中文摘要：

目的探讨构建基于网络的2型糖尿病患者医院一社区一家庭三位一体健康管理模式，并评价应用效果。方法选取2015年1—4月在甘肃省人民医院内分泌科住院、病情稳定出院且分属大小、规模相仿的2个社区卫生服务中心的2型糖尿病患者110例，按照所属社区分为试验组和对照组各55例。对照组患者出院后接受社区卫生服务中心的常规健康管理；试验组患者接受基于网络的医院一社区一家庭三位一体健康管理。于管理前、管理1年后进行应用效果评价，采用空腹血糖、糖化血红蛋白评估患者的血糖控制情况；采用2型糖尿病自我管理行为量表评价患者的自我管理行为水平。结果管理前，两组患者的空腹血糖、糖化血红蛋白水平比较，差异均无统计学意义（P〉0．05）；管理后，两组患者的空腹血糖、糖化血红蛋白水平比较，差异均有统计学意义（P〈0．05）。管理前，两组患者的饮食控制、规律锻炼、遵医嘱服药3个维度得分及量表总得分比较，差异均无统计学意义（P〉0．05）；自我监测、并发症的预防2个维度得分比较，对照组高于试验组，差异有统计学意义（P〈0．05）。管理后，两组患者的饮食控制、规律锻炼、遵医嘱服药、自我监测、并发症的预防5个维度得分及量表总得分比较，差异均有统计学意义（P〈0．05）。结论基于网络的2型糖尿病患者医院一社区一家庭三位一体健康管理模式可有效改善患者的血糖水平，提高患者的自我管理行为水平，可实现优势互补、资源整合。

英文摘要：

Objective To explore construction of Internet- based trinity health management model of hospital-community- family for patients with type 2 diabetes mellitus and to evaluate its application effects. Methods 110 patients with type 2 diabetes mellitus from two different community health service centers of similar size and scale,who were hospitalized in endocrinology department of Gansu Provincial Hospital from January to April in 2015 and left hospital with stabilized condition,were selected. They were divided into experiment group and control group according to their community,each had 55 cases. The patients in control group received routine health management from the community health service center after discharge; the patients in experiment group received Internet- based trinity health management of hospital- community- family. Before and one year after the management,the application effect was evaluated. The blood glucose control status of patients was evaluated by fasting blood glucose and glycosylated hemoglobin; the level of self- management behavior of the patients was evaluated by self-management behavior scale of type 2 diabetes mellitus. Results Before management,there was no significant difference in fasting blood glucose and glycosylated hemoglobin levels of patients in two groups（ P 〉0. 05）; after management,there was significant difference in fasting blood glucose and glycosylated hemoglobin levels of patients in two groups（ P 〈 0. 05）. Before management,there were no significant differences in the three dimensional scores of diet control,regular exercise and medication compliance and total scores of patients in two groups（ P 〉0. 05）; the scores of self- monitoring and prevention of complications in control group were significantly higher than those in experiment group（ P 〈 0. 05）. There were significant differences in the 5dimensional scores of diet control,regular exercise,medication compliance,self- monitoring,prevention of complications and total scores of patients in tw