Development of comprehensive care model for every state of CKD in primary health care unit applying the concept of health literate organization: a case study at Pikunthong health center

Abstract

Twenty-nine patients suffered from level 3 chronic kidney disease (CKD), whose eGFR level required referral service to secondary care, refused to change service provider from Pikunthong Health Center. They insisted to be cared in the same primary care service provider. Then Pikunthong Health Center adopt the “13 step to HLO” process innovation to develop comprehensive care for every state of CKD in primary care unit to postpone kidney failure through NCD clinic integration. This action research was conducted during March to November 2022. There were 127 participants consisting of family doctor, care team, public health officers, nurses, dental nurses, Thai traditional doctors, CKD patients and their family members.

The comprehensive care model for every state of CKD in Pikunthong Health Center originated from the linkage of CKD services in community hospital and primary care cluster system was the community health center. Then they completed the concept of “3 doctors”: 1) the first doctor was community health volunteers, trained to be care team, who monitored, cared, and followed up the patients at their homes in community; 2) the second doctor was multi- professional team of community health center staffs who provided holistic care for health promotion, diseases prevention and treatment for the patients; and 3) the family doctor who provided medical care in primary care cluster clinic located in the community health center. The mechanism drove the three connected parts of this service system was the flow of data. The implementation of comprehensive care model for every state of CKD in primary care unit contributed to the concept of “near home near hearth” service  accomplishment. The comprehensive care for every state of CKD in primary care unit could significantly postpone the renal failure among the CKD patients. In addition, all the patients showed high to highest satisfaction levels for the service provided in the comprehensive care for every state of CKD of Pikunthong Health Center.