Explain detailed 1. What are the objectives to launch MTM and when it was launched 2. Staff pattern for MTM at CHC,PHC,HSC and medical college hospital 3. Who will constitute the field team of MTM 4. List out the diseases covered under PBS(population based survey) 5. Treatment activities carried out by MTM field team 6. Diagnosis and treatment protocol for DM and HT 7. What is patient unique id and documents required for a patient to get registered under the 8. Hub and spoke model of MTM scheme 9. Activities carried out under NPCDCS in HSC,PHC,CHC and medical college hospital. 10. Registers maintained in NCD op in PHC,CHC and medical college hospital Skills to be acquired 1. Have a conversation with women health volunteer and women public health nurse in MTM 2. Have a conversation with physiotherapist and palliative care staff nurse in MTM team and 3. See the patient drug box and mention its constituents 4. Components in MTM card 5. Do NCD data entry in your medical college hospital and get it signed from NCD nodal officer 6. Give a health education on diet,physical activity,self care,complications and treatment 7. Take a detailed history and do clinical examination of a diabetic and hypertensive patients and 8.Self breast examination 9.VIA screening
Makkalai Thedi Maruthuvam MTM scheme Tamil Nadu objectives launch date field team
Makkalai Thedi Maruthuvam MTM staff pattern CHC PHC HSC medical college hub and spoke model
https://www.scribd.com/document/775311544/NCD-MTM-Operationa…
MTM Tamil Nadu patient unique ID MTM card population based survey PBS diseases screened NCD register PHC CHC
https://spc.tn.gov.in/makkalai-thedi-maruthuvam
Research the Tamil Nadu "Makkalai Thedi Maruthuvam" (MTM) doorstep healthcare scheme in depth, using web_search and web_extract. This is for a detailed academic answer for medical/nursing students. Find and report back on EACH of the following points with as much specific factual detail as you can find (cite source URLs for each fact): 1. Exact objectives of MTM scheme and exact launch date (day/month/year), who launched it, implementing department. 2. Staff pattern/composition of the MTM field team and institutional team at each level: Health Sub Centre (HSC), Primary Health Centre (PHC), Community Health Centre (CHC), and Medical College Hospital - i.e. which staff (Women Health Volunteer, Village Health Nurse/Public Health Nurse, MLHP, Palliative Care Nurse, Physiotherapist, Medical Officer, NCD nodal officer etc.) are posted/involved at each facility level under MTM. 3. Composition of the MTM field team specifically (who constitutes it). 4. The full list of diseases/conditions covered under the Population Based Survey (PBS) component of MTM (it is commonly cited as covering people 18+ years for around 10 conditions - find the exact list, e.g. hypertension, diabetes, oral cancer, breast cancer, cervical cancer, TB, leprosy, mental illness, elder care/geriatric conditions, disability etc. - find the authoritative list). 5. Treatment/service activities carried out by the MTM field team (drug delivery, screening, BP/glucose checks, referral, palliative care, physiotherapy, health education, etc.) 6. Any details on diagnosis and treatment protocol used for Diabetes Mellitus (DM) and Hypertension (HT) under MTM/NPCDCS in Tamil Nadu (diagnostic criteria used, drugs used - e.g. Metformin, Amlodipine/Telmisartan step-up protocol, target values, follow up schedule). 7. What is the "Patient Unique ID" under MTM/NCD program and what documents are required for a patient to register (e.g. Aadhaar, ration card etc.) - find any info on the MTM card / NCD card and unique ID system. 8. Details of the "Hub and Spoke" model of MTM (how hub and spoke facilities are organized, e.g. Medical College Hospital as hub, CHC/PHC as spokes, for services like dialysis/cancer treatment/cardiac catheterization). 9. Activities carried out under NPCDCS (National Programme for Prevention & Control of Cancer, Diabetes, CVD & Stroke) at HSC, PHC, CHC, and Medical College Hospital level in India generally (standard NPCDCS operational guidelines - screening, NCD clinic, drug dispensing, referral, cancer screening, CVD risk stratification, District NCD cell, etc. at each tier). 10. What registers are maintained in the NCD OPD/clinic at PHC, CHC, and Medical College Hospital (e.g. NCD screening register, NCD OPD register, referral register, line list of hypertensives/diabetics, MTM field register, drug stock register, death register etc.) Do 5-8 targeted web searches covering these topics (Tamil Nadu MTM scheme official guidelines, NPCDCS operational guidelines India, NHM Tamil Nadu NCD registers) and extract content from the most authoritative pages found (government PDFs, NHM Tamil Nadu, MoHFW NPCDCS operational guidelines, published journal articles/PMC articles on MTM). Return a structured, detailed report organized under each of the 10 numbered headings above, with source citations (URL) for each major fact. If某 specific detail cannot be found despite searching, explicitly say so rather than guessing.
Makkalai Thedi Maruthuvam scheme Tamil Nadu objectives launch date staff pattern PBS population based survey diseases
NPCDCS operational guidelines India NCD clinic PHC CHC district hospital registers screening
Makkalai Thedi Maruthuvam hub and spoke model unique ID card field team NCD register Tamil Nadu
https://spc.tn.gov.in/makkalai-thedi-maruthuvam
https://nhsrcindia.org/sites/default/files/2021-07/Supplemen…
https://pmc.ncbi.nlm.nih.gov/articles/PMC12822032
Makkalai Thedi Maruthuvam
"non-communicable disease" AND India AND "primary health care"
PMID: 41398228
PMID: 41551264
Tamil Nadu hub and spoke dialysis cancer cardiac model health system
Tamil Nadu NCD registry unique ID hypertension diabetes card
Makkalai Thedi Maruthuvam (MTM) — Detailed Notes
1. Objectives and Launch of MTM
- To provide a holistic, home-based health care service that ensures continuum of care for both communicable and non-communicable diseases at the patient's doorstep.
- To reduce out-of-pocket expenditure and geographic/access barriers to care, especially for the elderly, bedridden, disabled, and those with poor mobility.
- To improve early detection (screening) of common NCDs and cancers in the population ≥18 years.
- To ensure treatment initiation, drug adherence, and follow-up for diagnosed hypertensives and diabetics, particularly those ≥45 years.
- To integrate physiotherapy and palliative care into home-based service delivery.
- To reach a target of about 3 million families (~10 million population) in a phased manner.
- Post-launch state evaluations show it roughly halved out-of-pocket medical spending in lower-income groups and substantially raised DM/HTN screening coverage (~80% ever screened for diabetes, ~81% for hypertension).
2. Staff Pattern for MTM at HSC, PHC, CHC, and Medical College Hospital
| Level | Staff involved |
|---|---|
| HSC (Health Sub Centre) / village level | Women Health Volunteers (WHVs) doing house-to-house visits; Village Health Nurse (VHN)/Public Health Nurse supervising; Health Inspector |
| PHC | Medical Officer, MTM Staff Nurse (registers screened/positive cases in the Personal Health Record), Mid-Level Health Provider (MLHP)/Community Health Officer, Pharmacist, Physiotherapist, Palliative Care Staff Nurse - who coordinate/supervise the field teams under that PHC |
| CHC | Medical Officer + designated NCD Staff Nurse running the NCD clinic (as per NPCDCS structure); receives referrals from PHC-level MTM teams |
| Medical College Hospital | Functions as the tertiary referral/nodal centre; Community Medicine department faculty typically act as district NCD/MTM nodal officers for supervision, data monitoring and training; specialist departments (Medicine, Cardiology, Nephrology, Oncology) manage referred complicated cases |
3. Who Constitutes the MTM Field Team
- Women Health Volunteer (WHV) - frontline worker, does house visits, BP/glucose checks, drug delivery
- Village Health Nurse (VHN)/Public Health Nurse - supervises WHVs, conducts screening and follow-up
- Mid-Level Health Provider (MLHP) - oversees screening quality, links to PHC
- Physiotherapist - provides home-based physiotherapy for bedridden/disabled/stroke patients
- Palliative Care Staff Nurse - provides terminal/palliative home care
4. Diseases Covered Under Population Based Survey (PBS)
- Diabetes Mellitus (all adults ≥18 yrs)
- Hypertension (all adults ≥18 yrs)
- Oral Cancer (all adults ≥18 yrs)
- Cervical Cancer (women ≥30 yrs)
- Breast Cancer (women ≥30 yrs)
5. Treatment Activities Carried Out by the MTM Field Team
- Doorstep screening: BP measurement, capillary blood glucose testing, oral visual examination for oral cancer, breast/cervical cancer screening in eligible women
- Doorstep drug delivery and refill of antihypertensives/antidiabetics for patients ≥45 years or with restricted mobility
- Medication adherence review and counselling
- Home-based physiotherapy for bedridden, post-stroke, or disabled patients
- Palliative care for terminally ill/chronically bedridden patients
- CAPD (peritoneal dialysis) fluid delivery/support and follow-up for chronic kidney disease patients
- Referral of screened positives/suspected cases to PHC → CHC → Medical College Hospital as needed, with weekly line-lists sent up the reporting chain
- Health education (IEC) on lifestyle, diet, and disease self-care
- Registration of screened/positive individuals into the Personal Health Record (PHR) for continued follow-up
6. Diagnosis and Treatment Protocol for DM and HT
- Diagnosis: BP ≥140/90 mmHg on repeated readings (per Indian national guideline thresholds)
- First-line: Amlodipine (5 mg, step up to 10 mg)
- Step 2: add Telmisartan/ARB (40 mg)
- Step 3: add Chlorthalidone (a thiazide-like diuretic, 12.5 mg)
- All hypertensives are entered in the facility/HWC family folder and NCD register, and risk-stratified using WHO/ISH CVD risk charts
- Regular follow-up (monthly initially, then as stabilized) with home BP monitoring by field staff
- Diagnosis: FBS ≥126 mg/dl, or RBS ≥200 mg/dl (with symptoms), or HbA1c ≥6.5% per standard criteria
- First-line: Metformin (500 mg, titrated up); second drug added (e.g., sulfonylurea/glimepiride) if uncontrolled
- Regular follow-up glucose monitoring by field/PHC staff; periodic HbA1c and renal function checks where lab access permits
- In CKD/comorbid patients: avoid NSAIDs (ibuprofen, diclofenac, aspirin) and aminoglycosides which worsen renal function; check hemoglobin at least 6-monthly
7. Patient Unique ID and Registration Documents
- Registration under MTM is done using a unique identification number, primarily Aadhaar, along with any other available proof of identity.
- This unique ID links the patient's NCD data (screening results, diagnosis, treatment status) across visits and enables analysis by gender, caste, geography, and disability.
- Screened/positive patients are additionally registered in the Personal Health Record (PHR), which is the working record used by the MLHP/WHV for follow-up.
- A known equity gap: because Aadhaar/ID is required, people without any identity proof (often the most vulnerable - homeless, some elderly, migrants) can be excluded from formal registration.
- No distinct physical "MTM card" separate from Aadhaar-linked digital registration was verifiable in the sources reviewed - if your training material describes a specific MTM card format with a printed unique ID, treat that as the authoritative local reference (see also Skill #4 below).
8. Hub and Spoke Model of MTM
- Medical College Hospital = the "hub" - houses advanced diagnostics (CT, MRI, ECHO, cath lab), specialist consultations, dialysis units, cancer day-care/chemotherapy
- CHC/District Hospital = intermediate spokes - run the NCD clinic, manage moderately complex cases, refer upward
- PHC/HSC/field teams = outer spokes - population screening, uncomplicated case management, drug dispensing, referral upward
9. NPCDCS Activities at HSC, PHC, CHC, and Medical College Hospital
- ASHA does risk assessment using the Community-Based Assessment Checklist (CBAC)
- ANM/CHO conducts Population Based Screening (PBS) for hypertension, diabetes, oral, breast, cervical cancer
- Health promotion and IEC activities
- Referral of screen-positives to PHC
- Dispensing of medicines as prescribed by the Medical Officer
- CHO conducts an annual community NCD survey
- Health promotion
- Opportunistic screening of OPD attendees
- Manages patients referred from HSC via PBS
- Diagnoses and initiates treatment for uncomplicated NCDs
- Refers complicated cases to CHC/District Hospital
- Runs a dedicated NCD Clinic (on all working days or at least 3 days/week)
- Opportunistic screening (>30 years) by Medical Officer with a designated staff nurse
- Manages PHC-referred cases; diagnoses and treats
- Refers unmanageable cases to the District/Medical College Hospital
- Runs a District/Institutional NCD Clinic for referred and complicated cases
- Provides comprehensive diagnostics: blood sugar, lipid profile, KFT, LFT, X-ray, ECG, USG, ECHO, CT, MRI
- Functions as the top referral unit for all NCDs identified at lower tiers
- Houses day-care centres (e.g., chemotherapy day care)
- Acts through a District NCD Cell for supervision, private-sector lab partnerships, and programme monitoring
10. Registers Maintained in NCD OPD
| Register | Level | Maintained by |
|---|---|---|
| ASHA screening register (Form 1A) | Village/SHC | ASHA |
| ANM/CHO screening register (compiled into Form 1) | HSC/HWC | ANM/CHO |
| PHC OPD register (compiled into Form 2) | PHC | Medical Officer/staff |
| NCD Clinic/OPD register | CHC, Medical College Hospital | MO + staff nurse |
| Personal Health Record (PHR) | Community/PHC | MTM Staff Nurse, followed up by MLHP/WHV |
| Line-list of screened beneficiaries | Field | WHV |
| Line-list of drug-delivery beneficiaries | Field | WHV |
| Weekly line-list of palliative/physiotherapy eligible patients | Field → District | WHV → District Deputy Health Officer |
| NCD register in HWC family folder (hypertensives especially) | HSC/HWC | ANM/CHO |
| CPHC-NCD digital application/state NCD app entries | All tiers | ANM/CHO/MO |
| Drug stock register, referral register, death register | PHC/CHC/Medical College (standard NHM record-keeping) | Pharmacist/MO staff |
Skills to be Acquired — What Each Involves
- Digital BP apparatus (sphygmomanometer)
- Glucometer with lancets and test strips
- Weighing scale
- Antihypertensive drugs: Amlodipine, Telmisartan, Chlorthalidone
- Antidiabetic drugs: Metformin, Glimepiride/other OHAs
- IEC/health education materials
- Screening/referral forms and the patient's personal health record
- Diet: reduce salt/sugar/fried food, increase fiber, portion control
- Physical activity: at least 150 min/week moderate exercise (e.g., brisk walking)
- Self-care: home BP/glucose monitoring, foot care in diabetics, medication adherence
- Complications: stroke, MI, retinopathy, nephropathy, neuropathy, diabetic foot
- Treatment: importance of regular drug intake, not stopping medication once "feeling fine," and regular follow-up