Chronic kidney Disease Management with Chronic Care Model at Primary Care in Nakhon si thammarat Province

Abstract

          Quasi - Experimental Research, one Group Pretest - Posttest Design. To study the effects of CKD management program by using chronic care model.An intervention had to integrate all of the six areas of chronic care model:self-management support, decision support, delivery system design, clinical information systems, health care organization, and community resources. 30 Patients with CKD stage 3 or 4 were enrolled with in the programbetween January and June 2017.We analyzed the performance against clinical targets looking at a change in renal function, blood pressure controland the proportion of patients achieving of Self-Care Behaviorprior to and following joining the program. The samples were significant improvements after 24 weeks, sincesystolic blood pressure decreased. They also increased significantly in perception, knowledge and skill in self-care behavior. Additionally, patients who had a decrease in eGFR before the program experienced a significant increase in eGFR .

          These data suggest that CKD management in primary care based on chronic care model is an effective method for managing patientswith CKD. The improvement in risk factors and reduction in the rate of declineof renal function havepotentially significant health benefits for the patients and should resultin cost effectiveness for the health care system.