Table 2 Tools in A toolkit for hypertension and diabetes management at health centres in Cambodia (action numbers correspond to those in Fig. 1)

Action 0: Get unscreened people to be screened

0.1

Patient identification (ID) card

Clinic staff

This card is to be issued by clinic staff for new visitors to the HC and held by the patient. The ID card will have a unique HC ID issued to each patient by the HC, along with other personal and contact information. The patient ID card would, ideally, be linked to a national ID such as their Patient Management and Registration System or patient ID if available, along with information such as the health insurance/financing scheme they belong to or any means-tested benefits the patient may be eligible for at the time of payment

0.2

Risk-screening form

Nurse, clinic staff

This form is to be filled in by clinic staff for all adult patients at their first visit and, subsequently, every 5 years

The information collected in this form identifies whether a patient is a potential user of services aimed at treating type 2 diabetes and/or hypertension as indicated in the treatment algorithm (Tool 1.1). If they are, the attending nurse or physician shall proceed with filling in the treatment card (Tool 1.2) under the column “intake visit”, either on the day itself or at a follow-up confirmatory visit

For HCs collaborating with CHWs such as a PE or VHSG, this form can be used as a community screening form. Here, the form would be filled by the CHW, with a copy of this form retained by the CHW and a duplicate copy shared with the HC. The HC and CHW would then coordinate to arrange follow-up visits at the HC or community level

Action 1: History-taking

1.1

Treatment algorithm

Nurse, physician

The algorithm guides the attending nurse or physician to a treatment plan tailored to individuals based on their personal and familial history of CVD and assesses their lifestyle risk factors. The healthcare provider will use the algorithm to determine whether the patient should be managed locally or referred to a higher-level facility. If managed locally, the algorithm guides the nurse or physician in managing the patient at the clinic using the information recorded in the treatment card (Tool 1.2). The algorithm is designed based on the MOH’s National Standard Operating Procedure for Diabetes and Hypertension Management in Primary Care in Cambodia [16]

1.2

Treatment card

Nurse, physician

This card is to be filled in by the healthcare provider to whom the patient has been referred for evaluation

The card documents essential information for monitoring treatment of CVD risk and tracking changes in health and treatment. The form is the place to record key data the provider needs to assess CVD risk using the risk-based charts (Tool 3) and follows the treatment algorithm (Tool 1.1)

Action 2: Exams and lab tests

2

Laboratory flowsheet

Nurse, physician

The laboratory flowsheet is to be filled in by the healthcare provider based on point-of-care testing or outside laboratory results. The data elements are focused on the information required to follow the treatment algorithm (Tool 1.1) for managing elevated blood pressure

The flowsheet is to be used for HCs that have access to outside or more advanced lab testing

Action 3: Estimate risk

3

Risk-based charts for hypertension

Nurse, physician

The risk-based charts are CVD risk non-laboratory-based charts published in the WHO’s HEARTS package [10] and translated into Khmer for local use at the HC

Action 4: Refer

4

Referral form (to referral institution)

Nurse, physician

The referral institution (RI) is a designated centre for receiving hypertensive or diabetic patients deemed by the algorithm to require more advanced evaluations, either a clinic or a hospital. Alternatively, the HC may have a special clinic located at the HC to take NCD patients on designated days

The attending nurse or physician filled in the referral form to refer patients to a higher-level facility as indicated in the treatment algorithm (Tool 1.1)

The intended use of this form is to facilitate appointments made at the HC for a visit to a RI. Ideally, the RI would receive a copy of the referral form in advance of the patient’s visit and would, likewise, send a copy of the feedback form back to the HC in advance of the patient’s follow-up visit at the HC. If this is not possible, a modification will need to be made to simplify the process

Action 5: Counsel and treat as per protocol

5.1

Patient education material

Nurse, physician

The attending nurse or physician can use the patient education material to counsel all patients on risk factors for CVD and how to recognize symptoms. The material also includes information on how lifestyle changes in diet, exercise and smoking can be used to lower one’s risk of developing CVD

NCD awareness and prevention posters can be taped to a consultation wall or showcased at visible places at the HC. NCD leaflets can also be shared with patients to take home if sufficient resources are available

5.2

Prescription form (general purpose)

Nurse, physician

The prescription form is to be filled in by the attending nurse or physician to prescribe medications to patients visiting the HC. The form can be customized based on medications recommended in the treatment algorithm (Tool 1.1) and/or available at the HC. The healthcare provider can also fill in the form to purchase medications outside the HC, such as a private pharmacy, if unavailable in house. The prescription form will be handed to and retained by the pharmacist and a receipt issued to the patient on receipt of payment

Drugs included in the form would have to be consistent with those locally available either through the CMS or at a private pharmacy

Action 6: Follow up and revise as needed as per protocol

6.1

Patient missed visit form

Nurse, clinic staff

The patient missed visit form is to be filled in by clinic staff to record missed visits at the HC. It can also be used to keep track of rescheduled visits. The form assumes that contact can be made via a phone call; this can be modified to accommodate other means of contact, including text messages or house visits

6.2

Patient exit form

Clinic staff

The patient exit form is to be filled in by clinic staff to de-register patients at the HC for various reasons, including death, LTFU or patients declining care. If LTFU, the HC shall determine an appropriate definition to assign to the same