Abstract
Chronic diseases are a major public health problem that requires urgent solutions to
reduce mortality and health care expenditure. It has been found that value-based care and
community-based care can help improve the quality of care and create cost-effective services.
However, local agencies who are responsible for caring for vulnerable people and those
suffering from such diseases are not yet possible to identify the problems arising from
traditional services to redesign the services. Therefore, the objective of this project is to
1) study the clinical and financial outcomes of traditional services and 2) co-design valuebased service and cost analysis plans with local agencies.
A retrospective study of traditional service showed that the number of people with
diabetes and hypertension is increasing every year. Although the percentage of new cases and
the percentage of patients with complications (chronic kidney disease) are decreasing, the
percentage of these patients who are able to control the disease is decreasing every year. It
shows that traditional services still have vulnerabilities in the care of this group of patients. In
addition, from the historical analysis of service costs from 43 databases, it was found that there
were some types of service fees that were not stored in the 43 databases and were not
recorded in alphabetical form, such as telemedicine service fees and home visit service fees.
It is critical to calculate the cost-effectiveness that will occur if community-based value services
are provided. Therefore, from the meeting to discuss the problems arising from the historical
data obtained with local agencies. This resulted in a value-based service model and a data
collection approach to analyze service costs. The service model and costing are divided
according to the risk of the population group (high-risk, ill-controllable and ill-uncontrollable),
each group will use different levels of personnel, information, and frequency of monitoring
required to be able to properly care for each group of the population according to the
resources available.
After obtaining service models and data collection guidelines to analyze the cost of
services for value-based services, the research team will hold another meeting with local
agencies to consider the appropriateness of the service model and the collection of such
service charges. Appropriate adjustments will be made to ensure that the plan is practical in
a variety of areas. Then, the service model and service fee collection plan will be finalized
before ending the project.
