1. The Diabetes Project *** Empowerment of Chronic Disease Patients

2. Specific Objectives for the Pilot Phase To improve secondary preventative care provided by medical personnel to patients with Type 2 Diabetes Mellitus, in three villages in the West Bank. To enhance awareness of Diabetes, and health promotion messages for patients with Type 2 Diabetes Mellitus, their carers and families, and other members of the communities within which they live, in three villages in the West Bank.

3. Target Area The three villages to be targeted by this project are: 1. Aboud – Ramallah, West Bank 2. Singel – Ramallah, West Bank 3. Ithna – Hebron, West Bank These villages have been identified because the PMRS Doctors have particularly received training on Chronic Disease topics. Furthermore, PMRS health centers are established in these villages, and a good relationship exists between PMRS health workers and the identified beneficiaries.

4. Target Groups The target groups are patients who have Type 2 Diabetes Mellitus, and who are not properly controlled. –The target group will also be living in poverty, because it is usually Chronic Disease patients who are poor that are increasingly carrying the heaviest load of the NCD's burden.[1][1] –The most vulnerable to Chronic Disease are those living under the national poverty line in different countries[2][2] –and "This inequity is creating a rising demand for the provision of cost-effective care and for investment in prevention to reduce these burdens in regions where the social gradient of NCDs has already reversed and in others where it is expected to do so with the advancing health transition".[3][3] [1][1] World Health Organization World health report 1999: Making a difference Geneva: WHO, 1999 [2][2] World Health Organization World health report 1999: Making a difference Geneva: WHO, 1999 [3][3] World Health Organization World health report 1999: Making a difference Geneva: WHO, 1999

5. Beneficiaries Direct beneficiaries of the pilot phase were : 300 patients with type 2 Diabetes Mellitus from 3 villages in the West Bank: Singel, Aboud and Ithna. They have been identified by PMRS staff working at the PMRS health centers based in the three villages. Indirect Beneficiaries: –The carers of direct beneficiaries, as well as other members of their families and communities in which they live. Should the action contribute to the specific objective, then the economic and social burden of Diabetes that is inflicted upon the patient, carer, family, and community members, may be reduced. –Furthermore, health promotion messages delivered to the patients will also be conveyed to family and community members, which will contribute to their overall good health.

7. The Proposed ( NEW ) Project Project Objectives Create Diabetes and Hypertension Treatment Workgroups in 30 Palestinian Villages. Establish a registry of diabetics and hypertensives in these populations (10000 patients) Develop and implement well validated treatment self-treatment protocols and culturally accepted measurement tools (pre-tested for reliability and validity) for community based treatment for disadvantaged diabetic and hypertensive individuals. Identification of local project leaders in each of the population areas participating in this effort.. Training of project leaders in health promotion/self- management techniques pertaining to diabetes and hypertension. Collect baseline and ongoing information from each participating individual..

8. PMRS Management Approach of NCDs For more than six years PMRS has worked on the development of a new model to combat the epidemic of NCDs in Palestine. This model was built on the fact that managing NCDs is no more a pure medical problem, but rather wider, taking in consideration the environment and the style of living for people. The new model of disease management calls for more integrated approaches in the management of diseases. Such an approach is not just more effective than the pure biomedical one, but also needs much less resources.

9. PMRS Management Approach of NCDs, Cont.. the holistic approach in managing the NCDsThe approach advocated by PMRS is the holistic approach in managing the NCDs. This approach had been adopted and practiced in the Center for chronic diseases in Ramallah, and it is to be disseminated into more and more primary health care centers (PHC) across the West Bank and Gaza Strip. The proposed action is to be implemented as part of this mode

10. Actions Action 1: Capacity Building of Doctors and Health Workers. Capacity Building for Doctors, Nurses and Health Workers is a crucial part of developing a comprehensive approach to the management of chronic disease. Therefore, training of Doctors and Health Workers working at PMRS clinics in the three identified villages will build their capacities in the management of NCDs, and advocate the adoption of a holistic approach in their clinics. Training will center on secondary prevention – dealing with patients who already have the disease, on how to prevent the complications of the disease. Topics will include: –Health promotion - preventing risk factors such as unhealthy nutrition, smoking, obesity. –A comprehensive approach of management of the disease and proper management techniques at PHC level, and when to refer to the secondary or tertiary level. –Training will be implemented via a series of workshops, in cooperation with the PMRS School of Community Health, with local health professionals upgrading knowledge and improving the working ability of the relevant health professionals.

11. Actions Action 2: Community Support Groups This second action will concern work that will facilitate the involvement of carers, families and the local communities in the management of diabetes. This action will involve two main activities: –Home visits: The Health Workers will organize home visits to the identified patients with type 2 Diabetes Mellitus. They will use these home visits to answer queries from the beneficiaries and their carers, and deliver health education. These visits are intended to raise awareness on the patient's condition so that they are better equipped to manage it. –Community Support Groups: The Health Workers will establish community support groups for both the direct beneficiaries and their carers. These support groups will act as a support network that the beneficiaries and their carers can turn to for advice on the control and management of Type 2 Diabetes Mellitus.

12. Actions Action 3: Cooperation and Coordiation Improving coordination among Healthcare providers working in Palestine to better manage NCDs. This component will be implemented in full cooperation and integration with the capacity building component since the targeted PHC clinics for the exercise will include a large number of MoH, UNRWA, and other NGO clinics, and health workers. Establishing a national task force to deal with NCDs.

13. Monitoring In order to monitor whether the activities have contributed to achieving the specific objectives, a series of lab tests will be carried out to indicate the health of the patients, and whether their management of the disease has improved their health situation. The following lab tests will be carried out: 0 time – Initial tests –FBS –Lipid Profile –Creatinine –Hb A1c 3 months later –FBS –Hb A1c 6 months later –FBS –Lipid Profile –Creatinine –Hb A1c The lab tests will be carried out free of charge for the patients in order to encourage them to have them done. All the test results data will be registered in a special database and all the results will be compared and analyzed. The results will indicate whether we have succeeded in controlling and help the patients to control the disease.

14. Empowerment of diabetics/hypertensives Developing/ Collating the best set of information pertaining to Diabetes and Hypertension. This information will be both medical and community-oriented in nature. Providing this information, under the leadership of participating organizations, to health professionals and patients/families in an electronically appropriate and cost- effective manner using a variety of techniques.

15. Quality Improvement Conducting a 32 hour- training on quality improvement issues with a local Palestinian expert. Finalizing a QI instrument Finalizing patient’s file Finalizing electronic file

16. Summary Statement Most experts now believe that the success of any health care organization and, in particular, any managed care effort is predicated on enhancing consumer engagement/individual (or immediate family) management of his/her chronic illness and satisfaction with the care management process. In short we need to empower patients, if they wish, to become equal partners of the health care team.

17. In conclusion There is wide agreement that engaging patients to be an active part of the care process is an essential element of the quality of care. This will require three essential steps: 1) The development of a measure to assess patient activation and satisfaction with key components of the care management process; 2) The identification and use of evidenced-based interventions to increase patient activation; and 3) A method to hold providers and delivery systems accountable for supporting and increasing patient activation.