本研究的目的在探討出院期間糖尿病患者的素質因素及使能因素，在病人出院時進行轉介，並追蹤轉介結果。樣本來自某醫學中心近日內將出院之糖尿病患者共50名，採橫斷式調查研究法，問卷調查期間自82年12月1日起至83年7月31日止。
結果發現:(1)研究對象罹患糖尿病至今超過六年以上者共佔66%，八成的人患有其他慢性病，68%的人是初次住院，六成的人有親友罹患糖尿病。(2)全部對象都曾接受有關糖尿病的衛生教育，九成以上的人最近的一次的經驗是在本次住院時，護士與營養師是最主要的教導者。(3)糖尿病知識的答對率為80%:血糖控制的答對率最低，自我照顧及糖尿病相關因素的答對率次之，糖尿病的症狀與低血糖認知及其處理、有關合併症的認知答對率最高。(4)近八成的個案被轉介至當地衛生所，八成的轉介被接受，地段護士能在一週內訪到個案者僅佔四成，訪視結果，六成以上的個案被收案。(5)大多數的醫護人員均能支持轉介服務，記載糖尿病人需要的轉介單，能引導地段護士繼續追蹤服務的方向。

The purposes of this study were to investigate the predisposing and enabling factors of diabetes mellitus (DM) patients during discharing periods and inspecting the results of referrals. A total of 50 DM patients who met the sampling criteria were interviewed by way of a questionnaire. The crosssectional survey method was used and the survey period was from Dec.1, 1993 to July 31, 1994.
The findings were as follows: (1)Subjects of the study showed that 66% had DM over 6 years, 80% had other kinds of chronic diseases, 68% were the first-time inpatients, 60% had relatives who had DM. (2) All the subjects obtained health education about DM; over 90% of them had recent experiences when hospitalized this time; nurses and nutritionists played a major role as instructors. (3) The rate of correct answers about DM knowledge was 80%. (4) Almost 80% of the subjects were referred to district health centers; 80% of those referrals were visited by the centers; over 60% of the cases were accepted for further management; oney 40% of those visits were done by public health nurses within one week. (5) Most of the doctors and nurses made referrals; the referral sheets written about patients' health needs did help public health nurses in continuity care.