Abstract
Background: The Ministry of Public Health has realized improving quality of diabetes care in
response to the escalating global burden of diabetes. This study aimed to develop an integrated chronic
care model promoting dietary behavior changes through a low-carbohydrate diet and strengthening
self-care engagement via telemedicine. The intervention aimed to enhance self-management capacities,
achieve glycemic control.
Methodology: The study employed a research and development design divided into three phases:
problem situation analysis, model development, and evaluation of the model’s effectiveness. In phase
1, a qualitative study was conducted involving 7 service providers from the noncommunicable clinic
and 15 uncontrolled type 2 diabetes patients purposively selected. Phase 2 focused on developing an
integrated diabetes care model based on phase 1 findings, incorporating elements of the chronic care
model, health literacy principles, and motivational theory. In phase 3, a quasi-experimental study was
conducted among uncontrolled type 2 diabetes patients at four pilot sub-district health promoting
hospitals. Participants were systematically allocated into two groups: an experimental group receiving
the health behavior modification interventions and a comparison group receiving standard usual care.
Each group consisted of 20 participants. Qualitative data were analyzed using content analysis, while
quantitative data were analyzed using descriptive statistics, Fisher’s exact test, independent t-test, and
multivariable regression analysis.
Results: The standard usual care service was ineffective in assessing patients’ self-management
needs and providing individualized advice, resulting in service overcrowding and persistent inappropriate
health behaviors among patients with diabetes. To address these issues, an integrated care system
was developed, offering personalized self-management support, data transfer, and telemedicine-based
follow-up at sub-district health promoting hospitals. Following implementation, patients demonstrated
improved self-care behaviors, significant reductions in HbA1C levels, improved lipid profiles, and decreased
use of glucose-lowering medications.
Conclusion: The integrated diabetes care model was effective in better glycemic and lipid control
among uncontrolled type 2 diabetes patients. Scaling the implementation of this model to additional
community hospitals could enhance effective diabetes care delivery at the local level. Furthermore, the
model could be adapted as a diabetes remission model at sub-district health promoting hospitals.
