Objective  To evaluate the intervention effect of trinity (consisting of a center for disease control and prevention, a general hospital and a community health care center CHC) involved comprehensive disease management program on self-management ability among community patients with type 2 diabetic mellitus (T2DM) and to provide evidences for improving glycemic control in the patients.

  Methods  The participants were T2DM patients randomly recruited from six community health centers in an urban district of Nanjing city, Jiangsu province for a 2-year follow up study starting at October 2015. The participants were randomly assigned into an intervention group (Intv, n = 589) receiving a trinity involved comprehensive disease management program (including quarterly follow-up carried out by medical staff of CHC, a green channel for dual referral between a general hospital and a CHC, quarterly medical service provided by experts at a CHC, monthly health education on diabetes management conducted by nurses, 6-montly laboratory test for glycated hemoglobin (HbA1c) and blood lipid, and annual diagnostic examination for complications) and a control group (Ctrl, n = 563) only receiving disease management covered by basic public health services (including quarterly follow-up carried out by medical staff of CHC, dual referral between a general hospital and a CHC, and quarterly blood glucose test). Face-to-face interviews were carried out before and after the intervention with a general questionnaire and the Scale of Diabetes Self-Care Activities – Chinese version (SDSCA-C) among all the participants to assess the disparity in self-management ability between the two groups.

  Results  Before the intervention, there were no significant differences between the Intv and Ctrl group in the total score of SDSCA-C (12.49 ± 5.02 vs. 12.44 ± 4.84) and in the proportion of participants achieving a target total SDSCA-C score of≥17 (19.9% vs. 18.1%). After the intervention, the total SDSCA-C score of the Intv group was significantly higher than that of Ctrl group (16.94 ± 4.09 vs. 14.69 ± 4.36, P < 0.05) and the proportion of participants achieving a target total SDSCA-C score was significantly higher in the Intv group than that in the Ctrl group (57.1% vs. 31.3%, P < 0.05).

  Conclusion  The trinity involved comprehensive disease management program is more effective than the management scheme required by basic health care services in the improvement of self-management ability among community patients with type 2 diabetic mellitus.