Community-Oriented Primary Care
PRESENTED BY:
Dr. Ozaraga-Azarcon, Mikhaela Katrina
Dr. Sarigumba, Airish D.
Dr. Despoy, Lyka P.
Dr. Guantero, Mary Claire
PROJECT PLAN
ENHANCING SERVICE DELIVERY, PREVENTION AND CONTROL ON
HYPERTENSION AND DIABETES AMONG SENIOR CITIZENS
IN BRGY. BASAK, COMPOSTELA, CEBU
through
Project 3Gs:
Geriatric Golden Gathering
Towards Good Health & Well-Being
SIX STEPS OF COPC
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
SENIOR CITIZENS
AGED 60 YEARS OLD AND OVER
LIVING IN BRGY. BASAK, COMPOSTELA, CEBU
HEALTH SITUATION ANALYSIS
HIGH PREVALENCE OF HYPERTENSION
HIGH PREVALENCE OF DIABETES
LOW VACCINATION RATE
LOW LITERACY RATE
LOW EMPLOYMENT STATUS
GEOGRAPHIC PROFILE
DEMOGRAPHIC PROFILE
HEALTH PROFILE
SOCIOECONOMIC
MAJOR STAKEHOLDERS MEETING
Barangay Captain
Barangay Health Workers
Senior Citizens Representatives
MAJOR STAKEHOLDERS MEETING
HIGH CASES OF HYPERTENSION
HIGH CASES OF DIABETES
HIGH CASES OF ARTHRITIS
INCREASED NUMBER OF ALCOHOL USE
INCREASED NUMBER OF TOBACCO USE
LACK OF SOURCES OF INCOME
PROBLEMS IDENTIFIED
MAJOR STAKEHOLDERS MEETING
PROBLEM PRIORITIZATION
DO NEXT HIGH CASES OF ARTHRITIS INCREASED NUMBER OF ALCOHOL USE | DO NOW
HIGH CASES OF HYPERTENSION HIGH CASES OF DIABETES INCREASED NUMBER OF TOBACCO USE |
DO NEVER | DO LAST LACK OF SOURCES OF INCOME |
PROBLEM PRIORITIZATION
Problem List | Severity Wellness State [1] Health Deficit [2] Health Threat [3] Foreseeable Crisis [4] | Modifiability Easily Modifiable[3] Partially Modifiable[2] Not Modifiable[1] | Preventive Potential High [3] Moderate [2] Low [1] | Salience Needs immed. attention [2] Does not need immediate attention [1] Not perceived as problem[0] | TOTAL |
1. HIGH CASES OF HYPERTENSION | 3 | 3 | 3 | 2 | 11 |
2. HIGH CASES OF DIABETES | 3 | 3 | 3 | 2 | 11 |
3. HIGH CASES OF ARTHRITIS | 2 | 2 | 1 | 1 | 6 |
4. INCREASED ALCOHOL USE | 2 | 2 | 2 | 0 | 6 |
5. INCREASED TOBACCO USE | 3 | 2 | 3 | 0 | 8 |
6. LACK OF SOURCES OF INCOME | 2 | 1 | 1 | 0 | 4 |
PROBLEM TREE ANALYSIS
HIGH CASES OF UNCONTROLLED HYPERTENSION
Cardiovascular Diseases
Cerebrovascular Diseases
Kidney Diseases
Poor Quality of Life
Increased Patient’s Health Cost
Increased Risks for Complications
Increased Specialist Consultations
Premature
Deaths
Increased Economic Health Cost
Increased Hospitalizations
Consumption of Fatty Foods
High Salt Diet
Decreased Physical Activity
Poverty/Low-Income Households
Smoking
Lack of Formal Education
Poor knowledge on Hypertension
Unhealthy Lifestyle
Residing in GIDA Area
Poor Access to Health Services
Poor Health Seeking Behavior
No Consultation
Free HPN Meds Not readily available at All Times
Poor Compliance to Meds
No Money for HPN Meds
Misconceptions on Maintenance Meds Intake
PROBLEM TREE ANALYSIS
HIGH CASES OF DIABETES
Cardiovascular Diseases
Cerebrovascular Diseases
Kidney Diseases
Poor Quality of Life
Increased Patient’s Health Cost
Increased Risks for Complications
Increased Specialist Consultations
Premature
Deaths
Increased Economic Health Cost
Increased Hospitalizations
Consumption of Fatty Foods
High Sugar Diet
Decreased Physical Activity
Poverty/Low-Income Households
Smoking
Lack of Formal Education
Poor knowledge on Hypertension
Unhealthy Lifestyle
Residing in GIDA Area
Poor Access to Health Services
Poor Health Seeking Behavior
No Consultation
Free HPN Meds Not readily available at All Times
Poor Compliance to Meds
No Money for HPN Meds
Misconceptions on Maintenance Meds Intake
PROJECT PLAN
ENHANCING SERVICE DELIVERY, PREVENTION AND CONTROL ON
HYPERTENSION AND DIABETES AMONG SENIOR CITIZENS
IN BRGY. BASAK, COMPOSTELA, CEBU
through
Project 3Gs:
Geriatric Golden Gathering
Towards Good Health & Well-Being
ENHANCING SERVICE DELIVERY, PREVENTION AND CONTROL ON
HYPERTENSION AND DIABETES AMONG SENIOR CITIZENS
IN BRGY. BASAK, COMPOSTELA, CEBU
through
Project 3G’s:
Geriatric G lden Gathering
Towards Good Health & Well-Being
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
General Objectives:
To achieve Hypertension and Diabetes control by 25% among the senior citizens in Brgy. Basak, Compostela, Cebu by 2026-2028.
Specific Objectives:
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
STRATEGIES
| Objective 1: To establish a Hypertension and Diabetes Club with the Senior Citizens in Brgy. Basak, Compostela, Cebu by October 2023 | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Established Hypertension and Diabetes Club with senior citizens in Brgy. Basak, Compostela, Cebu | At least 50% of senior citizens joined in the Hypertension and Diabetes Club Biannual meeting of the officials, members and major stakeholders of the Hypertension and Diabetes Club | List of officials and members of the club List of attendance and minutes of the meeting Photo documentation of the meeting | Assumptions: Full support from the senior citizens and major stakeholders Risks: Lack of interest among senior citizens to participate in the club |
A C T I V I T I E S |
| 1 meeting with senior citizens and major stakeholders | List of attendance and minutes of the meeting Photo documentation of the meeting | |
| 1 meeting with senior citizens and major stakeholders to establish the club Elected set of officers of the club | List of names of the officers List of attendance and minutes of the meeting Photo documentation of the meeting | ||
| At least 1 mission and vision of the club Lists of the activities of the club | Copy of the mission and vision of the club List of of activities of the club | ||
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
| Objective 2: To improve knowledge on hypertension and diabetes among senior citizens of Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Adequate knowledge of senior citizens on hypertension and diabetes and their complications | Increased number of senior citizens monitoring their BP and Blood Glucose Increased number of senior citizens procuring their maintenance meds at LHC | Consultation Logbook Drug Inventory Logbook | Assumptions: Full support from the senior citizens and major stakeholders |
A C T I V I T I E S | 1.Conduct lecture on hypertension and diabetes | At least 2 lectures on hypertension and diabetes during Hypertension and Diabetes Awareness Month on May and November, respectively | Attendance of the senior citizens attending the lecture Photo documentation of the lecture | |
2. Distribute IEC materials on hypertension and diabetes | Number of senior citizens who receive the IEC materials | List of senior citizens who receive the IEC materials | Risks: Lack of budget for the IEC materials and signages | |
3. Place signages about hypertension and diabetes to strategic places in Brgy. Basak | At least 3 signages are placed strategically in Brgy. Basak | Photo documentation of signage | ||
STRATEGIES
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
| Objective 3: To establish smoking cessation program to senior citizens in Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Established smoking cessation program to senior citizens and/or their family members who are currently smokers in Brgy. Basak, Compostela, Cebu | At least 25% of senior citizens and family members who smoke successfully quit from smoking | List of the participants who successfully quit smoking Photo documentation of their smoking cessation sessions and their graduation | Risks: Lack of support Misconception Withdrawal symptoms |
A C T I V I T I E S | 1.Conduct lectures about smoking and discuss its harmful effects in relation to different diseases. | At least 2 lectures annually on tobacco and smoking and its associated risk | List of attendance of the lecture Photo documentation of the lecture | Risks: Lack of support Accessibility to transportation Availability |
2. Enroll Senior Citizen and/or family members who are currently smokers to smoking cessation program | At least 50% of senior citizens and their family members who smoke enrolled in the smoking cessation program | List of smokers who enrolled to the smoking cessation program | Risks: Lack of support Misconception Withdrawal symptoms | |
3. Formulate policy to designate no smoking places in Brgy. Basak, Compostela, Cebu | 1 resolution passed to designate no smoking places in Brgy. Basak | Copy of the resolution | Risks: Lack of support from BLGU | |
STRATEGIES
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
| Objective 4: To give a lecture on dietary intervention on hypertension and diabetes among senior citizens in Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Adequate knowledge of senior citizens on hypertensive and diabetic diet modification | Number of senior citizens practice hypertensive and diabetic diet modification | List of senior citizens who practice diet modification | Assumptions: Full support from the senior citizens and major stakeholders |
A C T I V I T I E S | 1. Conduct an informative lecture on hypertensive and diabetic diet modification to the senior citizens | Biannual HPN and DM informative lecture activity | Attendance and post lecture evaluation | |
2. Distribute IEC materials on hypertensive and diabetic diet modification | Number of senior citizens who receive the IEC materials | List of senior citizens who receive the IEC materials | Risks: Lack of budget for the IEC materials and signages | |
3. Place signages about hypertensive and diabetic diet modification to strategic places in Brgy. Basak | At least 3 signages are placed strategically in Brgy. Basak | Photo documentation of signage | ||
STRATEGIES
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
| Objective 5: To conduct physical activity intervention to senior citizens in Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Reduced insufficient physical activity among senior citizens in Brgy. Basak, Compostela, cebu. | At least 25% among senior citizens practice low to moderate intensity physical activity | Photo documentation of the physical activity practiced by senior citizens | Assumptions: Full support from the senior citizens |
A C T I V I T I E S | 1. Conduct lecture on physical activity intervention on hypertension and diabetes control | At least 2 lectures on the importance of physical activity in hypertension and diabetes | Attendance of the senior citizens attending the lecture Photo documentation of the lecture | |
2. Distribute IEC materials on the benefits of physical activity intervention on hypertension and diabetes | Number of senior citizens who receive the IEC materials | List of senior citizens who receive the IEC materials | Risks: Lack of budget for the IEC materials and signages | |
3. Establish “walk and dance for life” activity among senior citizens | Weekly brisk walking and zumba dancing activity | Photo documentation of the activity | Lack of interest among senior citizens to participate in the activity | |
STRATEGIES
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
| Objective 6: To improve service delivery on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Improved service delivery on hypertension and diabetes to senior citizens in Brgy. BAsak, Compostela, Cebu | At least 50% among senior citizens in Brgy. Basak availed the consultation services on hypertension and diabetes At least 75% of hypertensive and diabetic senior citizens procured maintenance medication on hypertension and diabetes | Consultation logbook Drug inventory logbook | Assumptions: Full support from the senior citizens |
A C T I V I T I E S | 1.Establish Hypertension and Diabetic Clinic at Brgy. Basak Health Station | At least 50% of the senior citizens consulted at the hypertension and diabetic clinic | Attendance of the senior Consultation logbook | |
2. Create a Hypertension and Diabetes Task Force at Brgy. Basak that will ensure effective service delivery on hypertension and diabetes | 1 meeting on the creation of HPN and DM Task Force At least 1 training annually of the members of the Task Force on HPN and DM service delivery | List of attendance and minutes of the meeting/training Photo documentation of the meeting/training | Risks: Lack of budget for the IEC materials and signages | |
3. Ensure adequate supply of free maintenance medications on hypertension and diabetes for senior citizens of Brgy. Basak Health Station | Monthly supply of hypertension and diabetes medications available for senior citizens of Brgy. Basak Health Station | Inventory of drug supply | Risks: Insufficient supply of medicines from DOH | |
2023
STRATEGIES
GANTT CHART
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Community
Profiling
Proposal and Preparation of Activities
2023
2024
Launching of
HPN & DM Club
Election of Officers
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
GANTT CHART
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Objective 1
Community
Profiling
Proposal and Preparation of Activities
2023
2024
Launching of
HPN & DM Club
Creation of Hypertension and Diabetes Task Force
Objective 1 ,6
ENROLLED
98 SENIOR CITIZENS OF
BRGY. BASAK, COMPOSTELA, CEBU
27
No HPN
No DM
65
With HPN
1
With DM
5
With HPN With DM
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Community
Profiling
Proposal and Preparation of Activities
GANTT CHART
Capacity Building of Hypertension and Diabetes Task Force
Enrollment to smoking cessation program
Launching of
“walk and dance for life” activity
Lecture on Hypertension, Smoking Cessation, Diet Modification, Physical Activity Intervention
2024
Launching of
HPN & DM Club
Creation of Hypertension and Diabetes Task Force
GANTT CHART
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Community
Profiling
Proposal and Preparation of Activities
2023
2024
Evaluation and Update of the Project
Launching of
HPN & DM Club
Election of Officers
GANTT CHART
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Community
Profiling
Proposal and Preparation of Activities
2023
2024
Improve Knowledge on HPN,DM (Lecture on
Proper Nutrition)
Evaluation and Update of the Project
Strengthening of Service Delivery
Launching of
HPN & DM Club
Election of Officers
REVISED PROJECT OBJECTIVES
Specific Objectives:
General Objectives:
To establish a Hypertension and Diabetes Club with Senior Citizens in Brgy. Basak, Compostela, Cebu
| Objective 1: To elect HPN and DM Club Officers in Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Elected Hypertension and Diabetes Club officers in Brgy. Basak, Compostela, Cebu | Election of HPN and DM Club members | List of Elected Officers of HPN and DM Club Photo documentation of the election | Assumptions: Full support from Senior Citizens of Brgy. Basak |
A C T I V I T I E S | 1.Conduct a meeting for election of officers of Hypertension and Diabetes Club Members | 1 Meeting with HPN and DM Club | List of attendance and minutes of the meeting Photo documentation of the meeting | |
2.Formulate the mission and vision of the club | At least 1 mission and vision of the club | Copy of the mission and vision of the club | ||
STRATEGIES
| Objective 2: To improve service delivery on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Improved service delivery on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu | More senior citizens avail the service delivery on HPN and DM by increasing the number of consults (new and follow-up), home visits, and timely procurement of maintenance medications | Logbooks on consults, home visits, medications dispensing Photo documentation of the consults, home visits, and medication dispensing | Assumptions: Full support from the senior citizens and major stakeholders of the HPN and DM Club |
A C T I V I T I E S | 1.Creation of an algorithm on the process flow on enrollment and follow up, and visit | 1 algorithm on the process flow on enrollment and follow up, and home visit | Copy of the algorithm on the process flow on enrollment and follow up, and home visit | |
2.Provision of hypertension and diabetes booklet to HPN and DM Club members | All members of HPN and DM Club received booklet | Photo documentation of the HPN and DM Club members who received the booklet | ||
3.Establishment of proper referral system | 1 algorithm on the process flow of referral system Numbers of senior citizens with HPN and DM complications needing immediate intervention properly referred to higher institution | Copy of the algorithm on the process flow of the referral system Copy of referral slip Photo documentation of the referral | ||
3. Timely dispensing of maintenance medication | Creation of monitoring sheet of senior citizens with HPN and DM maintenance medications All senior citizens with HPN and DM procured their maintenance medication timely | Copy of the monitoring sheet Logbook on drug inventory of HPN and DM Meds | ||
STRATEGIES
| Objective 3: To improve knowledge on hypertension and diabetes among senior citizens of Brgy. Basak, Compostela, Cebu | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Adequate knowledge of senior citizens on hypertension and diabetes and their complications | Increased number of senior citizens seeking consult at Basak Health Station Increased number of senior citizens monitoring their BP and Blood Glucose Increased number of senior citizens procuring their maintenance meds at BHS/LHC | Consultation Logbook Drug Inventory Logbook | Assumptions: Full support from the senior citizens and major stakeholders |
A C T I V I T I E S | 1.Conduct lecture on hypertension and diabetes | At least 2 lectures on hypertension and diabetes during Hypertension and Diabetes Awareness Month on May and November, respectively | Attendance of the senior citizens attending the lecture Photo documentation of the lecture | |
2. Distribute IEC materials on hypertension and diabetes | Number of senior citizens who receive the IEC materials | List of senior citizens who receive the IEC materials | Risks: Lack of budget for the IEC materials and signages | |
3. Place signages on hypertension and diabetes to strategic places in Brgy. Basak | At least 3 signages on HPN and DM are placed strategically in Brgy. Basak | Photo documentation of signage | ||
STRATEGIES
| Objective 4: To institutionalize the Hypertension and Diabetes Club in Brgy. Basak, Compostela, Cebu through Memorandum of Agreement | |||
| Project Description | Objectively Verifiable Indicators | Means of Verification | Risk/ Assumptions |
O U T P U T S | Signing of Memorandum of Agreement with Officials of Brgy. Basak | Signed Memorandum of Agreement | Copy of the signed Memorandum of Agreement Photo documentation of the signing of Memorandum of Agreement | Full support from the Barangay Officials of Brgy. Basak |
A C T I V I T I E S | 1. Conduct a meeting with Officials of Brgy. Basak to propose the program on HPN and DM to Senior Citizens 2. Create a Memorandum of Agreement with Officials of Brgy. Basak for collaboration on the proposed program | 1 Meeting with Brgy. Basak Officials 1 Memorandum of Agreement on HPN and DM Club | List of attendance and minutes of the meeting Photo documentation of the meeting Copy of the Memorandum of Agreement | |
STRATEGIES
Election of Officers
Objective No.1
Improving Service Delivery
Objective No.2
≥ 60
Years Old?
HPN & DM
Club Lane
Registration
Enrolled to
HPN & DM Club?
General
Consult Lane
Enroll
Patient Walk In
Vital Signs
Yes
No
No
Yes
Complete and/or Update the patient’s HPN and DM Health Record & Booklet
For Consult
Proceed to Consult
For Meds Refill
Dispense Meds
Schedule Follow-up Check-up
Send Patient Home
Figure 1. Algorithm of Field In Duty
BP >180/120
BP <180/120
Figure 4
Hypertensive Crisis
With HPN and DM booklet?
Provide HPN and DM booklet
No
Yes
Repeat BP after 30 mins rest period
BP >180/120
BP <180/120
Enrolled to
HPN & DM Club?
Enroll
Identify the Senior Citizens for Home Visit
No
Yes
Patient Seen
Figure 2. Algorithm of Field Out Duty
Travel to the location
Complete and/or Update patient’s
HPN and DM Health Record & Booklet
With HPN and/or DM
No HPN and/or DM
New Case?
Start Therapy
Update Therapy
Yes
No
Patient Ambulatory?
Schedule Follow-up
Check-up at BHS
Schedule Follow-up
Home Visit
Yes
No
With HPN and DM booklet?
Yes
Provide HPN and DM booklet
No
Figure 3. Algorithm for Follow up Check up and Referral
Identify the Enrolled Senior Citizens due for Monthly Follow-up
(Patients master list monitored & updated by BHW in-charge)
Patient capable to walk-in
No
Senior Citizens for Home Visit
*non ambulatory
*figure 2
Yes
Follow-up & Management
1. Measure blood pressure & CBG
2. Ask about new symptoms
Satisfactory outcomes
Unsatisfactory outcomes
Maintain Care
Dispense Meds
Schedule Follow-up
Check-up at BHS
Schedule Follow-up
Home Visit
Update the patient’s HPN and DM
Health Record
Intensify Management
Urgent Management + Referral
Enrolled to
HPN & DM Club?
Hypertensive Emergency
Enroll
No
Yes
Complete and/or Update the patient’s HPN and DM Health Record & Booklet
Schedule Follow-up Check-up
Send Patient Home
Figure 4. Algorithm for Management off Hypertensive Crisis
With HPN and DM booklet?
Provide HPN and DM booklet
No
Yes
Hypertensive Crisis
(BP >180/120)
Immediate Doctor Evaluation
With signs/symptoms of target organ damage OR abnormal PE findings
Hypertensive Urgency
Proceed to Consult
Advise hospitalization
Call Ambulance
Refer to Rural Health Unit
Transfer to nearest appropriate hospital
Yes
No
Improve Knowledge on HPN and DM
Objective No.3
GANTT CHART
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Community
Profiling
Proposal and Preparation of Activities
2023
2024
Launching of
HPN & DM Club
GANTT CHART
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Community
Profiling
Proposal and Preparation of Activities
2023
2024
Improve Knowledge on HPN,DM (Lecture on
Proper Nutrition)
Evaluation and Update of the Project
Strengthening of Service Delivery
Launching of
HPN & DM Club
Monitoring and Evaluation
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
6
4
3
2
1
5
Objective | Activity | Indicators | Source of Data | Frequency of Monitoring | Person Responsible | Target of Date of Completion |
1. To establish a Hypertension and Diabetes Club with the Senior Citizens in Brgy. Basak, Compostela, Cebu by November 2023 | | | | | | |
2. To elect officials of Hypertension and Diabetes Club and conduct quarterly meeting with them | | | | | | |
3. To improve service delivery on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu | | | | | | |
4. To improve knowledge on hypertension and diabetes among senior citizens of Brgy. Basak, Compostela, Cebu | | | | | | |
5. To institutionalize the Hypertension and Diabetes Club in Brgy. Basak, Compostela, Cebu through Memorandum of Agreement | | | | | | |
≥ 60
Years Old?
HPN & DM
Club Lane
Registration
Enrolled to
HPN & DM Club?
General
Consult Lane
Enroll
Patient Walk In
Vital Signs
Yes
No
No
Yes
Update the patient’s HPN and DM Data Information (including maintenance Meds)
For Consult
Proceed to Consult
For Meds Refill
Dispense Meds
Schedule Follow-up Check-up
Send Patient Home
≥ 60
Years Old?
HPN & DM
Club Lane
Registration
Enrolled to
HPN & DM Club?
General
Consult Lane
Enroll
Patient Walk In
Vital Signs
Yes
No
No
Yes
Update the patient’s HPN and DM
Health Record
For Consult
Proceed to Consult
For Meds Refill
Dispense Meds
Schedule Follow-up Check-up
Send Patient Home
Figure 1. Algorithm of Field In Duty
Enrolled to
HPN & DM Club?
Enroll
Identify the Senior Citizens for Home Visit
Locate Using the Spot Map
No
Yes
Schedule Follow-up
Check-up at BHS
Patient Seen
Figure 2. Algorithm of Maintenance Medicine Dispensing
Travel to the location
Ambulatory?
Update the patient’s
HPN and DM Data Information
Schedule Follow-up
Home Visit
FIELD DUTY
CONSULT DUTY
Community Rotation in Brgy. Basak
HPN AND DM
Program Workforce:
Medical Specialist
Medical Officer IV
Medical Officer III
Post-Graduate Interns
Barangay Health Workers
HPN & DM Club Officers
2 PGIs
BHWs
HPN & DM Club Officers
1 Resident/MO IV
2 PGIs
BHWs
Field Duty Task:
HPN & DM Club Activities
BHW Academy Activities
Consult Duty Task:
Patient Consultation
Wound Suturing
Team A:
Consult
Team B:
Field
Team A:
Consult
Team B:
Field
Team A:
Consult
Team B:
Field
Team A:
Field
Team B:
Consult
Team A:
Field
Team B:
Consult
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
Stakeholder’s
Meeting
Meeting with stakeholders and senior citizen
Objective 1
Community
Profiling
Proposal and Preparation of Activities
GANTT CHART
Capacity Building of Hypertension and Diabetes Task Force
Objective 6
Enrollment to smoking cessation program
Objective 3
Establishment of “walk and dance for life” activity
Objective 5
Lecture on Hypertension, Smoking Cessation, Diet Modification, Physical Activity Intervention
Objective 2,3,4,5
2024
Launching of
HPN & DM Club
Creation of Hypertension and Diabetes Task Force
Objective 1 ,6
Lecture on Diabetes, Smoking Cessation, Diet Modification, Physical Activity Intervention
Objective 2,3,4,5
2025
Monitoring and Evaluation
Monitoring and Evaluation
Lecture on Hypertension, Smoking Cessation, Diet Modification, Physical Activity Intervention
Objective 2,3,4,5
Lecture on Diabetes, Smoking Cessation, Diet Modification, Physical Activity Intervention
Objective 2,3,4,5
2026-2028
Launching of
“walk and dance for life” activity
Objective 5
1
COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
2
3
5
4
6
PROJECT EXPENSES
| Meals/Snacks | Supplies | Printing | TOTAL BUDGET |
1.Conduct a meeting with the stakeholders and senior citizens in Brgy. Basak, Compostela, Cebu | 3,000 | - | - | 3,000 |
2. Conduct an informative lecture on the importance of diabetes interventions , distribution of IEC materials, and baseline blood sugar determination | 3,000 | 1,000 | 200 | 4,200 |
3. Create a Hypertension and Diabetes Task Force at Brgy. Basak that will ensure effective service delivery on hypertension and diabetes | 1,000 | - | - | 1,000 |
4.Meeting with Formulate policies to designate no smoking places in the community, and areas to place information signage on hypertension and diabetes | 1,000 | 500 | 500 | 2,000 |
5. Establish “walk and dance for life” activity among senior citizens | 3,000 | - | - | 3,500 |
6. Conduct an informative lecture on the importance of hypertension, interventions and distribution of IEC materials | 3,000 | 200 | 200 | 3,400 |
TOTAL | | | | P17,100 |
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COMMUNITY DEFINITION
COMMUNITY CHARACTERIZATION
PRIORITIZATION
DETAILED ASSESSMENT
INTERVENTION
EVALUATION
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6
Objective | Activity | Indicators | Source of Data | Frequency of Monitoring | Person Responsible | Target of Date of Completion |
1. To establish a Hypertension and Diabetes Club with the Senior Citizens in Brgy. Basak, Compostela, Cebu by October 2023 | | | | | | |
2. To improve knowledge on hypertension and diabetes among senior citizens of Brgy. Basak, Compostela, Cebu | | | | | | |
3. To establish smoking cessation program to senior citizens in Brgy. Basak, Compostela, Cebu | | | | | | |
4. To give a lecture on dietary intervention on hypertension and diabetes among senior citizens in Brgy. Basak, Compostela, Cebu | | | | | | |
5. To conduct physical activity intervention to senior citizens in Brgy. Basak, Compostela, Cebu | | | | | | |
6. To improve service delivery on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu | | | | | | |
MONITORING & EVALUATION
THANK YOU!!!