Development of patient care guideline for diabetes and hypertension in Uthai-thani Province

Abstract

Caring for patients with chronic diseases is a challenging issue in the health care system. There is a need for a new paradigm in case management which pays attention to not only pathology of illness but also a long-term care process requiring close collaboration between multidisciplinary team and local medical service facilities with an aim to improve quality of life of both patients and family members. Patients and family should also play essential roles as members of the care team. To address to such challenge, Uthai-thani Provincial Health Office has included the continuum of care as one of the strategies in the provincial health plan for 2011. A pilot project was established to develop a patient care guideline (PCG) for diabetes and hypertension which linked all levels of health care facilities to jointly take care of the patients. The process included (1) the review of clinical practice guidelines for different levels of care; (2) a survey on patient needs; (3) strenthening medical care capacity of nurses in the general hospital, community hospitals and sub-district health promotion hospitals; and (4) organizing workshops to develop PCG and patient care handbook. Two documents were developed: (1) PCG-1 – the clinical pathway or care map for diabetes and hypertension and (2) PCG-2 – a practical patient handbook for self care. The PCG-2 also served as a communication tool for patients and care providers at all levels. This development of PCG was the first step in an overall process to develop a patient-centered health service system. If successful, the patient handbook could be further developed to become an information package embedded in individual smart cards which would be useful for all health facilities nationwide to utilize information for the joint care of patients.