โครงการสนับสนุนการปฏิรูประบบบริการสาธารณสุข(Thai-European Health Care Reform Project)

A case report of 60 years old single woman diagnosed with hypertension and Diabetes Mellitus type II, she was treated as an ambulatory patient at outpatient department of Ratchaburi Hospital for 2 years. Her blood pressure and fasting blood sugar were not under controlled since her first diagnosis. She was referred to a primary care unit (PCU) which responsible for patients in Na-Muaeng district where she lives. A family physician and team provided patient-centered care and home visit to this patient in order to maintain quality of life to this particular patient. Two years later, the patient health condition has been improved with controlled blood pressure and fasting blood sugar. No target organ damaged found. Moreover, she has have better understanding about her diseases, her own health, and the health care team. Patient-doctor relationship is well established as well.