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Implementin014 PDF
Implementin014 PDF
Department of Health
OFFICE OF THE SECRETARY
},|AY 2 3 2016
ADMINISTRATIVE ORDER
No.2016 - 00ll4
SUBJECT: Implementins Guidelines on the Orsanization of Health Clubs for
Patients with Hvpertension and Diabetes in Health Facilities
I. RATIONALE
Non-communicable Diseases (NCDs) continue to be the top causes of deaths among
Filipinos. Of these, hypertension remains the leading illness. Diabetes continues to be
significantraffecting around 5Yo of our adult population (Source: FNRI - National Nutrition
Survey,20l3).
To address the call for health interventions that are cost-effective and sustainable, the focus is
on the most vulnerable risk group using two most common and easily detectable clinical
manifestations of NCDs: hypertension and diabetes. By accelerating case detection of
patients with risk factors, illnesses will most likely be found at an early stage, that is, before
the onset of any damage to target organs.
Campaigns are needed to detect as many patients as possible in the early stages of
hypertension and diabetes. Organizing patients into active Health Clubs is one of the
strategies to ensure continuity ofcare, raise the effectiveness oflifestyle changes and prevent
complications.
The following guidelines are hereby issued to strengthen the fight against NCDs at the
primary health facilities specifically, the health centers and barangay health stations. These
guidelines reiterate the policies and thrusts outlined in the'National Policy on Strengthening
the Prevention and Control of Chronic Lifestyle Related Non-Communicable Diseases
(NCD)" (DOH AO 2011- 003), and "Implementing Guidelines on the lnstitutionalization of
Philippine Package of Essential NCD lnterventions (PhilPEN) on the lntegrated Management
of Hypertension and Diabetes for Primary Health Care Facilities" (DOH AO 2012 - 0029).
II. OBJECTIVES
A. General objectives
These guidelines aim to gulde various stakeholders in health care in creating and
sustaining Hypertension-Diabetes Health Club s.
B. Specific objectives
l. Define the process of accelerating the identification of patients based on the PhilPEN
protocol, of creating a Patient Registry and of recruiting these patients into health
clubs.
Building l, San lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila o Trunk Line 651-78-00 Drect Line: 711-9501
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Fax:743-1829;'143-1786 URL: httorl/www.doh.gov.ph; e-mail: osecG)doh.gov
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2. Define the services and activities of the health club that will ensure at least 90Yo
continuity of care to hypertensive and diabetic patients according to the PHIL PEN
guidelines on lifestyle changes and the DOH guidelines on conlmunity activities
especially patient education and motivation.
J. Promote better access to maintenance medications and management of
pharmaceutical supply chain.
4. Define the roles and responsibilities of the different DOH offices and agencies, the
LGUs and other stakeholders in organizing and sustaining health clubs.
5. Create a mechanism for conduct of patient clubs that can be applicable for other
diseases entities.
Chronic Lifestyle Related NCDs affect the vulnerable age groups in all economic levels. Case
finding and treatment shall no longer be limited to priority areas identified through the
Conditional Cash Transfer (CCT) program or to families under the National Household
Targeting System (NHTS) for Poverty Reduction.
B. Health Facilities - these are facilities that provide screening and management of
diseases like hypertension and diabetes. May include but not limited to city health
offices, rural health units (RHUs) and barangay health stations.
D. DOH Health Clubs - an organ izationthat consist of officers with rules and by-laws
and a common goal of improving the health and wellness of its members. lnitially,
these shall be organized in health facilities such as RHUs and expanded to barangays.
V. GENERAL GUIDELINES
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persons 40 years old and above.
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B. MANDATORY REGISTRY. All RHus/health centers shall have a registry of all
hypertensive and diabetic patients to closely monitor their health conditions and for
provision of medications.
D. SERVICE DELIVERY NETWORI(. Each health facility shall ensure that there is a
network of higher facilities and providers within the province or city-wide health
systems where referrals and other health care services can be provided.
3. Those found to have BP >140190 on both readings shall be referred to the local
government staff (midwife or nurse) who shall verify the elevated BP reading one
week later
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4. All those verified to have elevated BP >140/90 by the health center midwife or nurse
shall be:
a. Referred to the physician/Municipal Health Officer (MHO) to confirm diagnosis
of hypertension and examined for any sign or symptom of underlying causes (eg.
renal disease) and target organ damage. Using PhilPEN, risk prediction can be
done to estimate the cardiovascular risk of the patient.
b. Have their fasting blood sugar/glucose (FBS) tested
c. Started on the first line antihypertensive medicine as prescribed by the doctor and
if not contraindicated based on the available drugs provided by DOH
(Amlodipine 5 mg, 1 tablet, daily) and test blood cholesterol if available
d. Registered in the health center Hypertensive Patient Registry
e. Strongly encouraged to enroll in the Hypertension-Diabetes Health Club,
f. Assessed for secondary hypertension andl or signs and symptoms of some target
organ damage and then referred to a hospital for fuither evaluation
5. All other persons without hypertension but have a family history of diabetes, are
obese and with signs and symptoms of possible diabetes shall also have their fasting
blood sugar/glucose (FBS) tested.
6. All patients found to have high capillary FBS (>7.0 mmol/l or 126 mg/dl) shall have
their FBS retested using venous blood done by a medical technologist either in the
health center laboratory, local hospital laboratory or a private laboratory and shall be:
C. Health Education
1. All patients registered in the hypertensive and diabetic patient registries shall have
their first health education session given by the health facility nurse or midwife.
2. Topics on first health education session shall be composed of but not limited to the
following:
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a. Diet changes needed for their specific condition (e.g. increase intake of fruits and
vegetables)
b. Increased physical activity (at least 30 minutes brisk walking three times a week),
c. Cessation of smoking and reduction of alcohol intake, when relevant, and
d. Prevention of common infections
3. Subsequent health education sessions to reinforce the health messages may be given
by the midwife or a BHW specially trained for this task.
D. Follow-up
1. All patients with hypertension shall have their BP taken by the BHW at least once a
week to verify that their BP is under control. Follow-up of these patients with the
physician shall be monthly until BP is controlled and 3 - 6 months thereafter. Those
found to still have BP >T40190 shall be referred back to the physician who may decide
to:
a. Increase the dose of the current medication, OR
b. Shift medication to the second line drug if not contraindicated (Losartan 50 mg
daily), OR
c. Add Losartan on top of Amlodipine
2. All patients with diabetes shall have repeat capillary FBS testing every three (3)
months. Those found to still have FBS >7.0 mmolll or 126 mg/dl shall be re-evaluated
by the health center physician or any physician who may decide to:
a. Increase the dose of the current medication, OR
b. Shift to the second line drug (Gliclazide 80 mg daily), OR
c. Refer the patient to a hospital for further evaluation
3. Patient treatment booklet shall be given to the patient and shall be used to monitor the
dispensing of medications and health promotion activities. The booklet shall contain
all the essential clinical information that should be assessed and monitored on a
regular basis.
4. Clients who are 40 years old and above who still do not manifest any signs of
hypertension or diabetes but are known smokers, have a family history of diabetes
and/or are obese should continue to be followed up at least every 3 to 6 months since
they are still considered low to moderate risk or with <20yo CV risk.
1. Enrollment
a. All patients with Chronic Lifestyle Related NCDs shall be encouraged to enroll in
an appropriate health club in their respective health centers.
b. Patients who agree to enroll in the club shall fill- up the application form (Annex
B) and will be issued an ID and patient booklet.
c. The club member shall be informed of scheduled activities from which incentives
can be provided if attended (e.g. 1 activity - 1 raffle ticket; total of 3 raffle tickets
can be equivalent to a discount voucher for diagnostics/gift items)
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d. There shall be only one club for hypertensive and diabetic patients since many
diabetics are also hypertensive and the activities to promote lifestyle changes are
the same for both types of patients.
3. Core Activities of the Hypertension and Diabetes Health Club shall include:
a.Lifestyle improvement activities such as changes of diet, increased physical
activities, cessation of smoking, reduction of alcohol intake;
b. Health education especially on prevention of common infections and proper
use of medications, among othersi
c.Periodic measurement of BP and FBS including reminders when these have to be
repeated, eg. through mobile phones;
d. Replenishment of free medications; and
e.Mental health improvement activities to encourage bonding among members and
to relieve stress.
4. Membership Number
a. Each club member shall be given a unique chronological Club membership
number in the following format:
i. DOH Heath Facility Code (FC) of the National Health Facility Registry
System - Year of enrollment in the club -particular health club and
chronological number of patient
ii. Example for the first club member who is registered in Payatas B Health
Center, #I7 Bulacan St.,2nd District, Quezon City. Enrolled in the
Hypertension and Diabetes Health Club, year 2016: FC102 - 2016 - H/D
Club - 1
5. ID
a. Each patient shall receive a unique identification (ID) card color-coded according
to their clinical classification as follows:
i. YELLOW: (<20% risk score) the patient has hypertension OR diabetes only
(no signs or symptoms of target organ damage).
ii. ORANGE: (20-30% risk score) the patient has hypertension AND diabetes
without any sign or symptom of target organ damage.
11i. RED: (>30% risk score) the patient has hypertension and I or diabetes AND
signs of target organ damage.
b. When the clinical condition of the patient improves or deteriorates, he/she shall be
given an adjusted color ID.
c. Red coded patients shall also be enrolled in hospital-based health clubs but they
will retain their unique facility-based Club membership number. They can be
active in either clubs but shall claim their free medications only from their
respective RHUs.
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6. Medications
a. Newly diagnosed hypertensive and diabetic patients shall:
i. Receive a prescription good for 3 months from the City/Municipal Health
Officer
ii. Receive maintenance medications in the Rural Health Units where they are
registered on a monthly basis.
8. Affiliations
a. Patient-initiated health clubs, such as those organized in schools, workplace or
churches, may be recognized as affiliated chapters in the Barangay where the
school, workplace or church is located.
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b. The health club may start with a few members that is health center/RHU - based
and over time, with additional members, health promotion activities could be
organizedthrough a club in each Barangay.
c. The Barangay-based club shall maintain its links with the Main RHU-based Club
through specific activities that need the presence of physicians (e.g. during follow-
up health assessment).
1. The Task Force for Health Clubs shall develop a monitoring and evaluation
mechanism to measure the inputs, processes and outcomes expected from the
implementation of this issuance. The monitoring will be based on existing mechanism
that is currently used for PhilPEN implementation and for inventorylutilization reports
of medications.
2. The DOH Hypertension and Diabetes Club shall be measured in terms of:
a. Performance indicators to measure attainment of targets in terms of patients
identified and treated, health clubs organized and functional, and NCD drug
utilization
b. Indicators of the effectiveness of health clubs in preventing adverse health
outcomes.
3. Periodic reports on the performance of various DOH offices and agencies shall be
written and disseminated through quarterly monitoring and performance evaluation
meetings with appropriate DOH offices and stakeholders.
4. Guidelines for monitoring of drug reactions at the RHU level will be developed by the
Pharmaceutical Division in collaboration with the Food and Drug Administration.
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c. Collaborate with DPCB and other DOH units in developing a practical mechanism
to harmonize and monitor inputs, processes and outcomes related to the
organization and maintenance of health clubs.
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Pharmaceutical Division shall :
a. Collaborate with the KMITS-LMD and the Procurement Service to ensure the
timely purchase and distribution of essential medicines for NCDs.
b. Collaborate with DPCB and BLHSD in developing an efficient and secure drug
distribution and monitoring system for drugs and medicines purchased by the PD
for NCDs and distributed through Hypertension-Diabetes Health Clubs.
c. Assist the DOH Regional Offrces in disseminating important information on the
proper use, handling and utilization of drugs and medicines.
d. In collaboration with FDA, develop guidelines for monitoring drug reactions at the
RHU level (pharmacovigilance).
IX. FUNDING
The Department of Health Central Office through DPCB, BLHSD and HPCS shall provide
funds for technical assistance, commodities such as glucose strips, monitoring, capacity
building and health promotion campaigns to ensure that the above-mentioned activities are
implemented. Likewise, the Regional Offices through counterpart departments/divisions of
central office shall allocate funds for the same strategies.
The Pharmaceutical Division shall allocate funds and procure maintenance medications
needed for chronic diseases.
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Local government units shall provide funds for health facility activities in their respective
communities. Other goveflrment agencies, non-government organizations and other
stakeholders and partners in health shall provide funds as appropriate to ensure the
implementation of this guideline.
X. REPEALING CLAUSE
XI. EFFECTIVITY
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ANNEX A
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o The physician/MHO will further evaluate the patient (for target organ damage, secondary
hlpertension, etc.) and start appropriate medications:
First line anti-hypertensive.' Amlodipine (based on drugs provided by DOH)
First line anti-diab etic.' Metformin
o Monitor BP and capillary FBS monthly until target goals are met
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ANNEX B
APPLICATION F'ORM
DOH ITYPERTENSION AND DIABNTES CLUB
Date:
Name of patient:
LASTNAME FIRSTNAME MIDDLE NAME
Birthdate: Age: _ Sex:
b. Sample ID
DOH
HYPERTENSION AND DIABETES CLUB
Patient No.:
Name:
Address:
RHU:
Birthdate: Sex:
Contact number:
FRONT
ln case of emergency:
Name:
Address:
Contact number:
Signature of member
BACK
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