Abstract
An implementation research on the development of integrated-people centered care started a
pilot reform of service delivery system in 20 primary care clusters (PCCs). Patients with diabetes and/or
hypertension were employed in this pilot test model. An initial assessment was taken after a 4-months
implemention on patient’s experiences on receiving integrated people-centered care comparing between
PCC under the project with other primary and ambulatory care facilities in the same district. A community
survey of 200 samples was conducted from each district. There were totally 4,071 samples, 1,311
samples from hospital DM/HT clinics, 1,721 from PCCs in the project, 823 from other PCCs, and 216
samples from health centers.
Results showed that PCCs in the project had significantly better patient-family care team relationship
compared with other types of health facilities, a greater proportion of patients knew the name of family
physician, family care team, and had more convenient communication channel. However, the target of
receiving care from the same family doctor and team needed further improvement. The PCCs in the
project achieved significantly greater proportions of patients receiving care according to the guideline for
chronic illness care in most of the 5 dimensions (knowing health determinant factor, care plan, goal
setting, health behavior, and care result) compared with other types of facilities. However, the dimension
on health behavior modification got relatively low score compared with other dimensions. It is noticeable
that the other PCCs did not perform any better than hospital DM/HT clinics either in terms of patient-doctor/
family care team relationship or care for chronic illness. Further implementation research is needed
to evaluate implementation outcomes and service outcomes of the model.
