To explore the effect of the hospital–community–home (HCH) linkage management mode in patients with type 2 diabetic nephropathy (DN). A total of 80 patients with type 2 DN hospitalised in the Department of Nephrology of our hospital between July 2021 and June 2022 were recruited and subsequently divided into the observation group and the control group using the random number table method, with 40 patients in each group. The control group received routine health education and discharge guidance. The HCH linkage management model was implemented for the observation group based on routine care. The improvements in compliance behaviour, biochemical parameters of renal function, blood glucose level and self-management ability were compared before the intervention and at 3 and 6 months after the intervention. After the intervention, the scores for compliance behaviour of the observation group were better than those of the control group, with a statistically significant difference (P < 0.05). The biochemical indicators of renal function and blood glucose level were significantly lower in the observation group compared with in the control group, with a statistically significant difference (P < 0.05). After the intervention, the observation group showed a great improvement in self-management ability and cognition of the disease, with significant differences (P < 0.05). The HCH linkage management mode can improve the compliance behaviour of patients with type 2 DN, effectively improve the renal function and blood sugar level of patients, enhance the self-management ability and cognition of the disease and delay the development of the disease.

中文翻译：

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医院-社区-家庭联动管理模式在2型糖尿病肾病患者中的应用

探讨医院-社区-家庭(HCH)联动管理模式对2型糖尿病肾病(DN)患者的治疗效果。方法选取2021年7月~2022年6月期间在我院肾内科住院的80例2型DN患者,采用随机数字表法分为观察组和对照组,每组40例。 。对照组接受常规健康教育及出院指导。观察组在常规护理的基础上实施HCH联动管理模式。比较干预前、干预后3、6个月依从性行为、肾功能生化参数、血糖水平和自我管理能力的改善情况。干预后，观察组依从行为评分优于对照组，差异有统计学意义（P < 0.05）。观察组肾功能生化指标、血糖水平显着低于对照组，差异有统计学意义（P < 0.05）。干预后，观察组的自我管理能力和对疾病的认知均有较大改善，差异有统计学意义（P < 0.05）。HCH联动管理模式可以提高2型DN患者的依从性行为，有效改善患者的肾功能和血糖水平，增强患者的自我管理能力和对疾病的认知，延缓疾病的发展。