Documente Academic
Documente Profesional
Documente Cultură
Department of Health
ADMINISTRATIVE ORDER
No.2016
2016
00ll4
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
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
l,
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
4D \\tt'
2.
J.
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
B. Health Facilities -
V. GENERAL GUIDELINES
is applicable for
ftM
4,t
,V \*''
)
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.
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.
A. Identifying
1.
b. Household visits
2.
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
an
\:px
v{
t
/t4/f
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.
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.
3.
4.
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:
/ry/^
k,b
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.
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 <20yo CV risk.
5. Summary of above-listed procedures (Annex A)
Enrollment
a. All patients with Chronic Lifestyle Related NCDs shall be encouraged to enroll in
an appropriate health club in their respective health centers.
b. Patients who agree to enroll in the club shall fill- up the application form (Annex
B) and will be issued an ID and patient booklet.
c. The club member shall be informed of scheduled activities from which incentives
can be provided if attended (e.g. 1 activity - 1 raffle ticket; total of 3 raffle tickets
can be equivalent to a discount voucher for diagnostics/gift
tr)
items)
I ,r. ti
/"x
:a
EY iM
d.
There shall be only one club for hypertensive and diabetic patients since many
diabetics are also hypertensive and the activities to promote lifestyle changes are
the same for both types of patients.
Club -
5. ID
a.
Each patient shall receive a unique identification (ID) card color-coded according
to their clinical classification as follows:
i. YELLOW: (<20% risk score) the patient has hypertension OR diabetes only
(no signs or symptoms of target organ damage).
ii. ORANGE: (20-30% risk score) the patient has hypertension AND diabetes
without any sign or symptom of target organ damage.
11i. RED: (>30% risk score) the patient has hypertension and I or diabetes AND
signs of target organ damage.
b.
When the clinical condition of the patient improves or deteriorates, he/she shall be
given an adjusted color ID.
^r)vh'/r
6?d
6. Medications
a. Newly diagnosed hypertensive and diabetic patients shall:
i. Receive a prescription good for 3 months from the City/Municipal Health
ii.
Officer
Receive maintenance medications in the Rural Health Units where they are
registered on a monthly basis.
c.
d.
friendly)
Own fund raising activities to get free or discounted laboratory tests such as
cholesterol test and ECG, among others.
Involvement of family members to encourage participation especially health
promotion activities.
8. Affiliations
a. Patient-initiated health clubs, such as those organized in schools, workplace or
churches, may be recognized as affiliated chapters in the Barangay where the
school, workplace or church is located.
af:#7
b.
c.
The health club may start with a few members that is health center/RHU - based
and over time, with additional members, health promotion activities could be
organizedthrough a club in each Barangay.
The Barangay-based club shall maintain its links with the Main RHU-based Club
through specific activities that need the presence of physicians (e.g. during followup health assessment).
1. The Task Force for Health Clubs shall develop a monitoring and evaluation
mechanism to measure the inputs, processes and outcomes expected from the
2.
3.
4.
Periodic reports on the performance of various DOH offices and agencies shall be
written and disseminated through quarterly monitoring and performance evaluation
meetings with appropriate DOH offices and stakeholders.
Guidelines for monitoring of drug reactions at the RHU level will be developed by the
Pharmaceutical Division in collaboration with the Food and Drug Administration.
b.
c.
2.
AO 2011-0003).
Assist the DOH Regional Offices in translating the national DOH guidelines into
simple, locally useful field implementers' manuals and tools by providing samples
and models of patient manuals for adaptation to field conditions.
Oversee the development of a practical mechanism to harmonize and monitor
inputs, processes and outcomes related to these chronic diseases
a. In collaboration
amons others.
4oqf
c.
J.
4.
Collaborate with DPCB and other DOH units in developing a practical mechanism
to harmonize and monitor inputs, processes and outcomes related to the
organization and maintenance of health clubs.
b.
5.
a. Provide
withintheirRegionbyassistingtheminidentif,zingmethods'interventionsand
resources and by providing a responsive and supportive health system
c. Oversee the monitoring of the inputs, processes and outcomes of the activities of
Hypertension-Diabetes Health Clubs within their Region based on the monitoring,
feedback and evaluation mechanism developed for health clubs.
6.
ft-\'\f
a.
8.
b.
c.
9.
in the primary
a.
b.
c.
d.
e.
Develop their facility-based Hypertension and Diabetes Club using this guideline
Identify a point person within the facility (e.g. MHN) who will oversee the plans
and activities of the club. To guide club officers and members in ensuring that
plans are carried out and provide assistance in coordinating with other RHU staff
or stakeholders ifresource persons are needed during activities.
Ensure sustainability of health clubs through regular follow-up of patients and
registry and conduct of activities that promote education/awareness
Submit monitoring and evaluation reports on a regular basis
Ensure close coordination with the Regional and Provincial Health Offices, LGUs
and other stakeholders
a.
b.
Implement and support the formation of the club per primary health care facility
within their area.
Provide support to PHOs/CHOs/MHOs in the logistics needed by the club.
IX. FUNDING
The Department of Health Central Office through DPCB, BLHSD and HPCS shall provide
funds for technical assistance, commodities such as glucose strips, monitoring, capacity
building and health promotion campaigns to ensure that the above-mentioned activities are
implemented. Likewise, the Regional Offices through counterpart departments/divisions of
central office shall allocate funds for the same strategies.
The Pharmaceutical Division shall allocate funds and procure maintenance medications
needed for chronic diseases.
^(.\}-/r
10w
Local government units shall provide funds for health facility activities in their respective
communities. Other goveflrment agencies, non-government organizations and other
stakeholders and partners in health shall provide funds as appropriate to ensure the
implementation of this guideline.
X. REPEALING CLAUSE
The provisions of Department of Health Administrative Order 2011-0013 (Implementing
Guidelines on the DOH Treatment Pack) limiting the distribution of ComPack medicines to
CCT priority areas and NHTS families are hereby repealed. A11 other previous Orders and
other ielated issuances inconsistent or contrary to the provisions of this Administrative Order
are also hereby repealed, amended or modified accordingly. A11 other provision of existing
issuances which are not affected bv this Order shall remain valid and in effect.
XI. EFFECTIVITY
This Order takes effect immediatelv.
JANETTE
ealth
're
/
\n
z-rA1--\Nl
/
/\-V/"a
11
ANNEX A
ffir"s
>- 140190
xflw
BP >140/90 - referred to
physician/MHO for diagnosis and
further management
.T
ffir+
H lIW
['ffi;l
fillF:,.F.ltN"_-]
ru
I
I Fl.*t';-::*il ll ",r,*
\/iattackorl''y
+
/
\
Initial: capillary FBS by
nurse/midwife
lt''rne'tensionl
@
I
cholesterol.
if available)
by medical technologist
<zo-zo"t
RED)
t-+
risk
a. Health lifestyle
zr26mfldr_
,'i:I::o.r::: ORL\GE) or
(>
iOo/o
'b. Monitor BP
Every3-6months
I
||
II
II
l'6mgtdr
yELLow)
Gzl%ri.k rcor":
The physician/MHO will further evaluate the patient (for target organ damage, secondary
hlpertension, etc.) and start appropriate medications:
First line anti-hypertensive.' Amlodipine (based on drugs provided by DOH)
First line anti-diab etic.' Metformin
Monitor BP and capillary FBS monthly until target goals are met
I
I
to
I
I
12M
ANNEX B
a. Sample application form
APPLICATION F'ORM
DOH ITYPERTENSION AND DIABNTES CLUB
Date:
Name of patient:
FIRSTNAME
LASTNAME
Age:
Birthdate:
No.
MIDDLE NAME
Sex:
Street Brgy./City,Municipality
Contact number:
PhilHealth Number:
b. Sample ID
DOH
DIABETES CLUB
AND
HYPERTENSION
Patient No.:
Name:
Address:
RHU:
Birthdate:
Contact number:
Sex:
FRONT
ln case of emergency:
Name:
Address:
Contact number:
Signature of member
BACK
-,.p\_ar7
13M