Model for effective non-communicable diseases prevention and care: “Total Care Cycle”

Background To respond to the emerging needs of NCDs in China, Project HOPE launched a 3-year program in 2009 to improve the accessibility and quality of care for people with NCDs in 4 Chinese cities. The post-stroke rehabilitation sub-program effectively reached and improved the lives of patients in community settings.

Method: Developed a “Total Care Cycle” model which emphasizes continuity of care from the acute to post-discharge phases and involves a broad spectrum of stakeholders including health professionals, community members (CHWs), patients and family members. Using a community based participatory method, the post-stroke rehabilitation sub-program conducted trainings for CHWs on how to provide home-based rehabilitation and trainings for patients and families on disease self-management and home-based rehabilitation. Results: The sub-program established a post-stroke rehabilitation network of 6 tertiary hospitals, 4 secondary hospitals and 14 community centers focused on building capacity at community health centers, benefiting patients and strengthening the health system. 634 stroke patients completed the 5-month home-based rehabilitation intervention. 53.8% of participants improved upper limb function, 37.5% improved hand function and 49.5% improved lower limb function. Their average scores on the “Activity of Daily Life” index increased by 76.5%.

Recommendation and Implication: Low-cost community based interventions have high impact on quality of life and ease the NCD burden on the health system. Multi-sectoral cooperation and community mobilization are key elements in the “Total Care Cycle” approach to reducing the negative impact of NCDs.