1 of 57

Community-Oriented Primary Care

PRESENTED BY:

Dr. Ozaraga-Azarcon, Mikhaela Katrina

Dr. Sarigumba, Airish D.

Dr. Despoy, Lyka P.

Dr. Guantero, Mary Claire

2 of 57

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

3 of 57

SIX STEPS OF COPC

COMMUNITY DEFINITION

COMMUNITY CHARACTERIZATION

PRIORITIZATION

DETAILED ASSESSMENT

INTERVENTION

EVALUATION

4 of 57

SENIOR CITIZENS

AGED 60 YEARS OLD AND OVER

LIVING IN BRGY. BASAK, COMPOSTELA, CEBU

5 of 57

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

6 of 57

MAJOR STAKEHOLDERS MEETING

Barangay Captain

Barangay Health Workers

Senior Citizens Representatives

7 of 57

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

8 of 57

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

9 of 57

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

10 of 57

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

11 of 57

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

12 of 57

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

13 of 57

ENHANCING SERVICE DELIVERY, PREVENTION AND CONTROL ON

HYPERTENSION AND DIABETES AMONG SENIOR CITIZENS

IN BRGY. BASAK, COMPOSTELA, CEBU

through

Project 3Gs:

Geriatric G lden Gathering

Towards Good Health & Well-Being

14 of 57

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. To establish Hypertension and Diabetes Club with Senior Citizens in Brgy. Basak, Compostela, Cebu

  • To improve knowledge on hypertension and diabetes among senior citizens of Brgy. Basak, Compostela, Cebu

  • To establish smoking cessation program to senior citizens in Brgy. Basak, Compostela, Cebu

  • To give a lecture on dietary intervention on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu

  • To conduct physical activity intervention to senior citizens in Brgy. Basak, Compostela, Cebu

  • To improve service delivery on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu

15 of 57

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. Conduct a meeting with the stakeholders and senior citizens in Brgy. Basak, Compostela, Cebu

1 meeting with senior citizens and major stakeholders

List of attendance and minutes of the meeting

Photo documentation of the meeting

  1. Establish the Hypertension and Diabetes Club among senior citizens in Brgy. Basak, Compostela, Cebu

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

  1. Formulate the mission and vision and organize the activities of the club

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

16 of 57

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

17 of 57

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

18 of 57

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

19 of 57

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

20 of 57

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

21 of 57

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

22 of 57

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

23 of 57

24 of 57

25 of 57

26 of 57

27 of 57

28 of 57

29 of 57

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

30 of 57

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

31 of 57

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

32 of 57

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

33 of 57

REVISED PROJECT OBJECTIVES

Specific Objectives:

  1. To elect HPN and DM Club Officers in Brgy. Basak, Compostela, Cebu

  • To improve service delivery on hypertension and diabetes to senior citizens in Brgy. Basak, Compostela, Cebu

  • To improve the knowledge on hypertension and diabetes among senior citizens of Brgy. Basak, Compostela, Cebu

  • To institutionalize the Hypertension and Diabetes Club in Brgy. Basak, Compostela, Cebu through Memorandum of Agreement

General Objectives:

To establish a Hypertension and Diabetes Club with Senior Citizens in Brgy. Basak, Compostela, Cebu

34 of 57

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

35 of 57

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

36 of 57

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

37 of 57

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

38 of 57

Election of Officers

Objective No.1

39 of 57

Improving Service Delivery

Objective No.2

40 of 57

41 of 57

≥ 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

42 of 57

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

43 of 57

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

44 of 57

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

45 of 57

Improve Knowledge on HPN and DM

Objective No.3

46 of 57

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

47 of 57

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

48 of 57

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

49 of 57

≥ 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

50 of 57

≥ 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

51 of 57

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

52 of 57

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

    • Enrollment
    • Home Visit
    • Lectures

Consult Duty Task:

Patient Consultation

Wound Suturing

53 of 57

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

54 of 57

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

55 of 57

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

56 of 57

1

3

4

5

COMMUNITY DEFINITION

COMMUNITY CHARACTERIZATION

PRIORITIZATION

DETAILED ASSESSMENT

INTERVENTION

EVALUATION

2

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

57 of 57

THANK YOU!!!