Chronic Diseases Management in Community Setting

Abstract

This speech mainly focuses on the management of chronic diseases in community setting. It starts discuss about challenge faced : aging society, changing life style and family structure and having limited sources, those all requiring individual and systematic approach with efficient resources allocation. Intersectorality driven policy that on going in Thailand are 4 excellent policy: e.g promotion and prevention excellent, service excellent, people excellent, and governance excellent. Key component of NCD prevention and control including Intersectorality driven policy, comprehensive service plan, life course approach, comprehensive discharge plan, multi-sectoral and multi-disciplinary care team, comprehensive family and community assessment tool, effective information system and effective referral system. Key success of chronic diseases management in community setting is to “be in”: insider (to be part of the community), insightful (depth and breadth insight), integrative, innovative (community-based innovation and research), inspired (inspirational management). This speech also discuss about the 7 community tool include Geo Social Mapping, genogram, Community Organization Chart, Local Health Systems, Community Calendar, Local history and Life Stories. Three-Power Strategy of Health, including District Health System Accreditation in Thailand also discussed. The speech concludes that to have good chronic desease management in the community setting should be supported by good health care policy, good health care system and good multi-disciplinary team work.