Development of an integrated care model for Type 2 diabetes patients with hyperglycemia at Phonsawan Hospital, Nakhon Phanom Province.

Abstract

      This action research aimed to develop and evaluate an integrated care model for type 2 diabetes mellitus (T2DM) patients with hyperglycemia at Phon Sawan Hospital, Nakhon Phanom Province. The sample consisted of 50 T2DM patients attending the NCDs Clinic between January and June 2026. The study executed the PAOR action research process, integrating a multidisciplinary team and community-level support alongside the application of the Health Belief Model (HBM). Research instruments comprised two main parts: (1) intervention tools, specifically the newly developed integrated care model, and (2) data collection tools, including a health behavior evaluation form, fasting blood sugar (FBS or DTX) levels, and glycated hemoglobin (HbA1c) levels. Data were analyzed using descriptive statistics frequency, percentage, mean, and standard deviation and pre-post comparative outcomes were evaluated using the paired t-test.

      The findings were as follows:

1. Developmental Model: The resulting integrated care model categorized patient management based on clinical severity into three distinct tiers: non-urgent, urgent, and emergency.
2. Clinical and Behavioral Outcomes: Post-implementation health behaviors improved significantly across medication adherence, dietary control, symptom monitoring, and complication prevention (p < .05). Most notably, medication adherence scores increased from a mean of 7.60 to 13.90, reflecting the synergistic impact of in-depth pharmaceutical counseling and HBM-based nursing education. Conversely, physical exercise scores rose marginally from 6.38 to 6.42 without statistical significance, constrained primarily by physical limitations, age, comorbidities, or long-standing lifestyle patterns.
3. Glycemic Control: Blood glucose levels (DTX or FBS) decreased significantly from a mean of 320.64 (SD = 80.20) to 237.30 mg/dL (SD = 98.93), while HbA1c levels decreased from 12.24% (SD = 2.74) to 10.55% (SD = 1.97) (p < .05).