Development of an Integrated Diabetes Care System within the Health Service Network of Nadun Hospital, Mahasarakham Province

Abstract

This action research aimed to develop and evaluate an integrated diabetes care system within the health service network of Nadun Hospital, Mahasarakham Province. The purposive sample consisted of 40 participants, including 30 patients with type 2 diabetes mellitus whose HbA1c levels ranged from 7–9%, and 10 multidisciplinary healthcare professionals. The study was conducted from October 2023 to September 2024. Research instruments included a service-problem questionnaire, a diabetes patient handbook, a diabetes knowledge test, a self-care behavior assessment form, and a satisfaction questionnaire. Data were analyzed using descriptive statistics and paired t-test.

The results revealed that most participants were female (63.3%), with a mean age of 58.4 ± 9.2 years and an average disease duration of 7.6 ± 4.3 years. The developed integrated care system comprised three key components: (1) community-based screening and surveillance, (2) One Stop Service delivery, and (3) referral and continuous follow-up through primary healthcare units. Following implementation, significant improvements were observed. Mean HbA1c levels decreased from 8.12 ± 0.61% to 7.03 ± 0.58%, while fasting blood sugar levels decreased from 187.4 ± 28.3 to 142.6 ± 24.7 mg/dL (p < 0.001). Diabetes knowledge scores increased from 12.3 ± 2.4 to 18.7 ± 1.8, and self-care behavior scores improved from 54.6 ± 7.8 to 72.4 ± 6.3 (p < 0.001). The proportion of patients achieving target glycemic control increased from 23.3% to 86.2%. No cases of diabetic foot ulcer or toe amputation were reported during the study period. Overall patient satisfaction was high, reaching 90%.

In conclusion, the integrated diabetes care system developed through multidisciplinary collaboration effectively enhanced patients’ knowledge and self-care behaviors, resulting in significantly improved glycemic control. The model also contributed to improving the quality and continuity of diabetes care across the health service network.