Non-communicable disease program in Ampangan Health Clinic
AbstractNon-communicable diseases (NCDs) represent among the most common and debilitating conditions seen in primary care.Patients’ care will often involves multiple providers and follow-up requires persistence by patients and clinicians alike, thereforeideal outcomes are often difficult to achieve. The need for better disease management policies and practice is growing. Thisis due to the changing demographic profile of the population, the increasing cost of managing people in acute care hospitalsand the availability of new technologies and services. All these changes enable a different care paradigm which is more costeffective and provides people with chronic conditions an improved quality of life. Management of the NCDs therefore offersan excellent opportunity to practice chronic disease management - a systems approach designed to ensure excellent care.The NCD team has developed a comprehensive approach to chronic disease care. We would like to describe the NCDProgram in Ampangan Health Clinic which represents many typical government health clinics in Malaysia and the processesby which it was developed. Included are specific examples of the tools and how they can be used by individual clinicians incaring for patients. The integration of Chronic Disease Management Services into health care systems is the direction beingundertaken to tackle the burden of chronic disease. Disease management supports the shift in healthcare from an emphasison managing the acute episode to managing the entire disease course, highlighting both prevention and maintenance ofwellbeing for patients with chronic diseases. Disease management promotes better integration and coordination of careacross all aspects of the health sector.
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