Jiangsu Province Center for Disease control-Hospital-Community integration comprehensive management program to patients with type 2 diabetes

Ten diabetes intervention sessions including scheduled glucose monitoring, diabetes specific nutritional plan, and group diabetes education are designed for this study. The number of sessions that participants attend is determined based on the pilot study we completed in 2017-2018. It was evident the intervention was effective if participants can attend at least 8 sessions. If participants skipped sessions, the local physicians will catch up the participants by phone or sending session materials to participants so they can catch up with the activity contents. These participants will be given opportunities to participate in activities to review their understanding of the intervention content. All intervention group participants will be provided diabetes intervention materials used for weekly group activities led by experienced community based physicians. The diabetes intervention materials are specially designed for this study. Each group consisted of 10-15 patients for 1 to 1.5 hours activities. The information included the following topics: thoughts and beliefs in diabetes management, diabetes self care behavious, behavioral and lifestyle modification including quitting smoking and drinking, physical activity, and knowledge of diabetes education, diabetes self care skills, healthy eating instruction and low glycemic foods based on Chinese Health Diet plan. In the education and information sessions, participants will attend workshop, learn the content through demonstrations, to conduct role plays and group discussion, Participants will attend weekly group sessions at their respective communities. For each session, it lasted 60 to 90 minutes, participants met with a community physician for diet consultations and medical evaluation in the same session. This includes review of behavioural modifications actions, assessment of blood glucose measurements and adjustment of medications. The integrative health care model will be developed by integrating Disease Control Center as project management, tertiary hospital to provide guidance and training and community doctors to do monitoring and management. We are also trialing the online monitoring the patients weight control by using E-health method. This measure participants body weight, BMI, fat, bone and muscle strength, and metabolism process. Participants will measure their weights every week six months. The APP developed for the intervention will receive patients data and provide patients guidance after they send data through telecommunication method.