1. The patient has not completed the self-management plan: The self-management plan is an important part of the management of diabetic patients, including diet control, exercise plan and blood sugar monitoring. If the patient has not completed the self-management plan, the case manager will continue to provide support and guidance instead of closing the case.
2. Patients haven't mastered the skills of self-management: Self-management of diabetic patients requires certain skills and knowledge, such as how to use blood glucose monitor correctly and how to calculate insulin dosage. The patient has not mastered the necessary skills in these areas, and the case manager will continue to provide training and guidance instead of closing the case.