Development of a Home-Based Care Model (Home Ward) for Patients with Diabetes and Hypertension in the Community Hospital Network in Trang Province

Abstract

This action research aimed to develop a home-based care model (home ward) for patients with diabetes and hypertension in the Trang Province community hospital network. The target groups included: a) 102 inpatients diagnosed with diabetes and hypertension, b) 30 home ward patients, and c) 30 healthcare workers from community hospitals in Trang Province. The research procedure was divided in three phases: 1) situation analysis (assessing the current situation and challenges in diabetes and hypertension patient care), 2) model development, and 3) model evaluation. Both qualitative and quantitative data were collected through observations, unstructured and semi-structured interviews, as well as focus group discussions. The study period was from January to November 2024. The data was analyzed using paired t-tests, one-sample t-tests, and content analysis. The findings showed the following.

1. There were seven main challenges in home-based care for diabetic and hypertensive patients in the community hospital network of Trang Province: 1) healthcare personnel lacked sufficient understanding of home care for patients, 2) roles and responsibilities of staff were unclear, 3) patients did not receive comprehensive care and lacked continuous follow-up, 4) adherence to standard patient care guidelines was at a high level (M = 8.32, SD = 3.22), 5) compliance with nursing care protocols was also at a high level (M = 17.27, SD = 5.86), 6) quality of service related to the model was highly rated (M = 3.88, SD = 0.47), 7) patient participation was at a high level (M = 3.99, SD = 0.44).

2. The developed model, called the "3SAP Home Ward Model", consisted of five core characteristics: 1) high-quality healthcare services, 2) healthcare workers and caregivers, 3) operational framework for home-based care, 4) a home patient medical record system, and 5) measurable patient care outcomes. The overall quality assessment of the model was rated at a high level (M = 4.45, SD = 0.51).

3. The total scores for adherence to patient care standards, compliance with nursing care guidelines, service quality, and patient participation were significantly higher than the target values (p-value < .01). Blood sugar and blood pressure levels significantly decreased after implementing the model (p-value < .001).

Therefore, this model can be applied to improve chronic disease management within hospital networks, aligning with local healthcare contexts.