DEVELOPMENT OF A CARE SYSTEM FOR PATIENTS WITH CHRONIC DISEASES AND RENAL COMPLICATIONS IN KHONKAEN MUNICIPALITY PRIMARY CARE UNIT

Abstract

This Action research aimed to analyzing the situations and development of a care system for patients with chronic disease and renal complication in Khonkaen municipality primary care unit.By using the conceptual framework of Expanded Chronic Care Model. The target groups were patients with chronic disease and renal complication, caregivers, health volunteers, community leaders, health service providers, agency executives and local government administration a total of 57 people. A content analysis was used to examine qualitative information. Quantitative data was analyted to obtain descriptive statistic. The research was performed during September 2020 – May 2021. The results in the stage of situational study revealed that patients lack skills in proper self-health behavior management. The caregivers provided less self -management support of patients. The information systems was not update. The agency does not have clinical practice guidelines. The community had not yet participated in patients care. Development system 1) Service system development 2) Creating the clinical practice guideline 3) Development information systems 4) Development knowledge and skill of health volunteers and community leader for patients care The evaluation found that 1) systematic results the agency has a service system that encourages helps support self-management of patients. There is an up-to-date database system. The agency has clinical practice guidelines for caring of patients. All sectors participates in the formulation of policies and implementation plan in patients. 2) results in better clinical outcomes resulting in decreased blood pressure of 82.37 %, decreased HbA1C of 60 % and increased glomerular filtration rate of 52.9 %