Type 2 diabetes mellitus
Conditions
Interventions
Intervention group:Hospital-Community-Home Tiered Transitional Care Program
Control group:Hospital-Community-Home Routine transitional care (HCH-RTC)
Sponsors
Gongli Hospital of Pudong New Area
Eligibility
Sex/Gender
All
Age
40 Years to 85 Years
Inclusion criteria
Inclusion criteria: 1. Participants who meet the diagnostic criteria for type 2 diabetes according to the 2020 China Type 2 Diabetes Prevention and Treatment Guidelines; 2. Aged 18 years or older; 3. With HbA1c levels at or above 7.0% (53 mmol/mol) in the past month; 4. Individuals capable of regularly participating in community-based collaborative transitional care services; 5. Possession of self-monitoring blood glucose instruments or the ability to measure at community health service centers; 6. Stable internet conditions for long-term use of smartphones and applications; 7. Voluntary participation and signing of an informed consent form after receiving a thorough explanation.
Exclusion criteria
Exclusion criteria: 1. Pregnant or lactating women; 2. Individuals with serious complications or comorbidities; 3. Those experiencing cognitive impairments, communication and reading difficulties, or mental illness; 4. Patients discharged for long-term intervention in other healthcare facilities such as nursing homes; 5. Those who drop out, are lost to follow-up, non-compliant, or deceased during the study for various reasons.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Glycated hemoglobin (HbA1c);Blood Glucose (Fasting Blood Glucose (FBG) and 2-Hour Postprandial Blood Glucose (2hPPG)); | — |
Secondary
| Measure | Time frame |
|---|---|
| Diabetes self-management ability;Diabetes knowledge level;Diabetes treatment adherence;Diabetes complication rate;Nursing service satisfaction;Unplanned readmission rate; | — |
Countries
China
Contacts
Public ContactYanmei Wang
Gongli Hospital of Pudong New Area
Outcome results
None listed