Table 1.

MSF diabetes and hypertension model of care, Shatila primary care clinic, Beirut, Lebanon, 2013–2017

Model of care component	Details
Case-Management	Nurse’s consultation consists of checking vital signs, fasting blood glucose and blood pressure measurements done at every consultation for DM and HTN patients. In addition, the NCD nurse checks vital signs for all scheduled NCD patients including the ones who present to see the doctor
	Doctor’s consultation is provided by trained general practitioners. Patients are not seen by specialist doctors at the MSF clinic at any time. If and when advised by the treating doctor, a patient with DM and/or HTN might be referred to a specialist as clinically indicated. All new patients are diagnosed by the doctors following MSF guidelines. DM is diagnosed with: a fasting plasma glucose level of ≥ 126 mg/dl (≥ 7 mmol/L) and clinical symptoms at first visit, or at ≥2 consecutive visits without clinical symptoms; or a random glucose level of ≥200 mg/dl (≥ 11.1 mmol/L) at ≥ 2 consecutive visits; or an HbA1C of ≥ 6.5%. HTN is diagnosed with: a SBP > 140 mmHg and/or a DBP > 90 mmHg at three clinical visits over 3 weeks; or a SBP > 180 mmHg and/or a DBP > 110 mmHg at first visit; or a SBP from 140 to 159 mmHg and/or DBP from 90 to 99 mmHg with a cardiovascular risk > 20% [WHO/ISH risk prediction chart] or a co-morbidity (cardiovascular disease, chronic kidney disease, DM).
	NCD nurse and doctor consultations are provided interchangeably based on the below schedule:
		NCD nurse	Doctor
	New patients with DM and/or HTN	None	Every 1 to 2 months until they are controlled
	Uncontrolled HTN	None	Every 1 to 2 months
	Improving uncontrolled DM	Every 3 to 6 months	Every 2 to 4 months
	Controlled DM or HTN	Every 6 months	Every 6 months
	Patients with exacerbations	None	As needed
	Drugs and glucometers are provided and renewed by the MSF pharmacist. Glucometers are provided for patients on insulin and pregnant women.
	Primary laboratory investigations carried out are:
	* HbA1C every 3 months for uncontrolled DM patients and every 6 months for controlled DM patients.
	* Total cholesterol, creatinine, and urine dipstick at enrollment (new patients) and annually or as needed.
	All laboratory tests, including HbA1C were done in the same external quality assured reference laboratory
Patient support and education counseling (PSEC)	PSEC is provided only for DM patients. HTN patients are not included in the PSEC due to a limited program capacity forcing prioritization of resources.
	Patients are referred to the PSEC by doctors. Referral is based upon the doctor’s clinical judgment for patients with uncontrolled DM who are willing to be supported in self-managing their disease, while all the newly diagnosed DM patients and the pregnant women are referred.
	PSEC services are provided one-on-one by trained health promotion personnel in the same primary healthcare center.
	The PSEC package includes education support and counseling on the disease and its complications, adherence to medications, self-monitoring of blood glucose and lifestyle habits with diet instructions, the latter being the first-step considered in the case management of DM patients besides introducing medications. It is a package adapted to the resources available for refugees.
Mental health	Mental health services are integrated in the NCD model of care.
	Patients are referred by the doctors or by the PSEC personnel based on clinical judgment.
	Mental health sessions are provided by psychologists in the same primary healthcare center.
Health promotion	Sessions are provided systematically and on a regular basis in waiting areas in groups by health promoters. They tackle general topics related to DM and HTN awareness.

DBP diastolic blood pressure, DM diabetes mellitus, HTN hypertension, ISH international society of hypertension, MSF Medecins Sans Frontieres, NCD non-communicable diseases, PSEC Patient Education Support and Counseling, SBP systolic blood pressure, WHO world health organization