The document discusses chronic disease management, particularly for respiratory patients in Thailand, emphasizing a patient-centered model that integrates care across various health services. It highlights the impact of chronic diseases, the importance of lifestyle changes, and the effectiveness of disease management programs in improving patient outcomes and reducing healthcare costs. Strategies for enhancing the quality of care include education for patients and caregivers, use of technology for follow-ups, and coordinated efforts among healthcare teams and community organizations.

1. หายใจ
Chronic Disease Management in
Respiratory Patients
นายแพทย์ชูชัย ศรชานิ
รองเลขาธิการ
สานักงานหลักประกันสุขภาพ
แห่งชาติ

2. ระบบทางเดินหายใจ
จานวนปี สุขภาวะที่สูญเสียเนื่องจากภาวะบกพร่องทางสุขภาพ
(YLD)

3. Years)
ของประชากรไทยกลุ่มอายุ 60 ปี ขึ้นไป พ.ศ. 2557 จาแนก
ตามเพศ และสาเหตุหลัก
ที่มา: รายงานภาระโรคและการบาดเจ็บของประชากรไทย พ.ศ. 2557

4. Health insurance system research office, 2011
อัตราการใช้บริการผู้ป่ วยนอกต่อประชากร 100,000 คน

5. Equity : Chronic Diseases and Illness
Universal Health Coverage
WHO promoting a ‘patient-centred model to
coordinate management of chronic diseases from
prevention to palliative care, at all levels of the health
system, across institutional boundaries
• People with multiple chronic diseases are able to
afford universal health coverage
• Promote integrated health service delivery networks
for the organization of the response to chronic
conditions , emphasize the importance of horizontal
integration between hospitals, primary health careที่มา WHO Europe 2012

6. คาจากัดความ โรคเรื้อรัง Chronic disease or chronic
condition
Need to promote lifestyle changes and medical
breakthroughs
They are of long duration and generally
slow progression. The four main
types are
1. Cardiovascular diseases (like heart attacks
and stroke)
2. Cancers
3. Chronic respiratory diseases (such as
chronic obstructed pulmonary disease
and asthma)
WHO. Noncommunicable Diseases. (2016). Available from: http://www.who.int/topics/noncommun

7. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1(1):2-4.
of people
 Chronic Care Model  กระบวนทัศน์ใหม่การ
จัดการ

8. Extend Your Care Beyond the Walls of the
Practice
Coordination across settings affects patients' clinical outcomes and
satisfaction with their care
• A chronic health condition can affect a
patient’s life in many ways and lead to
increased healthcare costs if not
managed effectively.
• While patients receive excellent care from
their providers, 95% of their lives are
spent outside the healthcare system.
• This makes it extremely challenging to
ensure that patients adopt and sustain
healthy behaviors outside the practice.
HOSPITAL
HOME EXACERBATIONS

9. Health Service Delivery System 4.0
Chronic diseases have a substantial impact on the lives
of people
Activated / Informed
patient and caregiver
Prepared / Proactive
Primary Care Team
Payer Service
Delivery
Design Special HC
Provider
Local
Community
Health IT System Social
Network mobile devicesAssociations
Patient and HC
Provider
Community
Population
Health Mnt.
Care mng. /
wellness / dz.
Mnt.
Distribution
Life Science :
Medicine Medical Devices
Diagnose

10. การจัดการโรคเรื้อรัง โรคระบบทางเดินหายใจ
Disease-management programs may enhance the quality of care provided
to patients with chronic diseases
• COPD disease-management programs modestly
improved exercise capacity, health-related quality of
life, and hospital admissions
• The goal of a disease management programs for
patients with COPD asthma is to provide home care
to patients with continuum and to improve their
wellbeing
• Chronic disease management programs for people
with COPD involving primary care improved quality
of life
Respir Med. 2007 Nov;101(11):2233-9. Epub 2007 Sep 4.
Systematic review of the effects of chronic disease management on quality-of-life in people with chronic obstructive pulmonary disease.
Niesink A1, Trappenburg JC, de Weert-van Oene GH, Lammers JW, Verheij TJ, Schrijvers AJ.

12. PATIENTS NEEDING HOME CARE
Comprehensive strategies to manage chronic disease and to deliver
improved chronic disease care
DISEASE & HEALTH EDUCATION
FOR PATIENTS AND CAREGIVERS
• Patients educational content to support
self-management of their health
conditions as they go about their lives
outside hospital
CONTINUUM OF CARE
• Patient responses to communications,
which solicit feedback over the course
of condition management
• Clinical staff follow up when patients

13. APPOINTMENT FOLLOW UP
• Patients receive (mHealth) follow up with
personalized appointment reminders and
opportunities to connect with clinical staff
when necessary
MEDICATION ADHERENCE
• Remind patients to take their medications
appropriately and queries patient
behavior with short surveys and response
mechanisms for a two-way dialogue.
PATIENTS NEEDING HOME CARE
Comprehensive strategies to manage chronic disease and to deliver
improved chronic disease care

14. What is Disease Management ?
Extend Care Beyond the Hospital
“Multi-disciplinary, continuum-based approach
to healthcare delivery that:
1. Supports the physician/patient relationship and
plan of care
2. Emphasizes prevention of exacerbations and
complications utilizing cost-effective, evidence-based
practice guidelines, and patient empowerment
strategies
3. Continuously evaluates clinical, humanistic, and

15. Multi-disciplinary Healthcare
Service Delivery

16. DISEASE MANAGEMENT ELEMENTS
For good health and don’t need to be
hospitalized
Patients leave the hospital with a personalized discharge
plan to help them avoid being re-admitted
1. Transition to home planning  Follow-up visit at home by
Transition Coach
2. Care management : Fitting People to Health Care in Their
Home Environments , clinical support and care coordination.
Caregivers (Family, Friends, อสม.) work toward helping their
patients achieve a full and speedy recovery
3. Information Communication Technology
4. Self-management : Telephone based service to improve self
managementProc Am Thorac Soc Vol 9, Iss. 1, pp 9–18, Mar 15, 2012 . Copyright ª 2012 by the American Thoracic

17. DISEASE MANAGEMENT ELEMENTS
+ Chronic Respiratory Diseases
Extensive wellness programs design to coach
people how to stay well.
6. Specialty referrals
7. Close links to Pulmonary Rehabilitation Program
8. Oxygen management,
9. Medical Devices and Equipment ,Pulmonary function
testing, Long-acting B2-agonists (LABA), Inhaled
corticosteroids (ICS)
10. Tobacco Cessation
Proc Am Thorac Soc Vol 9, Iss. 1, pp 9–18, Mar 15, 2012 . Copyright ª 2012 by the American Thoracic

18. DISEASE MANAGEMENT ELEMENTS
Spirometry : A Key to Early Detection of Chronic
Respiratory Diseases
• Spirometry in primary care setting is crucial
– Simple, inexpensive, office-based
– Consider every smoker (past and present)
• Decline in lung function is often undetected
– Patients may be asymptomatic or may
unconsciously
modify activity to compensate
• Identification and aggressive intervention

19. Good Chronic Disease Management
Listen to patients and hear their concerns
1. Use of information systems to access key data on
individuals and populations
2. Identifying patients with chronic disease and
stratifying patients by risk
3. Patients being discharged from the hospital have a
clear understanding of their after-hospital care
instructions, including how to take their medicines
and when to make follow-up appointments
4. Social worker can encourage the patient to contact
their doctor or offer how to appointments their

20. An effective COPD disease management
program
Continuum of Care
Reduce hospital admissions and decrease hospital and
total healthcare costs (excluding development and
management costs of DM programs). They also improve
health outcomes, including health-related quality of life.
(1) Assess and monitor disease
(2) Reduce risk factors
(3) Manage stable COPD
(4) Manage exacerbations
http://www.who.int/respiratory/copd/
management/en/

21. Self-management Skills and Healthy
Behaviors

22. Expanded Chronic Care Model
COMMUNITY
ORGANIZATIONS
HEALTHCARE
ORGANIZATIONS
Self Management
Support
Decision
Support
Delivery System Design
Clinical Information
Systems
Informed
Activated
Patient
Activated
Community
Prepared
Proactive
Practice Team
Prepared
Proactive
Community
Partners
Productive
Interactions &
Relationships
Improved Health and Functional Outcomes
บทบาทเครือข่าย
ชุมชน คนไข้
กองทุนหลักประกัน
สุขภาพแห่งชาติ
อบต. เทศบาล
ผู้ป่ วย อสม. ผู้นา
ชุมชน พระ ครู
NETWORK
Offer proven, effective
programming
Outreach to & engagement
of high risk populations
Provide gap-filling and
linkage
services
Increase access to
benefits and services Advocate for policies that improve health
ดัดแปลงเพิ่มเติมจาก
Victoria J. Barr, Sylvia Robinson, Brenda Marin-Link, Lisa Underhill, Anita Dotts, Darlene Ravensdale and Sandy Salivaras.

23. Achieving Chronic Diseases and Illness
Management
Holistic Care
Provide care that does not vary in quality because of
personal characteristics such as gender, ethnicity,
geographic location, and socioeconomic status
• Understand patients and their needs, Mental,
spiritual, and social needs of patients are considered
as biological machines
• Educating patients about self-care and helping them
to perform their daily activities independentlyที่มา
1. The 2001 Institute of Medicine report ; Crossing the Quality Chasm: A New Health System for the 21st
Century
2. Vahid Zamanzadeh, Madineh Jasemi,1 Leila Valizadeh, Brian Keogh,2 and Fariba Taleghan. Effective

24. Chronic Respiratory Conditions กับ Service Plan ใน

25. แนวทางการให้บริการรักษา ป้ องกันโรค ส่งเสริมสุขภาพ แ

26. Primary Care Cluster
กับ District Health Board
คณะกรรมการพัฒนาคุณภาพชีวิตระดับอาเภอ
District Health Board
(นายอาเภอ ผอ. เขต กทม. ประธาน สสอ. ผอ. ศูนย์บริการ สธ. เขตเลขา )
เวชกรรมสังคม
เวชศาสตร ์ครอบครัว
หน่วยบริการที่ไม่สังกัด สป. สธ.
มีแพทย์เวชศาสตร ์ครอบครัว
ศสม
.
รพ.
สต.
รพ.
สต.
รพ.
สต.
คลินิก
ชุมชน
อบอุ่น
ร้าน
ยา
คุณภา
พ
หน่วย
ร่วม
ให้บริ
การ
หน่วย
ร่วม
ให้บริ
การ
ทีม
1
ทีม
2
ทีม
3
ทีม
1
ทีม
2
ทีม
3
PCC 1 PCC 2
ทีมอาเภอ
ทีมตาบล /
พื้นที่ / แขวง
ทีมชุมชน

27. Value Based Healthcare
UCS กับการจัดการโรคเฉพาะ

28. Value Based Healthcare
Patient Centric

29. นายแพทย์ ชูชัย ศรชานิ
chuchai.s@nhso.go.th