Abstract
Background and aims: Non-communicable diseases (NCDs) such as diabetes, hypertension, and chronic obstructive pulmonary disease (COPD) account for over 70% of global deaths and 65% of total mortality in India [1]. Fragmented, physician-centered healthcare systems often result in delayed care, poor treatment adherence, and high hospital readmissions. This study evaluates a structured multidisciplinary care model integrating medical, nutritional, psychological, and community-based interventions. Methods: A mixed-method longitudinal study was conducted from January 2023 to June 2024 at Lok Nayak Hospital, New Delhi. A total of 200 patients diagnosed with Type 2 diabetes and at least one comorbidity (hypertension or COPD) were selected using systematic random sampling. Quantitative data were collected using HbA1c values, BMI, hospital readmission rates, Morisky Medication Adherence Scale (MMAS-8), and WHOQOL-BREF satisfaction scores. Qualitative data were analyzed using thematic coding from 30 in-depth patient interviews and 12 healthcare provider interviews. Statistical analysis was performed using SPSS v26, with p < 0.05 considered significant. Results: After 12 months of multidisciplinary intervention, the mean HbA1c decreased from 9.2% to 7.8% (p < 0.001), hospital readmissions reduced from 38% to 16%, BMI decreased by 5.1%, medication adherence increased from 52% to 79%, and overall patient satisfaction improved from 72% to 91%. Qualitative findings revealed improved trust, enhanced communication, and greater emotional support. Conclusion: The multidisciplinary care model significantly improves clinical outcomes, adherence, and patient satisfaction in chronic disease management. This approach is feasible, scalable, and suitable for integration into India’s public healthcare system.