Abstract
The one of leading non communicable disease burdens around the world including Thailand are Diabetes Mellitus and Hypertension. Health delivery system in Thailand was not proactive enough even having some focal innovative good practicing around country but lack to integration as a system. The management initiative of linking between concepts of Diseases Management, Chronic Care Model (CCM) and Chronic Diseases Management Model was integrated to WHO’s “Chronic disease prevention model”. Our conceptual framework is stress on ‘continuums’ ‘integrations’ and ‘comprehensive’ aiming to developing and testing “The integration of chronic disease management system in Diabetes Mellitus and Hypertension Model: phase I ” in provincial level.
Method : Action research by purposive sampling. Develop assessment tools for assessing the situation in 4 issues. Field testing those assessment tools was performed in the area of Sakon Nakhon province and participatory develop the provincial strategic plan.
Results : 1) The situation assessment tools was developed: a) Health service policy and community strengthening. b) Health service delivery design. c) Self management and self management support. d) Performance indicators. 2) Participatory Sakon Nakhon’s provincial strategic plan.
