Development and Implementation of Diabetes Care by a Community Network Based on a Chronic Care Model

Area of Science:

• Public Health
• Chronic Disease Management
• Community Health Research

Background:

• Diabetes mellitus is a growing public health concern requiring innovative management strategies.
• Primary care settings are crucial for effective diabetes management and patient support.
• Community participation is vital for developing sustainable healthcare models.

Purpose of the Study:

• To collaboratively develop and evaluate a community-based diabetes care model using the Chronic Care Model (CCM).
• To assess the effectiveness of the implemented CCM on diabetic patients, family caregivers, and community networks in primary care.
• To enhance community involvement in managing diabetes within a district in Thailand.

Main Methods:

• Participatory action research involving a collaborative health team and community network (25 members).
• Inclusion of 41 type 2 diabetes patients and 41 family caregivers in data collection (Oct 2021 - Mar 2022).
• Four-stage research process: planning, action, observation, and reflection, utilizing quantitative and qualitative data.

Main Results:

• Significant increases in average knowledge scores for diabetic patients, family caregivers, and community representatives.
• Diabetic patients reported highest satisfaction with family caregiver support; community networks valued participation in model planning.
• A significant increase in the percentage of patients achieving controlled HbA1c levels (<7 mg%) post-implementation (0% to 9.76%).

Conclusions:

• The CCM-based diabetes care model successfully promoted community participation and engagement in diabetes management.
• The model demonstrated a positive impact on diabetic patients' HbA1c control and the satisfaction of the community network.
• This approach highlights the potential of community-driven initiatives in improving chronic disease care within primary healthcare settings.