[[alternative]]Implement and Evaluate the Effect of Interdisciplinary Telecare Teamwork Model on Patients with type 2 Diabetes Mellitus in Home Care

[[abstract]]本研究旨在建構「居家照護糖尿病人遠距照護整合專業模式」，及探討介入後，對居家照護第二型糖尿病人、主要照顧者，及整合專業團隊的成效。研究採隨機對照類實驗研究設計（Quasi-experimental study），收集北部某醫學中心居家照護≧65歲第二型糖尿病病人為對象，依立意取樣（Purposive sampling）隨機分配選取實驗組與對照組，透過居家訪視、問卷調查、資料庫分析等方式收集資料，瞭解居家照護≧65歲第二型糖尿病人，在介入遠距照護整合專業模式前、介入後1個月、2個月、3個月，在主要照顧者、病人、整合專業團隊的成效。採用SPSS 22.0zh-TW版統計軟體，依研究目的進行描述性及推論性統計分析，期藉由研究發現，作為長期照護發展政策、醫療機構介入遠距團隊照護模式的參考，以落實在地老化之目標。研究有效樣本共53位，實驗組與對照組(現有居家照護模式)兩組病人飯前及飯後血糖自我監測結果及高低血糖發生次數均達到穩定控制，雖兩組未達顯著差異，但實驗組個案飯前飯後血糖穩定度均高於對照組。主要照顧者遠距照護科技使用接受度整體量表平均4.26分，具正向成效，主要照顧者或整合專業團隊皆認為，遠距整合專業團隊照護能提供即時溝通、迅速即時的服務，讓病人及照顧者有安全感，應該投入更多整合專業人力資源，透過建立護病關係，提升主要照顧者對疾病照顧的自我效能。另此研究結果僅能了解研究機構≧65歲第二型糖尿病人、主要照顧者及整合專業團隊成效，由於收案期間較短，無法看到較長時間的成效。建議未來可擴大收案來源及樣本數，增加介入期間，以瞭解較長時間病人、主要照顧者，及整合專業團隊成效。[[abstract]]This study aims to construct " home Care Type 2 Diabetics Care with Telehealth Professional Integrated Team ", and investigate the effect on home care Diabetics, caregivers and the teamwork after the Telehealth intervention.This research adopted Quasi-experimental study. The objects were collected from a medical center in northern Taiwan home care Type 2 Diabetics, equal to or more than 65 years old. According to purposive sampling, selected experimental group and control group randomly, collected data via home visiting, questionnaire, database analysis. To understand the effect on home care Type 2 Diabetics, equal to or more than 65 years old, care givers and the teamwork before the Telehealth intervention and after the Telehealth interventions one month, two months, and three months. We chose the statistical software SPSS 22.0 of Chinese version, analyzed descriptive and inferential statistics according to the study goal. We expect the study result as a reference of long-term care policy, the telehealth team care interventions from medical institutions, carry out the objective of aging in place.The valid samples totaled 53. The self-monitoring of blood glucose before and after meals, number of hyperglycemia and hypoglycemia of the experimental group and the control group (home health care modeled) both controlled steadily. Although there is no significant differences between two groups, the stability of blood glucose before and after meals of the experimental group is higher than the control group. The acceptance of the use of technology of telehealth care givers averaged 4.26 points in the overall scale, is provided with positive achievements. Both of the care givers and professional integrated team considered telehealth care can provide real-time communication, rapid real-time service, offered security to the patients and the care givers. We should devote more professional integrated human resources, through the establishment of nurse-patient relationship, improve the self-efficacy care of the care givers. This result can only unveil the effectiveness of Type 2 Diabetics, equal to or more than 65 years old in the medical institution, care givers, and professional integrated team. Due to the participated period in this study is short, we cannot see the longer outcome. It recommends that we can expand the cases sources and the sample numbers, prolong the duration of the interventions, to understand the results of the patients, care givers, and the professional integrated team in a longer period in the future