的2型糖尿病合并糖尿病足患者的成功管理路径及诊疗过程分析，探索以"专科-全科"特色家医签约服务为依托的共同照护管理模式在社区糖尿病及其并发症人群管理中推广应用的可行性。

方法

通过梳理分析"专科-全科"特色家医签约服务新模式对1例糖尿病足患者的全程治疗及管理路径。同时以"糖尿病足，社区"为中文关键词分别检索中国知网、万方数据知识服务平台、维普网，以"Diabetic foot and Management，Diabetic foot and Administration，Community diabetic foot"为英文关键词检索PubMed相关英文文献，检索时间为2004—2024年，对糖尿病足现有社区管理模式及内容进行分析比较，突出以"专科-全科"特色家医签约服务为依托的共同照护管理模式的成效与优势。

结果

本例患者经"专科-全科"特色家医签约服务为依托的共同照护管理后坏疽足趾得以保全、足部感染得到治愈，与此同时患者的血糖、血脂、血压均达到控制标准；结合文献检索结果，目前国内、外对于社区糖尿病足的管理模式多处在探索阶段，包括基于社区的管理模式、医院-社区联动管理模式、医院-社区-家庭管理模式、互联网+医院-社区-家庭智慧护理模式、自我管理模式、多学科团队管理、利用计算机软件、智能手机、平板电脑应用程序和网络摄像头等设备进行远程诊疗和指导模式、人工智能糖尿病足溃疡预测模式以及跨专业糖尿病足管理团队等。

结论

以"专科-全科"特色家医签约服务为依托的共同照护管理模式对社区糖尿病足患者管理效果显著，且此模式与目前国内外研究的糖尿病足管理模式相比团队构架简单，成员分工明确、服务强调个体化、运作效率更高，值得在社区卫生服务中心推广应用。

关键词: 糖尿病足, 糖尿病并发症, 家庭医生签约服务, 共同照护, 社区管理, 病例报告

CLC Number:

R 587.29

WANG Shujuan,FENG Xiaokai,LI Na, et al. The Whole Course Management of Diabetic Foot Based on the Co-care Model of "Specialist-General Practitioner" Family Medicine Team Contractual Services: a Case Report and Literature Review[J]. Chinese General Practice, 2026, 29(27): 4004-4010. DOI: 10.12114/j.issn.1007-9572.2024.0435.
王淑娟,冯晓凯,李娜等. 以"专科-全科"特色家医签约服务为依托的共同照护模式对一例糖尿病足患者全程管理实践并文献复习[J]. 中国全科医学, 2026, 29(27): 4004-4010. DOI: 10.12114/j.issn.1007-9572.2024.0435.

Figures/Tables 4

References 40

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第一作者	发表年份（年）	DF管理模式	具体方案	优点	缺点
Jia^[21]	2023	"医院-社区-家庭"全程无缝隙管理模式（the whole-process seamless management model of "hospital - community - family" ）	（1）医院提供专业的足部支持和指导，社区负责日常疾病管理和转诊，家庭负责实施家庭康复计划；（2）家庭照护者需及时发现和反馈足部异常情况；社区护士定期对患者及其照护者进行DF部护理教育以提高患者自我管理能力；（3）当出现趾甲变形或溃疡复发时，社区医院协助患者预约三级医院DF门诊，接受进一步专科治疗	强调连续性护理	分工不够细化
Chen^[23]	2023	以自我效能模型为指导的数字化足部自我管理计划（a digital foot self-management program guided by a self-efficacy model）	（1）开发的一套以Bandura自我效能模型为指导的数字化足部自我管理计划，包括4周的课程和3个月的随访；（2）第1周包括1 h的面对面会议，介绍关键主题并浏览应用程序功能，包括与研究护士讨论和练习活动的机会。第2~4周，参与者每周都会接到电话和通过应用反馈系统收到消息。第2~3个月，鼓励参与者使用数字平台在家中监测他们对该计划的遵守情况；（3）采用中文版足部护理自我效能量表进行自我效能评估，使用DF部自我护理行为量表评估自我护理行为，最后由经过培训的社区护士收集整理问卷信息及相关资料	（1）以自我效能模型为指导来进行数字化设计，使该计划有一定的理论依据；（2）以随机对照试验论述该计划确实有可操作性；（3）对自我效能、自我护理行为和血糖控制均产生了积极影响	（1）研究结束后尚不清楚接受DF护理的老年人是否会继续坚持；（2）无法记录个人与应用程序的互动时间及其与结果的关联
Joret^[25]	2019	大型三级医院的多学科DF门诊[a new multidisciplinary diabetic foot clinic（MDDFC）in a large tertiary hospital ]	（1）多学科团队成员包括：血管外科医生+登记员+内分泌专家+足病医生+DF病专科护士+矫形师；（2）血管外科医生负责评估伤口是否需要手术处理；（3）内分泌专家负责评估患者糖尿病控制情况及优化降糖方案；DF专科护士负责患者教育包括：饮食、运动、药物治疗、伤口护理；（4）足病医生和矫形师密切合作，优化鞋袜，足部减压治疗及足部护理	（1）团队合作达到对DF患者全方位评估管理；（2）减低DF住院率和截肢率，从而降低患者的治疗费用	成员组成较复杂，适合在综合医院开展实施，不适合社区开展
Watt^[26]	2021	国家医疗服务体系批准的"应用程序"和基于网络的个性化教育（a National Health Service approved 'App' and web-based personalized education）	根据英国半乡村低收入糖尿病患者开发的，以社区全科医生及社区护士为基础，开发出模拟多学科患者评估+足部病例转诊+非面对面帮助热线来对社区糖尿病及DF进行综合服务。	（1）软件的可及性及利用率高，DF的诊断率、足部护理普及率提高；（2）提高转诊效率、血糖达标率，截肢率降低；（3）社区全科医护工作效率及工作认可度提高	以特定区域人群软件开发为基础的服务模式,不适合大范围推广
Graham^[30]	2023	实时视频远程医疗足部服务[a real-time video-based telehealth foot service（TFS）]	（1）血管外科医生和其他专家组成会诊小组参与线上会诊；（2）由当地专业卫生人员转介患者，以电话、视频的方式直接对接多学科团队特定专科医生；（3）通过使用电话等社交媒体促进远程医疗咨询	（1）访问便捷、灵活，可及性强，增强偏远地区居民就医获得感；（2）减少农村患者的出行负担；（3）减低住院率；（4）提高诊疗效率，避免延误病情	（1）是特定地区的诊疗模式探索，需要再广泛抽样去证实模式推广的必要性；（2）容易受网络条件限制

第一作者	发表年份（年）	DF管理模式	具体方案	优点	缺点
Jia^[21]	2023	"医院-社区-家庭"全程无缝隙管理模式（the whole-process seamless management model of "hospital - community - family" ）	（1）医院提供专业的足部支持和指导，社区负责日常疾病管理和转诊，家庭负责实施家庭康复计划；（2）家庭照护者需及时发现和反馈足部异常情况；社区护士定期对患者及其照护者进行DF部护理教育以提高患者自我管理能力；（3）当出现趾甲变形或溃疡复发时，社区医院协助患者预约三级医院DF门诊，接受进一步专科治疗	强调连续性护理	分工不够细化
Chen^[23]	2023	以自我效能模型为指导的数字化足部自我管理计划（a digital foot self-management program guided by a self-efficacy model）	（1）开发的一套以Bandura自我效能模型为指导的数字化足部自我管理计划，包括4周的课程和3个月的随访；（2）第1周包括1 h的面对面会议，介绍关键主题并浏览应用程序功能，包括与研究护士讨论和练习活动的机会。第2~4周，参与者每周都会接到电话和通过应用反馈系统收到消息。第2~3个月，鼓励参与者使用数字平台在家中监测他们对该计划的遵守情况；（3）采用中文版足部护理自我效能量表进行自我效能评估，使用DF部自我护理行为量表评估自我护理行为，最后由经过培训的社区护士收集整理问卷信息及相关资料	（1）以自我效能模型为指导来进行数字化设计，使该计划有一定的理论依据；（2）以随机对照试验论述该计划确实有可操作性；（3）对自我效能、自我护理行为和血糖控制均产生了积极影响	（1）研究结束后尚不清楚接受DF护理的老年人是否会继续坚持；（2）无法记录个人与应用程序的互动时间及其与结果的关联
Joret^[25]	2019	大型三级医院的多学科DF门诊[a new multidisciplinary diabetic foot clinic（MDDFC）in a large tertiary hospital ]	（1）多学科团队成员包括：血管外科医生+登记员+内分泌专家+足病医生+DF病专科护士+矫形师；（2）血管外科医生负责评估伤口是否需要手术处理；（3）内分泌专家负责评估患者糖尿病控制情况及优化降糖方案；DF专科护士负责患者教育包括：饮食、运动、药物治疗、伤口护理；（4）足病医生和矫形师密切合作，优化鞋袜，足部减压治疗及足部护理	（1）团队合作达到对DF患者全方位评估管理；（2）减低DF住院率和截肢率，从而降低患者的治疗费用	成员组成较复杂，适合在综合医院开展实施，不适合社区开展
Watt^[26]	2021	国家医疗服务体系批准的"应用程序"和基于网络的个性化教育（a National Health Service approved 'App' and web-based personalized education）	根据英国半乡村低收入糖尿病患者开发的，以社区全科医生及社区护士为基础，开发出模拟多学科患者评估+足部病例转诊+非面对面帮助热线来对社区糖尿病及DF进行综合服务。	（1）软件的可及性及利用率高，DF的诊断率、足部护理普及率提高；（2）提高转诊效率、血糖达标率，截肢率降低；（3）社区全科医护工作效率及工作认可度提高	以特定区域人群软件开发为基础的服务模式,不适合大范围推广
Graham^[30]	2023	实时视频远程医疗足部服务[a real-time video-based telehealth foot service（TFS）]	（1）血管外科医生和其他专家组成会诊小组参与线上会诊；（2）由当地专业卫生人员转介患者，以电话、视频的方式直接对接多学科团队特定专科医生；（3）通过使用电话等社交媒体促进远程医疗咨询	（1）访问便捷、灵活，可及性强，增强偏远地区居民就医获得感；（2）减少农村患者的出行负担；（3）减低住院率；（4）提高诊疗效率，避免延误病情	（1）是特定地区的诊疗模式探索，需要再广泛抽样去证实模式推广的必要性；（2）容易受网络条件限制