Implementation of Primary Care Based Chronic Disease Management Programs for Hypertensive and Type 2 Diabetes Mellitus Patients: A Scoping Review

Introduction The increased prevalence and complexity of chronic disease in the community highlights the role of primary care through chronic disease management programs (CDMPs). However, there is a need to review the evidence about implementation of CDMPs to provide understanding of contextually related factors and possible strategies to improve those programs. The aim of this review is to identify primary care‐based CDMP implementation studies and potential interventions to enhance CDMPs. Methodology A scoping review was conducted following PRISMA‐ScR guidelines. We searched four electronic databases (PubMed, CINAHL, Embase, and Web of Science) combining the terms “diabetes and hypertension,” “chronic diseases management program,” “implementation,” and “primary health care.” We included peer‐review studies that involved patients with hypertension and/or type 2 diabetes mellitus participating in the primary care‐based CDMPs. Narrative synthesis analysis was used to present the results. Results This review identified 29 studies that investigated 18 different CDMPs. The components of the CDMPs encompass education and counseling, the use of protocols and guidelines for delivering care, community and club engagement, provision of financial subsidies and incentives, and regular laboratory checks and records. Only about half of the included studies reported improvements in clinical health outcomes, whereas improvements in patient knowledge, attitudes, practices, and care processes were more consistently observed. The primary challenges were the limited skills and knowledge of health workers, especially in counseling, their excessive workload, and the lack of adherence to scheduled visits by patients. The enhancement of skills, assistance and involvement of patients, participation of community health workers (CHWs), and provision of financial incentives and subsidies all played a role in attaining the targets of the CDMP. Conclusion CDMPs are multifaceted interventions centered on self‐management support with potential to improve care processes and patient‐related outcomes; however, their implementation success is context‐dependent and shaped by organizational capacity, workforce readiness, and persistent access barriers.