Diabetes is a lifelong chronic illness. Effective diabetes treatment has to adjust patients’ behaviors by integrating the care techniques of the health team and service science.
This study is aimed at developing an integrated care model for diabetes patients and developing diabetes patients’ potential. The study population  consisted of 204 diabetes patients
of all kinds, selected by using the purposive sampling technique, in the two tambon service
area of the primary care unit of Borabue Hospital.  The study was a research and development model. Before developing it, data were collected for assessing problem conditions as
a supplement to planning. Development was divided into two rounds of six months each.
Round 1 assessed the period before development, and then the model was improved so
that it would be appropriate for operating in the next round. Round 2 assessed operations
based on the developed and improved model from Round 1, compared the operational
outcomes with Round 1, and further developed the model for more appropriateness. Then
the study results were concluded. The instruments used for collecting data were: 1) patient
records, 2) a patient data-recording form comprising personal data, body mass index, complications (diseases), and values of sugar in the blood, HbA1c,  3) an interview form on
knowledge, attitude, and self-behavior to control diabetes, and a questionnaire on patient
stress using the GHQ-28 questionnaire; and 4) a guideline for an in-depth interview. Data
were comparatively analyzed using paired t-test, independent t-test, 95% confidence interval, and content analysis. For development outcomes in Round 1, the following were found.
The developed integrated care model for diabetic patients covered the dimension of service
provision at the hospital and at family/community levels, the dimension of the interdisciplinary team of service provision practitioners at the hospital and at the family/community levels, and the dimension of the services provided using the science of modern medicine and the science of alternative medicine in these five aspects: physical, mental and emotional, intellectual, social, and environmental. The assessment outcomes after development
in Round 1 were as follows.  The diabetic patients had statistically significant higher knowledge of diabetes, attitudes toward diabetes, and diabetes control behaviors (p < 0.05); the
mean of stress decreased statistically and significantly (p = 0.002); sugar in the blood of
both the female and male diabetic patients  statistically and significantly decreased (p <
0.05); and the HbA1c mean after development in Round 1 was 7.84 per cent (SD=1.49).
From in-depth interviews with patients in a group with well-controllable diabetes and in a
group with not-well-controlled diabetes, it was found that their beliefs were different with
regard to correct healing and self-adjustment so that they would still have joy despite their
diabetic ailment.  Development in the next round had to create confidence in healing and
self-care of the patients.   The interdisciplinary team, in providing services at the clinic and
at the family/community levels, had to foster correct behaviors according to the normal
way of life, together with increasing the potential for caring for diabetic patients by the
interdisciplinary team.