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Our aim is to reduce morbidity and mortality related to Non communicable diseases such as hypertension, diabetes, cardiovascular disease, stroke, Obesity, Cancer and lifestyle diseases among those least able to withstand the burden of the disease.

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non communicable disease ncd global scenario role of family physician

Non Communicable Disease(NCD)-Global Scenario & Role of family Physician

Dr Rajesh Jain MD

EX-Medical Officer- WHO

Project Manager Diabetes Prevention Control Project-

Uttar Pradesh(NRHM)

&

Supported by World Diabetes Foundation,Denmark

global ncd targets

Global NCD Targets

20%15%

<15.0%

23%15%

32.2%24.0%

HED* <1.2%

8.7 6.0gm

35.2%30.0%

* Heavy episodic drinking

Source of icons: World Heart Federation Champion Advocates Programme

seven strategies prevention and promotion

Seven Strategies:

Prevention and Promotion

Clinical Management

Increasing Patient Compliance

Action with NGOs, Professional Bodies & Other Stakeholders

Monitoring, Research and Surveillance

Capacity Building

Policy and Regulatory interventions

seven strategies prevention and promotion 1

Seven Strategies:

  • Prevention and Promotion
  • Clinical Management
  • Increasing Patient Compliance
  • Action with NGOs, Professional Bodies & Other Stakeholders
  • Monitoring, Research and Surveillance
  • Capacity Building
  • Policy and Regulatory interventions
translating chronic care model into our primary care
Translating Chronic Care Model into Our Primary Care

Coordinated, Continuous and

Comprehensive Care

Productive Interactions

Multidisciplinary NCD Team

  • Physician
  • MO
  • Nurse / DE
  • Dietician
  • Pharmacist

Informed, Empowered Patient

Self-management support

46

Decision support

Efficient Clinical Information System

Community Resources

1 peer support diabetes program
1. Peer Support Diabetes Program
  • The program module was reviewed twice and now in the final stage of preparation.
  • NCD will be responsible for developing the program and training modules, conduct training, implement and monitor the program.
peer support diabetes program
Peer Support Diabetes Program
  • Rationale:
    • Informed, Empowered Patient is one of the crucial component of the Chronic Care Model.
    • Patients are more likely to accept advise from their peers or people living with the same condition.
  • Successful implementation of a Peer Support Group Program in other countries (e.g. US, Canada) have shown to:
    • Help patients understand and in control of their disease better;
    • Help patients achieve good disease control; and
    • Reduce rates of referral to hospitals due to complications.
certified training for gps
Certified Training for GPs
  • This program has been carried out by 100 centers across India by 200 trainers across country
    • PRAYAS – since 2009-13, “mentor-mentee system”.
    • Lucknow ,Prayas (and Aventis,Bohreinger,WDF) – peer as trainers during diabetes education session.
2 appraisal system for excellent diabetes health centre uttar pradesh
2. Appraisal System for Excellent Diabetes Health Centre ,Uttar Pradesh
  • This appraisal system will act as a motivational drive for healthcare providers to improve quality of Diabetes care at 42 District hospitals and 634 CHC by 2018 in Uttar Pradesh.
  • NCD Clinic at CHC & District hospital 2014, involving officers from the Family Health Development Division, State Epidemiologist (NCD), Family Medicine Specialists, Medical Officers and Diabetes Educators.
  • 3000 Doctors & 6000 Staff Nurse and 1 lakhs ASHA to be trained in Diabetes & NCD Control by 2018
  • Programme is supported by World Diabetes Foundation,WDF,Denmark.
  • NCD Training for Doctors and Nurse in 20 Districts with Bohreinger already started.
3 personalised ncd care
3. Personalised NCD Care
  • Definition:
    • Personalised care planning empowers individuals (patients with chronic diseases), promotes independence and helps people to be more involved in decisions about their care.
    • It centres on listening to individuals, finding out what matters to them and finding out what support they need.
  • Rationale:
    • Individuals with long term conditions will be at a point be able to take more control over their condition and understand how it affects their lives.
    • 70% of individuals with a long term condition say their care has improved as a result of personalised care planning (GP Patient Survey 2009/10, Department of Health, UK).
basic concept of
Basic concept of

Coverage of NCD

ASHA, ANM & Volunteers as agent of change

Positive behavioural change at the community level through effective interventions

Extensive coverage through collaboration between NGOs, ASHA & Volunteers

Target Uttar Pradesh:

200 Trainers

1,00000 ASHA,

6000 ANM,GNM 3000 GP

Trained by 2018

strategies

Strategies

Scope

  • Healthy eating
  • Active living
  • Smoke-free
  • Weight management
  • Early detection of NCD risk factors
summary
Summary
  • In order to achieve the voluntary NCD global targets, we need to prioritise our actions
    • NCD prevention
    • NCD control / management
  • What are the biggest contributors or determinants?
  • What factors are within our control? What factors are beyond?
  • Can we do more beyond clinical care?
    • Social determinants of health