7

27 2555

(.)



(.)

(.)

. . . 13170
02-4419040-3 15-18
02-4410163
Website: www.aihd.mahidol.ac.th,
www.thaiichr.org

(.)



(.)

(.)

. . . 13170
02-4419040-3 15-18
02-4410163
Website: www.aihd.mahidol.ac.th,
www.thaiichr.org

. .



.






..



.


.

60
97,900
47,000 128

90

( 2554
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.


.

60
97,900
47,000 128

90

( 2554
| 

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1

7
100 35 7
( 7)



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30-40

:

25 .. 2555
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3.2

()

15-29
30-44
45-59
60-69
70-79
80+

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3.7
8.5
13.6
14.3
12.9
6.0

(..2552)
(..2547)
(..2539)
(..2534)

0.5
3.2
11.6
19.2
17.1
10.5
7.7

6.9
6.8
4.6
2.3

.. .. .. ..

2534 2539 2547 2551


17.6 - 12.2 28.5



37.4 48.7 31.0 37.0



42.6 - 1.8 3.3




364 - 29.4 31.2
( ()
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: .. 25342535, .. 2539-2540, .. 2546-2547, .. 2551-2552

2534-2552

( 8)

| 

 1.8 2 )

1

7
100 35 7
( 7)



50-60
30-40

:

25 .. 2555
 |

3.2

()

15-29
30-44
45-59
60-69
70-79
80+

0.8
3.7
8.5
13.6
14.3
12.9
6.0

(..2552)
(..2547)
(..2539)
(..2534)

0.5
3.2
11.6
19.2
17.1
10.5
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6.9
6.8
4.6
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.. .. .. ..

2534 2539 2547 2551


17.6 - 12.2 28.5



37.4 48.7 31.0 37.0



42.6 - 1.8 3.3




364 - 29.4 31.2
( ()
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: .. 25342535, .. 2539-2540, .. 2546-2547, .. 2551-2552

2534-2552

( 8)

| 

10
1 6

()




15-29
4.6
0.9
30-44
15.4
10.1
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60-69
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44.9
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51.1
52.3
80+
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57.4


(..2552)
21.4
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22.1
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.. .. .. ..

2534 2539 2547 2551

61.5 50.8 8.6 20.9
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Systotic < 140 mm.Hg.

Diastolic
< 90 mm.Hg

71.3 - 15.0 20.7


10.2 26.6 4.9 8.7

1,606 - 71.4 50.3

()

: .. 25342535, .. 2539-2540, .. 2546-2547, .. 2551-2552

21 100
21

50
28
20
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1) (Primary Care)







80-90

| 

10
1 6

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15-29
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0.9
30-44
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10.1
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30.6
60-69
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44.9
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2534 2539 2547 2551

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Systotic < 140 mm.Hg.

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10.2 26.6 4.9 8.7

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: .. 25342535, .. 2539-2540, .. 2546-2547, .. 2551-2552

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28
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14 |

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| 35




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| 35




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36 |

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HbA1c
(Hemoglobin A1c) 2-3
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. ..
| 37




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HbA1c
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2554-2555 60

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7
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38 |

| 39

2554-2555 60

HbA1c (Hemoglobin A1c)

3 7
30-40



2-3

(Fundus
Camera)
(Distribute) ..

HbA1c (Hemoglobin A1c)

7
(http://hph.moph.go.th)

38 |

| 39


Monofilament
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..

40 |

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| 41

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3
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(20 ) CUP (6 )
CUP (1 ) CUP
(4 ) CUP 46 (1 ) 32

| 43

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.

3
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2)
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1.7
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Unit for Primary Care) CUP
(20 ) CUP (6 )
CUP (1 ) CUP
(4 ) CUP 46 (1 ) 32

| 43


3
1) PCU
(Primary Care Unit)

2)

PCU 3)

CUP
PCU 20
60-70


PCU




Case PCU
(.) (.)
Case (Uncontrolled
Complicated Case)

(Controlled Uncomplicated Case)

PCU . .

44 |

PCU
(Self Care) (Family
Care) (Community Care)
(Behavior Modification)
(Screening)





PCU
(Continuity of Care) PCU












(FCG: Fasting Capillary Blood Glucose)
1
| 45


3
1) PCU
(Primary Care Unit)

2)

PCU 3)

CUP
PCU 20
60-70


PCU




Case PCU
(.) (.)
Case (Uncontrolled
Complicated Case)

(Controlled Uncomplicated Case)

PCU . .

44 |

PCU
(Self Care) (Family
Care) (Community Care)
(Behavior Modification)
(Screening)





PCU
(Continuity of Care) PCU












(FCG: Fasting Capillary Blood Glucose)
1
| 45


Metabolic Syndrome




PCU
Walk in




PCU




(Fundus Camera)


PCU 20


PCU
(Continuous Care
in PCU)

46 |

[Clinical (Appropriate)
Practice Guideline DM HT] 4




(Appropriate)



(Electronic Medical Record) HAMIS (Hospital
Advance Management Information System)
Smart DM


(DM Center) Version 1.1 1.5




PCU
4

DM Diabetes Mellitus HT
Hypertension
| 47


Metabolic Syndrome




PCU
Walk in




PCU




(Fundus Camera)


PCU 20


PCU
(Continuous Care
in PCU)

46 |

[Clinical (Appropriate)
Practice Guideline DM HT] 4




(Appropriate)



(Electronic Medical Record) HAMIS (Hospital
Advance Management Information System)
Smart DM


(DM Center) Version 1.1 1.5




PCU
4

DM Diabetes Mellitus HT
Hypertension
| 47





(LAB)







(Pneumonia )

PCU

PCU
(Admit)



/

48 |

(Non Drug Treatment)
(Behavior Change)

HbA1c
8
One Day Camp




One Day Camp









4



( )
| 49





(LAB)







(Pneumonia )

PCU

PCU
(Admit)



/

48 |

(Non Drug Treatment)
(Behavior Change)

HbA1c
8
One Day Camp




One Day Camp









4



( )
| 49

 1
10-20






.


3-5




1) 2) . 3) / 4)
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100 2555

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| 51

 1
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.


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1) 2) . 3) / 4)
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100 2555

PCU

| 51


HbA1c 7

40
(Hypoglycemia, Hyperglycemia, Infection)





PCU





7-11 (Seven + Eleven
= 7-11) 7-11 PCU

PCU

52 |

. PCU

| 53


HbA1c 7

40
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PCU





7-11 (Seven + Eleven
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PCU

52 |

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| 53

.








.
120



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1
1
15
.


2
54 |

(EMS: Emergency Medical Service)
- 5

..

3 1
3



Metabolic Syndrome


2
Metabolic Syndrome

(Cholesterol, Triglyceride, HDL, LDL)
Metabolic Syndrome

| 55

.








.
120



..

1
1
15
.


2
54 |

(EMS: Emergency Medical Service)
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..

3 1
3



Metabolic Syndrome


2
Metabolic Syndrome

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Metabolic Syndrome

| 55





2



7
(Range)
(Trend)

21
30-44 45-59

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..

56 |

2552
2568
65 22
15 17 2
40 60
15-65

60 40

60
40-50
22 10

30





Case

| 57





2



7
(Range)
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21
30-44 45-59

(Ageing Society) 65
..

56 |

2552
2568
65 22
15 17 2
40 60
15-65

60 40

60
40-50
22 10

30





Case

| 57



3





2546 ..





(Package)

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(Model)

58 |

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200
7
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| 59



3





2546 ..





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7
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Primary
Prevention

| 59







(Sodium)
(Literacy)







(
)

60 |

-



PCU

1

| 61







(Sodium)
(Literacy)







(
)

60 |

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1

| 61

Primary
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2

1
.

62 |

.
2



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(Dynamic)








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| 63

Primary
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62 |

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2



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| 63






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(Case Manager)
. ..


3

. (Contract)

.





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74 |

(Outcome)

| 75





(Case Manager)
. ..


3

. (Contract)

.





. 2

74 |

(Outcome)

| 75


On top payment 5
..

2


Metabolic Syndrome

(On top payment)

2554
5.4 (

(www.nkp.moph.go.th)
76 |

(Health Promotion)
(Prevention) (Human Resource)


Metabolic Syndrome



..












| 77


On top payment 5
..

2


Metabolic Syndrome

(On top payment)

2554
5.4 (

(www.nkp.moph.go.th)
76 |

(Health Promotion)
(Prevention) (Human Resource)


Metabolic Syndrome



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| 77




(Outcome Mapping)

.





78 |

(Glucose)

1) 2) 3)

--
3
1

| 79




(Outcome Mapping)

.





78 |

(Glucose)

1) 2) 3)

--
3
1

| 79




3 . 2 . (3 . --
2 . -)











2






...

1-2
80 |

| 81




3 . 2 . (3 . --
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2






...

1-2
80 |

| 81

:

. .

. .



(...)
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82 |

NPL (Non Performing Loan)

. . .



..
.
..
















| 83

:

. .

. .



(...)
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82 |

NPL (Non Performing Loan)

. . .



..
.
..
















| 83




--
3

(Specialist)

(Tertiary Care) (Secondary Care)

84 |

(Primary Care)











21




(Shift)








| 85




--
3

(Specialist)

(Tertiary Care) (Secondary Care)

84 |

(Primary Care)











21




(Shift)








| 85





.


Accredited
HA (Hospital Accreditation)

(Self Care) (Family Care) (Community
Care) Accredited






3 EQE

E Equity Q Quality
2 E
Efficiency



17 GDP (Gross Domestic
Product) (Advance)
86 |

(Well-Trained)



6



(Barack Obama)











80,000

(Hemophilia )

| 87





.


Accredited
HA (Hospital Accreditation)

(Self Care) (Family Care) (Community
Care) Accredited






3 EQE

E Equity Q Quality
2 E
Efficiency



17 GDP (Gross Domestic
Product) (Advance)
86 |

(Well-Trained)



6



(Barack Obama)











80,000

(Hemophilia )

| 87









3

(Spirit)

2-4


140/90 .

(Systolic pressure)
(Diastolic pressure)
, Prehypertension, hypertension stage1, hypertension stage 2

60

88 |

| 89









3

(Spirit)

2-4


140/90 .

(Systolic pressure)
(Diastolic pressure)
, Prehypertension, hypertension stage1, hypertension stage 2

60

88 |

| 89

97,900 2 5
47,000 128
* 90


( 2554
1.8 2 )




2547
9
(DALYs)
( 3.2 DALYs) 3
( 6.9 DALYs)
5 2
70,000 ( 18)

6 ( 6

* : (
)

25 2555
90 |

DALYs) (,
2550)

4
2551-2552
15 6.9 3.2 (

6-7 100 )
7.7 0.6 1529 70-79 (
19.2) 60-69 ( 16.7)

()
( 31.2)
( 3.3)

(
37.0) (
< 126 ./.) ( 28.5)


21.4 10

1 6

50.3
8.7

| 91

97,900 2 5
47,000 128
* 90


( 2554
1.8 2 )




2547
9
(DALYs)
( 3.2 DALYs) 3
( 6.9 DALYs)
5 2
70,000 ( 18)

6 ( 6

* : (
)

25 2555
90 |

DALYs) (,
2550)

4
2551-2552
15 6.9 3.2 (

6-7 100 )
7.7 0.6 1529 70-79 (
19.2) 60-69 ( 16.7)

()
( 31.2)
( 3.3)

(
37.0) (
< 126 ./.) ( 28.5)


21.4 10

1 6

50.3
8.7

| 91

20.7 ** 20.9

( 1 96)

***

**
Systolic <140 mm.Hg. Diastolic<90mm.Hg)
***: .

; 2552 (32)

1.
2.
Lifestyle modification
Lifestyle


(Mindset)




( 2 96)

( >
90 . 80 . ) 15
15 36

( 150
)
21
24
5
15-74 17.34

15-74
22.25

92 |

| 93

20.7 ** 20.9

( 1 96)

***

**
Systolic <140 mm.Hg. Diastolic<90mm.Hg)
***: .

; 2552 (32)

1.
2.
Lifestyle modification
Lifestyle


(Mindset)




( 2 96)

( >
90 . 80 . ) 15
15 36

( 150
)
21
24
5
15-74 17.34

15-74
22.25

92 |

| 93

94 |

:


Self-management support




:


Self-management support

:

1. Clinic:

2. Tertiary prevention:

3. Secondary prevention:

4. Primary prevention:

| 95

94 |

:


Self-management support




:


Self-management support

:

1. Clinic:

2. Tertiary prevention:

3. Secondary prevention:

4. Primary prevention:

| 95

4 5
3

+

/++
+

2

1

4





1.

44 ( .) 505 .

2.
(NHES)1-4
.
BRFSS 3.
Cancer, ACS, Stroke, DM, COPD

1


2

4
/

5
96 |

| 97

4 5
3

+

/++
+

2

1

4





1.

44 ( .) 505 .

2.
(NHES)1-4
.
BRFSS 3.
Cancer, ACS, Stroke, DM, COPD

1


2

4
/

5
96 |

| 97



P
r
e
p
a
r
e
d

-
- &
-
-

ted
Motiva

-
-

-

-

Info
rne
d

Better Outcomes for Chronic conditions
: Innovative Care for Chronic Conditions: building blocks for
action, World Health Organization, 2002.

3


3

98 |

3 1)
2) 3)

| 99



P
r
e
p
a
r
e
d

-
- &
-
-

ted
Motiva

-
-

-

-

Info
rne
d

Better Outcomes for Chronic conditions
: Innovative Care for Chronic Conditions: building blocks for
action, World Health Organization, 2002.

3


3

98 |

3 1)
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| 99

.
(..)


(..)

..

-


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http://portal.in.th/diabetes/pages/14095

104 |