Development of a Diabetes Care Model by Applying the Integrated Chronic Care Model in Phang Nga Province

Abstract

This research and development study had three objectives: (1) to examine factors influencing self-care behaviors for blood glucose control among patients with diabetes, (2) to develop a diabetes care model by applying the concept of an integrated chronic care model, and (3) to evaluate outcomes before and after implementation of the model. The study was conducted in two phases. Phase 1 involved 372 patients with diabetes. Phase 2 included 192 local stakeholders who participated in developing the model and 58 patients with diabetes who were enrolled in the model implementation. Data were collected using a structured questionnaire and a researcher-developed focus group discussion guide between May 2025 and April 2026. Quantitative data were analyzed using descriptive statistics and inferential statistics, namely multiple linear regression and paired t-test, while qualitative data were analyzed using content analysis.

The results showed that the factors significantly associated with self-care behaviors among patients with diabetes were self-care health knowledge (β = 0.19, 95% CI: 0.12 to 0.27), health self-regulation (β = 0.04, 95% CI: 0.01 to 0.07), and health self-care (β = 0.90, 95% CI: 0.93 to 0.98). The diabetes care model developed by applying the integrated chronic care model in Phang Nga Province consisted of seven components: (1) a health promotion and behavior change program, (2) development of a counseling system, (3) establishment of a DM Remission Clinic, (4) establishment of a community-based NCDs operations center, (5) implementation of a continuous symptom monitoring and follow-up process, (6) development of a multidisciplinary care model based on family medicine, and (7) provision of postal medication delivery services. Following implementation of the model, 36 participants (62.07%) were able to discontinue antidiabetic medication, and fasting blood sugar (FBS) levels decreased significantly (mean difference = 32.18 mg/dl, SD = 15.39, 95% CI: 28.14 to 36.23).