DEVELOPMENT OF CARE MANAGEMENT MODEL FOR UNCONTROLLED HYPERTENSIVE AND DIABETES WITH CHRONIC KIDNEY DISEASE STAGE3B AND/OR HEART FAILURE PATIENTS

Abstract

The research and development study aimed to development of care management model for uncontrolled hypertensive and diabetes with chronic kidney diseases stage3b and /or heart failure patients on analysis health literacy and clinical outcome of patients. The conceptual framework model were research and development with case management model from CMSA 2016 combine health literacy and self –management program. This study in patients 45 case from medical physician diagnosis uncontrolled hypertensive and diabetes with chronic kidney diseases stage3bor/and heart failure patients and multidisciplinary total number 30 case. The study was carried out during February 2019 to February 2020. The equipment of this study divides into 2 categories : 1). The form for patient of test health literacy and self–management, clinical outcome information and questionnaires quality of life. 2) The form for multidisciplinary test of nurse, knowledge and satisfaction, the questionnaires on structural operational of focus group discussion. Data analysis were using percentage for descriptive, mean and standard deviation which test hypothesis by pair-t-test at the level of statistical significance were set P<0.05. The operational of focus group discussion was data analysis using by content analysis. The result of this study were as follow : The case management model combine health literacy and self–management program. Mean score of health literacy total dimension of patients after development case management model higher than before. The clinical outcome that glycemic and blood pressure and lipid in blood stream and estimated glomerular filtration rate (eGFR) decrease level in to delaying progression of chronic kidney disease as the result of good quality of life.The suggestion that next research study about value for money of case management model.