Development of Care for Patients with Type 2 Diabetes under the Chronic Disease Management Model (Chronic Care Model) in Diabetes Clinic Khunhan Hospital, Khunhan District, Sisaket Province

Abstract

This study was an action research, aimed to develop the diabetes care system for patients under the Chronic Care Model in the diabetes clinic Khunhan Hospital, Khunhan District, Sisaket Province. The co-researchers were collected according to the criteria including. 1) The administrative group of 15 people. 2) The citizen group of 94 people. 3) The group of 15 people multidisciplinary team. This research conducted co-researchers 124 people. The data were collected by using participatory observation forms, interview questionnaires and evaluation forms for participation in health service system management. The data were analyzed by using descriptive statistics including percentage, average, mean and standard deviation, lowest - highest value and analyzed content analysis. The study found that the management of chronic non-communicable diseases in the diabetes clinic was managed in accordance with the 6 components of the Wagner's chronic care model, which are 6 important things: 1)Service system have adjusted the working system to make patients more easily accessible. 2) Self-management support have group activity providing knowledge and checking up by appointment. 3) Service design the same service format is provided in the network, clearly define the activities of the diabetes clinic. 4) Decision support creates guidelines for diabetes care and the village public health volunteers are volunteers to help patients in the community. 5) Clinical information system develop the entire network of information systems have a map to track home visits and a lack of appointment monitoring programs. 6) Community support develops a participatory management system. After implementing the developed care process making the target patients able to control blood sugar levels well at a more controlled level. The results show that the developed service system development process was a successful result of a new service system focusing on a complete system of activities. Focus on working with communities and local networks. There was good support mechanisms of the service unit and the care team both interior and exterior the service place.