การพัฒนาระบบการดูแลผู้ป่วยโรคเบาหวานและความดันโลหิตสูง โดยใช้รูปแบบคลินิกหมอครอบครัวเครือข่ายพิมาน อำเภอนาแก จังหวัดนครพนม

Abstract

     Development of care system for patients with diabetes and hypertension The model was used as a family doctor clinic of the Piman Network, Na Kae District, Nakhon Phanom Province. The purpose of this study was to develop and study the effects of developing a care system for patients with diabetes and hypertension. The model was used as a family doctor clinic of the Piman Network, Na Kae District, Nakhon Phanom Province. Action research model: There are 2 groups of samples: 1. The service provider group includes a multidisciplinary team and a network of 4 sub-district health promoting hospitals, 26 people; 72 people and 80 hypertension patients were selected by purposive sampling that met the research criteria. Research procedures/methods Step 1: Planning (Planning) Analyze the problem. Set guidelines for practice. Step 2: Acting. Implementation. According to the form of service defined. Step 3 Observing (Observing) is to provide information about the action. Step 4: Reflecting Processes and results from development. Data Analysis 1. General Information Questionnaire, Opinion Questionnaire, Satisfaction Questionnaire Data were analyzed by descriptive statistics using frequency. percentage and standard deviation. (FBS)/accumulated sugar (HbA1c) was compared before and after by Pair T-test.

     The system of care for patients with diabetes and hypertension consists of 1) weighing, measuring blood pressure, and blood sugar testing 2) joining a group to educate about adjusting health behaviors 3) seeing a doctor, adjusting medication 4) The nurse gave advice/next appointment. 5) Received advice on the use of medication from a pharmacist. 6) Home visit by a team of family doctors according to the specified criteria. Health information of diabetic patients found that after developing the system. Diabetic patients had a statistically significant decrease in blood sugar and hypertensive patients had a statistically significant decrease in blood pressure of 0.05 (X=8.95, SD=1.12, X=7.99, SD=0.87; X SBP=22.75, SD SBP=11.86, X DBP =7.65, SD DBP =7.44). There are opinions about the organization of the service system. statistically significantly better than before system development in both the service recipient and the service provider group (X =3.26, SD=0.45, X =4.46, SD=0.50; X =3.15, SD=0.36, X=4.50, SD =0.51) Satisfaction with the service system of service users and service providers found that after system development satisfied per service system statistically significantly better than before the system development in both the service recipient and the service provider group (X =1.8, SD=0.57, X=4.42, SD=0.49; X=1.88, SD =0.58, X=4.42, SD =0.50)