community practice chronicdiseasemanagement

8/12/2019 Community Practice ChronicDiseaseManagement

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7

27 2555


2/53

7

(.) (.)

.

(.) . . . 1317002-4419040-3 15-18 02-4410163Website: www.aihd.mahidol.ac.th,www.thaiichr.org


3/53

|

. .

.

..

.

.

60

97,900

47,000 128

90

( 2554

.


4/53

| |

1.8 2 )

1

7 100 35 7

( 7)

50-60

30-40

: ..2534-2535, ..2539-2540, ..2546-2547, ..2551-2552

1 : - 25 .. 2555

2534-2552

( 8)

.. .. .. ..

2534 2539 2547 2551

17.6 - 12.2 28.5

37.4 48.7 31.0 37.0

42.6 - 1.8 3.3

364 - 29.4 31.2( ())

3.2

()

15-29 0.8 0.530-44 3.7 3.245-59 8.5 11.660-69 13.6 19.270-79 14.3 17.180+ 12.9 10.5 6.0 7.7

(..2552) 6.9(..2547) 6.8(..2539) 4.6(..2534) 2.3


5/53

| |

21 100

21

50

28

20

1) (Primary Care)

80-90

: ..2534-2535, ..2539-2540, ..2546-2547, ..2551-2552

.. .. .. ..

2534 2539 2547 2551 61.5 50.8 8.6 20.9* **

Systotic < 140 mm.Hg.Diastolic < 90 mm.Hg 71.3 - 15.0 20.7 10.2 26.6 4.9 8.7 1,606 - 71.4 50.3 ()

10 1 6

()

15-29 4.6 0.930-44 15.4 10.145-59 28.3 30.6

60-69 42.8 44.970-79 51.1 52.380+ 53.9 57.4

(..2552) 21.4(..2547) 22.1(..2539) 11.0(..2534) 5.4


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10 | | 11

2) (Secondary Care)

(Self-management Support)

3) (Tertiary Care)

3

1)

: . .

.

..

2) (Self-management) :

..

.

3)

:

.


7/53

12 | | 13

10

(.) (.)

2549 .

.

(.)

1)

.


8/53

14 | | 1

2552-2554

(SRM:Strategic Route Map)

.

(SLM:

Strategic Linkage Model Construction)

(Road Map)

(.) .

.

.

.

70

-


9/53

1 | | 1

1

2

.

4 3

10

4

2553-

2554 42

40 95.24


10/53

1 | | 1

.

(IT: Information Technology)

.

.

.

1)

2)

3) 4)

5) 6)

7)


11/53

20 | | 21

.

2542

. ( )

2549

. .

. .

1) ..


12/53

22 | | 23

. (..)

.

.

.

.

.

.

-

2

.

.

.

(Vinyl)


13/53

24 | | 2

(Promote)

.

-

..

. .. . 4

.. .

2

. ..

.

.

.

.

.

.


14/53

2 | | 2

(..)

..

PCU (Primary Care Unit)

327 (

132 ) 5,859

3 . 5

.. 3 .

129

.

. ..

.

.

2 2555 3

4

3,166

55

4

3

3,166

(BP : Blood Pressure)

90

9


15/53

2 | | 2

..

.

..

5 5

1

.


16/53

2547

3

5

( )

(On call)

7

5-6

2) (Self-management)

.

| 31


17/53

0.5 - 1 3

2-3

KM

.

10,000-20,000

2549-2551

32 | | 33


18/53

.

13 .. 17 .. 3

.. 2

5 90,000

5

.. .. ..

.. ..

..

..

..

(Guideline)

..

..

..

3 1) , ,

/, 2) 3)

3 (Visit)

..

-

34 | | 3


19/53

..

..

(Self

Help Group)

1) 2)

4

/

..

2

(FCG: Fast ing

Capillary Blood Glucose)

(FPG: Fasting plasma glucose)

(Calibrate)

4

HbA1c

(Hemoglobin A1c) 2-3

3

. ..

2 8 (FCG: Fasting Capillary Blood Glucose) (FPG: Fasting plasma glucose) (http://healthdata.moph.go.th)

3 | | 3


20/53

2554-2555 60

HbA1c (Hemoglobin A1c)

3 7 30-40

2-3

2

(Fundus

Camera)

(Distribute) ..

3 HbA1c (Hemoglobin A1c) 7 (http://hph.moph.go.th)

3 | | 3


21/53

Monofilament

()

3 1

2 ..

3

.. ..

..

..

40 | | 41


22/53

3) .

| 43

(Dynamic)

1.7

5 CUP (ContractingUnit for Primary Care) CUP

(20 ) CUP (6 )

CUP (1 ) CUP

(4 ) CUP 46 (1 ) 32

3 1)

2) 3)


23/53

44 | | 4

3

1) PCU

(Primary Care Unit)

2)

PCU 3)

CUP PCU 20

60-70

PCU

Case PCU

(.) (.)

Case (Uncontrolled

Complicated Case)

(Controlled Uncomplicated Case)

PCU . .

PCU

(Self Care) (Family

Care) (Community Care)

(Behavior Modification)

(Screening)

PCU

(Continuity of Care) PCU

(FCG: Fasting Capillary Blood Glucose)

1


24/53

4 | | 4

Metabolic Syndrome

PCU

Walk in

PCU

(Fundus Camera)

PCU 20

PCU

(Continuous Care

in PCU)

[Clinical (Appropriate)

Practice Guideline DM HT]4

(Appropriate)

(Electronic Medical Record) HAMIS (Hospital

Advance Management Information System)

Smart DM

(DM Center) Version 1.1 1.5

PCU

4 DM Diabetes Mellitus HT Hypertension


25/53

4 | | 4

(LAB)

(Pneumonia -

)

PCU

PCU

(Admit)

/

(Non Drug Treatment)

(Behavior Change)

HbA1c

8

One Day Camp

One Day Camp

4

( )


26/53

0 | | 1

1

10-20

.

3-5

1) 2) . 3) / 4)

/ 5) . 6) .. 7)

Seven

Seven 7

Seven

Eleven 7

11 8) ./ . 9)

10) 11)

100 2555

PCU


27/53

2 | | 3

HbA1c 7

40

(Hypoglycemia, Hyperglycemia, Infection)

PCU

7-11 (Seven + Eleven

= 7-11) 7-11 PCU

PCU

. PCU


28/53

4 | |

.

.

120

..

1

1

15

.

2

(EMS: Emergency Medical Service)

- 5

..

3 1

3

Metabolic Syndrome

2

Metabolic Syndrome

(Cholesterol, Triglyceride, HDL, LDL)

Metabolic Syndrome


29/53

| |

2

7

(Range)

(Trend)

21

30-44 45-59

(Ageing Society) 65

..

2552

2568

65 22

15 17 2 40 60

15-65

60 40

60

40-50

22 10

30

Case


30/53

| |

3

2546 ..

(Package)

(Monitor)

(Model)

..

200

7

5

.

Primary

Prevention


31/53

0 | | 1

(Sodium)

(Li teracy)

(

)

-

PCU

1


32/53

2 | | 3

Primary

Prevention

.

2

1 .

.

2

2

(Dynamic)

..

..


33/53

4 | |

..

..

5-

7

. (.)

2

3

2 1)

2)

.


34/53

| |

(.)

(.)

.

.

.

..

..

..


35/53

| |

..

..

.

.

.


36/53

0 | | 1

..

. .

.

.

..

40 .

40

8

8


37/53

2 | | 3

.

2551 .

50

All for Health

40 .

..

2

2

.

(..)

2

..

.. 2

3

1) 2)

3)

3


38/53

4 | |

(Case Manager)

. ..

3

.

. (Contract)

.

. 2

.

(Outcome)


39/53

| |

On top payment 5 ..

.

2

Metabolic Syndrome

(Health Promotion)

(Prevention) (Human Resource)

Metabolic Syndrome

..

5(On top payment) 2554 5.4 ( ) (www.nkp.moph.go.th)


40/53

| |

(Outcome Mapping)

.

.

(Glucose)

3

1) 2) 3)

--

3

1


41/53

0 | | 1

3 . 2 .(3 . --

2 . -)

2

...

1-2


42/53

2 | | 3

. .

(...)

. .

: . .

NPL (Non Performing Loan)

. . .

.. .

..


43/53

4 | |

--

3

(Spec ialist )

(Tertiary Care) (Secondary Care)

(Primary Care)

21

(Shift )


44/53

| |

.

Accredited

HA (Hospital Accreditation)

(Self Care) (Family Care) (Community

Care) Accredited

3 EQEE Equity Q Quality

2 E

Efficiency

17 GDP (Gross Domestic

Product) (Advance)

(Well-Trained)

6

(Barack Obama)

80,000

(Hemophilia-

)


45/53

| |

3

(Spirit)

2-4

140/90 .

(Systolic pressure)

(Diastolic pressure)

, Pre-

hypertension, hypertension stage1, hypertension stage 2

60


46/53

0 | | 1

97,900 2 5

47,000 128

* 90

( 2554

1.8 2 )

2547

9 (DALYs)

( 3.2 DALYs) 3

( 6.9 DALYs)

5 2

70,000 ( 18)

6 ( 6

* : ( ) 25 2555

DALYs) (,

2550)

4

2551-2552

15 6.9 3.2 (

6-7 100 )

7.7 0.6 15-29 70-79 (

19.2) 60-69 ( 16.7)

()

( 31.2)

( 3.3)

(

37.0) (

< 126 ./.)( 28.5)

21.4 10

1 6

50.3

8.7


47/53

2 | | 3

20.7 ** 20.9

(1 96)

*** ( >

90 . 80 . ) 15 15 36

( 150

)

21

24

5

15-74 17.34

15-74

22.25

** Systolic


48/53

4 | |

:

:

Self-management support

:

Self-management support

:

1. Clinic:

2. Tertiary prevention:

3. Secondary prevention:

4. Primary prevention:


49/53

1 2 3 4 5

1 23 4 5

| |

+

+ /+++

/

1

2

3

4

5

1

2

4

1.

44 ( .) 505 .

2.

(NHES)1-4

.

BRFSS 3.

Cancer, ACS, Stroke, DM, COPD


50/53

| |

: Innovative Care for Chronic Conditions: building blocks foraction, World Health Organization, 2002.

3

3

3 1)

2) 3)

Prepar

ed

Info

rned

Motivated

Better Outcomes for Chronic conditions

- -

-

-

- - & -

-


51/53

100 | | 101

.

(..)

(..)

..

-

.

()

/

(

)


52/53

102 | | 103

..

- : . 4 (- 32 ), , / ., . . -..

- DM- . +

( 0-14 )6

-

-

.. 10

+.

()

-

- (DM,HT, DLP) ..

.


53/53

() 4 ..2551-2552 ; 2553.

. (3) 2553. : , 2553.

(.)

1 2552. : ; 2552.

(.) : 1: ; 2553.

. : 1 2552: ; 2552.

. 3 ..2546-2547. : ; 2548.

, . ..2550.

http://portal.in.th/diabetes/pages/14095

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