Effectiveness of a care management model for priority chronic diseases in Thai Binh province in the 2024-2025 period

Abstract

This study evaluates the effectiveness of a management model for five priority chronic diseases (Hypertension, Type 2 diabetes, Osteoarthritis, Alzheimer’s disease, and Gastritis) identified through the Delphi technique. Methods: A community-based intervention study with a before-and-after comparison design was conducted among 444 residents in 8 communes/towns in Thai Binh province (before the administrative merger), now Hung Yen province. Results: The model recorded breakthrough improvements in treatment adherence, particularly the role of village health workers in medication reminders (Effectiveness Index – EI) reached 512.4%. The periodic follow-up rate reached a definitive 100%, demonstrating a clear shift towards primary healthcare as the follow-up rate at commune health stations increased by 127.4%, significantly reducing the burden on provincial hospitals (-60.4%). Lifestyle behaviours showed positive transformations: the habit of exercising increased by 263.9%. Furthermore, homebased care activities were strengthened, with household visits increasing by 567.4%, leading to an overall public satisfaction rate of over 74%. Conclusion: The model has affirmed its effectiveness and practical value in bringing chronic disease management services closer to the people, optimising the role of primary healthcare, and reinforcing community trust in the primary healthcare system.