The development of a case management model for caring for diabetic patients to control blood sugar levels by coordinating care from the hospital to primary care

Abstract

     The research was aimed to development of case management care model for diabetic patients to control blood sugar levels by coordinating care from hospital to Primary care. Study during October, 2018 to September, 2020. The sample included 48 Diabetic patients with uncontrolled of blood sugar by specific selection, HbA1c ≥ 8.0%. The research instrument are General information record form of the sample, 4 Health Behavior Assessment form, Blood pressure and blood sugar record form by registered nurse at Primary care, This record form used to refer the patient from hospital to Primary care. Data were analyzed by
descriptive statistics and Paired samples t-test.

     The results showed that after the development of a case management care model for diabetic patients by coordinating care from hospitals to Primary care, Get a new model of diabetes care with the participation of a multidisciplinary team. The results of patient care found that diabetic patients had higher health behaviors after development than before, HbA1c of diabetic patients statistically significant decreased from before participation to the study. The outcome of this development result in the percentage of patients with diabetes mellitus with good glycemic control (HbA1c < 7.0%) of diabetic patients in Huai Yot district, 2020 was 40.84% that was the highest control in 10 districts of Trang (2018 is in good control for the last time, was 15.82%) and passed the target criteria of the Ministry of Public Health. Furthermore, this development model can be used to develop in other areas.