Development of care model for diabetic and hypertension patients in Tambon Health Promoting Hospital, Kosumphisai District, Mahasarakham

Abstract

The objective of this study is to develop and establish caring model for diabetic and hypertension patients at Tambon health promoting hospital. The method of this action research base on conceptual framework of chronic care model.The participants were 30 multidisciplinary service providers. Data were collected using diabetes and hypertension care assessments and fill out surveys via Google form and group discussions. Data were analyzed using descriptive statistics and content analysis. This study was conducting since October 2017 - September 2018.

          Results: analysis phase was found that the care guideline was changed, the service team was confused with their role, insufficient number of service providers, redundant information systems, patients were not receiving continuous treatment and cannot control the disease. The average total score of the care component is 6.7. We aim for the development of 2 components with scores below the average which are 1) delivery system design and 2) self-management support by developed the potential of nurses to be a mini case manager, co-ordinate supervision from network partners in the community. A caring model for diabetes and hypertension patients in Tambon health promoting hospital have been implemented and effect to : patients have access to 84 percent of the service, the average care component score increased from 6.7 to 8.6. The service system design from 6.5 to 8.8 points, self-care support from 6.3 to 8.3 points. The improved diabetes control rate increased from 7.72 percent to 16.28, also improved blood pressure control rate increased from 26.94 percent to 46.39. The result shown that the development of some components have affects on the development of others as well. The success factors is analyze problems and design services and continuously improve the service. Therefore, the model of chronic care model should be applied in the care of other chronic diseases.