Development of a Home-Based Stroke Care Network through Collaboration of Family Physician Teams and the Community, Nuea Khlong Hospital, Krabi Province

Abstract

            Stroke patients require continuous monitoring, care, and rehabilitation to ensure an optimal quality of life. This mixed-methods research aimed to develop a home-based stroke care network model through the collaboration of Family Care Teams and the community at Nuea Khlong Hospital, Krabi Province. The study employed a four-stage action process: planning, action, observation, and reflection. Qualitative data were gathered via in-depth interviews and focus groups. Quantitative data were collected from 90 caregivers with at least three months of experience, selected through random drawing. The research instruments demonstrated content validity and reliability scores of 0.98 and 0.99. Data analysis included descriptive statistics, Wilcoxon signed-ranks Test, and McNemar Test. The results led to the development of the "5I Model for Participatory Home-Based Stroke Care." Following implementation: 1) activities of daily living (ADL) scores significantly increased to a median of 72 (IQR = 65–81, p < 0.05) 2) disability levels significantly decreased to a median of 72 (IQR = 65–81, p < 0.05) 3) patients were free from complications rate reached 98.89%(p < 0.05) and 4) the non-readmission rate reached 97.78% (p < 0.05). In conclusion, establishing a collaborative network between FCTs and the community effectively enhances home-based care efficiency, reduces complications, and promotes a sustainable quality of life for both patients and caregivers within the local context.