Implementing Guidelines on the Organisation of Health Clubs (DOH AO 2016-014)

Republic of the Philippines

Department of Health

OFFICE OF THE SECRETARY },|AY 2

ADMINISTRATIVE ORDER No.2016

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3

2016

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SUBJECT: Implementins Guidelines on the Orsanization of Health Clubs for Patients with Hvpertension and Diabetes in Health Facilities

I. RATIONALE Non-communicable Diseases (NCDs) continue to be the top causes of deaths among Filipinos. Of these, hypertension remains the leading illness. Diabetes continues to be significantraffecting around 5Yo of our adult population (Source: FNRI - National Nutrition Survey,20l3). To address the call for health interventions that are cost-effective and sustainable, the focus is on the most vulnerable risk group using two most common and easily detectable clinical manifestations of NCDs: hypertension and diabetes. By accelerating case detection of patients with risk factors, illnesses will most likely be found at an early stage, that is, before the onset of any damage to target organs. Campaigns are needed to detect as many patients as possible in the early stages of hypertension and diabetes. Organizing patients into active Health Clubs is one of the strategies to ensure continuity ofcare, raise the effectiveness oflifestyle changes and prevent complications.

The following guidelines are hereby issued to strengthen the fight against NCDs at the primary health facilities specifically, the health centers and barangay health stations. These guidelines reiterate the policies and thrusts outlined in the'National Policy on Strengthening the Prevention and Control of Chronic Lifestyle Related Non-Communicable Diseases (NCD)" (DOH AO 2011- 003), and "Implementing Guidelines on the lnstitutionalization of Philippine Package of Essential NCD lnterventions (PhilPEN) on the lntegrated Management of Hypertension and Diabetes for Primary Health Care Facilities" (DOH AO 2012 - 0029).

II. OBJECTIVES

A.

General objectives

These guidelines aim

to gulde various stakeholders in health care in

sustaining Hypertension-Diabetes Health

creating and

Club s.

B.

Specific objectives

l.

Define the process of accelerating the identification of patients based on the PhilPEN protocol, of creating a Patient Registry and of recruiting these patients into health clubs.

Building

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San lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila o Trunk Line 651-78-00 Drect Line: 711-9501 Fax:743-1829;'143-1786 URL: httorl/www.doh.gov.ph; e-mail: osecG)doh.gov

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2.

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Define the services and activities of the health club that will ensure at least 90Yo continuity of care to hypertensive and diabetic patients according to the PHIL PEN guidelines on lifestyle changes and the DOH guidelines on conlmunity activities especially patient education and motivation. Promote better access to maintenance medications and management of

pharmaceutical supply chain. 4. Define the roles and responsibilities of the different DOH offices and agencies, the LGUs and other stakeholders in organizing and sustaining health clubs. 5. Create a mechanism for conduct of patient clubs that can be applicable for other diseases entities.

IIL SCOPE AND COVERAGE This issuance applies to all DOH units including its attached agencies, local government units (LGUs), non-govemment orgarizations, professional organizalions, the private sector and other relevant partners in the health sector. Chronic Lifestyle Related NCDs affect the vulnerable age groups in all economic levels. Case finding and treatment shall no longer be limited to priority areas identified through the Conditional Cash Transfer (CCT) program or to families under the National Household Targeting System (NHTS) for Poverty Reduction.

IV. DEFINITION OF TERMS

A. PhilPEN Protocol - is the Philippine Package of Essential Non Communicable Disease Interventions for low-resource settings adopted from WHO PEN. This protocol consists of guidelines for the integrated management of hypertension and diabetes through a total risk approach. The individual client/patient is assessed and managed based on using the risk prediction chart. The prediction charts can estimate the client/patients risk of having a cardiovascular event (CV risk) in the next ten years. This will be applied to all patients screened for and found to have NCDs. these are facilities that provide screening and management of diseases like hypertension and diabetes. May include but not limited to city health offices, rural health units (RHUs) and barangay health stations.

B. Health Facilities -

a registry of patients diagnosed with hlpertension and diabetes in the health facilities, linked to iClinicSys of RHUs and Integrated Chronic Non Communicable Disease Registry of hospitals.

C. DOH Hypertension and Diabetes Registry

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D. DOH Health Clubs -

an organ izationthat consist of officers with rules and by-laws and a common goal of improving the health and wellness of its members. lnitially, these shall be organized in health facilities such as RHUs and expanded to barangays.

V. GENERAL GUIDELINES

A. ACCELERATED CASE FINDING.

Accelerated case finding

is applicable for

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persons 40 years old and above.

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B. MANDATORY REGISTRY. All RHus/health centers shall have a registry of all hypertensive and diabetic patients to closely monitor their health conditions and for provision of medications. C.

VOLUNTARY ENROLLMENT. All diagnosed patients with hypertension andlor diabetes in all public and private health facilities shall be encouraged to enroll in designated Hypertension-Diabetes Health Clubs in their health center but will remain voluntary. The list of health clubs shall be submitted to DOH Central Office after validation of the Provincial and Regional Offices.

D. SERVICE DELIVERY NETWORI(. Each health facility shall ensure that there is a network of higher facilities and providers within the province or city-wide health systems where referrals and other health care services can be provided. E.

STANDARDIZING DIAGNOSTICS. Fasting Blood Sugar/Glucose (FBS) with 8 10 hours fasting shall be the standard of screening for diabetes instead of random blood sugar to promote efficiency in use of resources and facilitate follow-up. This shall be initially through the capillary method (glucometer) and confirmed using the venous FBS.

F. FOLLOW - UP OF PATIENTS. A11 patients with diagnosed

hypertension and diabetes, regardless of membership into a Health Club, shall be scheduled for regular follow-up and re-evaluation by a physician based on philpEN.

G. ADOPTION OF PhilPEN PROTOCOL. The PhilPEN protocol shall be the basis for further assessment, screening, management and follow-up of patients seen in the facilities. Risk assessment of persons betw een 25 and 39 years old apparently healthy, with risk factors or with early manifestation of disease shall continue as defined in this protocol.

VI. SPECIFIC GUIDELINES STAGE 1: Accelerated case finding among the highest risk group

A. Identifying

1.

patients with hypertension and diabetes

Case Finding shall be done during: a. Community campaign, or

b. Household visits

2.

Case Finding shall be done through:

a. Blood pressure (BP) measurement of all persons 40 years old and above measured twice, 15-30 minutes apart, by a Barangay Health Worker (BHW). b. Risk assessment of clients 25 years old and above who visit the health center for other clinical complaints, based on philpEN.

3.

Those found to have BP >140190 on both readings shall be referred to the local government staff (midwife or nurse) who shall verify the elevated BP reading one week later

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4. All those verified

to have elevated BP >140/90 by the health center midwife or nurse

shall be: Referred to the physician/Municipal Health Officer (MHO) to confirm diagnosis of hypertension and examined for any sign or symptom of underlying causes (eg. renal disease) and target organ damage. Using PhilPEN, risk prediction can be done to estimate the cardiovascular risk of the patient. b. Have their fasting blood sugar/glucose (FBS) tested c. Started on the first line antihypertensive medicine as prescribed by the doctor and

a.

contraindicated based on the available drugs provided by DOH (Amlodipine 5 mg, 1 tablet, daily) and test blood cholesterol if available Registered in the health center Hypertensive Patient Registry Strongly encouraged to enroll in the Hypertension-Diabetes Health Club, Assessed for secondary hypertension andl or signs and symptoms of some target organ damage and then referred to a hospital for fuither evaluation

if not

d. e. f. 5. All

other persons without hypertension but have a family history of diabetes, are

obese and with signs and symptoms of possible diabetes shall also have their fasting blood sugar/glucose (FBS) tested.

6. All patients found to have high capillary FBS (>7.0 mmol/l or 126 mg/dl)

shall have

their FBS retested using venous blood done by a medical technologist either in the health center laboratory, local hospital laboratory or a private laboratory and shall be:

a.

b. c. d. e.

Referred to the physician/MHO to confirm diagnosis of diabetes and examined for any sign or symptom of target organ damage. Using PhilPEN, risk prediction can be done to estimate the cardiovascular risk of the patient. Started on the first line anti-diabetic drug as prescribed by the doctor and if not contraindicated (Metformin 500 mg daily). Registered in the health center Diabetic Patient Registry Strohgly encouraged to enroll in the Hypertension-Diabetes Health Club Assessed for signs and symptoms of target organ damage and then referred to a hospital for further evaluation

B. Enrollment to the NCD Registries 1. Newly diagnosed patients shall be registered in the specific Chronic Disease Registry. 2. A patient who has both hypertension and diabetes shall be registered in both the

3. 4.

Hypertension and Diabetes registries. Deaths and geographic ffansfers in and out of their specific health facility shall now be recorded in the Chronic Disease Registries and reported to the DOH Regional Offices through the appropriate LGUs. National Chronic Disease registries shall also be maintained by DOH through the Knowledge Management and Information Technology Service (KMITS).

C. Health Education 1.

All

patients registered in the hypertensive and diabetic patient registries shall have their first health education session given by the health facility nurse or midwife.

2. Topics on first health education session shall be composed of but not limited to the following:

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3.

a.

Diet changes needed for their specific condition (e.g. increase intake of fruits and

b. c.

vegetables) Increased physical activity (at least 30 minutes brisk walking three times a week), Cessation of smoking and reduction of alcohol intake, when relevant, and

d.

Prevention of common infections

Subsequent health education sessions to reinforce the health messages may be given by the midwife or a BHW specially trained for this task.

D. Follow-up 1. All patients with hypertension shall have their BP taken by the BHW

at least once a week to verify that their BP is under control. Follow-up of these patients with the physician shall be monthly until BP is controlled and 3 - 6 months thereafter. Those found to still have BP >T40190 shall be referred back to the physician who may decide to: a. Increase the dose of the current medication, OR b. Shift medication to the second line drug if not contraindicated (Losartan 50 mg daily), OR c. Add Losartan on top of Amlodipine

2. All patients with diabetes shall have repeat capillary FBS testing every three (3) months. Those found to still have FBS >7.0 mmolll or 126 mg/dl shall be re-evaluated by the health center physician or any physician who may decide to: a. Increase the dose of the current medication, OR b. Shift to the second line drug (Gliclazide 80 mg daily), OR c. Refer the patient to a hospital for further evaluation 3. Patient treatment booklet shall be given to the patient and shall be used to monitor the dispensing of medications and health promotion activities. The booklet shall contain all the essential clinical information that should be assessed and monitored on a regular basis.

4. Clients who are 40 years old and above who still do not manifest any signs of hypertension or diabetes but are known smokers, have a family history of diabetes and/or are obese should continue to be followed up at least every 3 to 6 months since they are still considered low to moderate risk or with