Development of the participatory continuity of care model among persons with stroke in the community
Keywords:
continuum of care model, stroke, stakeholder participationAbstract
Home-based continuous care is a crucial nursing process for stroke patients in the community, aimed at reducing complications and enhancing quality of life. This research and development aimed to design a continuous care model and assess its feasibility for real-world implementation. A purposive sampling method was used to select participants, consisting of the study was conducted in three phases: (1) situation analysis, involving data collection from 20 participants; (2) model development and implementation; and (3) evaluation, where the same 7 participants from the development phase were assessed, along with an additional 21 participants for feasibility testing. The research instruments included questionnaires on issues, needs, and barriers to continuous care; semi-structured interview guides; and secondary patient data records. Additionally, the research instruments comprised an activity plan for model development and a feasibility assessment questionnaire. The instruments were validated for content validity and reliability (Cronbach’s alpha coefficient=.98). Data analysis involved descriptive statistics and content analysis. The results showed that the participatory continuous care model consisted of three key processes: (1) discharge planning, (2) information transfer, and (3) home healthcare services. Stakeholders involved in the care process include healthcare team members, primary care unit, village health volunteers (VHVs), and caregivers. A handbook and an operational activity plan were provided as implementation guidelines. The feasibility assessment revealed that the model was highly viable ( =52.10, SD=7.90) In conclusion, the developed participatory continuous care model for stroke patients in the community serves as an effective guideline for continuous care, reducing complications and improving patients' quality of life.
References
Bureau of Nursing, Ministry of Public Health. (2016). Community nursing standards. Sun Media Publishing Co., Ltd.
Buriram provincial health office. (2024, February 15). Health information. https://brm.hdc.moph.go.th/hdc/main/index.php (in Thai)
Busadee, S. (2022). The development of home visit service system and continuity of care for stroke patients at Mahasarakham Hospital, Mahasarakham Province. Mahasarakham Hospital Journal, 19(1), 193–206. (in Thai)
Chanaman, P. (2023). Development of stroke patients care model. Academic Journal of Mahasarakham Provincial Public Health Office, 13-29. (in Thai)
Chansri, P., Samrannet, W., & Kor-issaranuphab, N. (2021). Empowerment of caregivers for rehabilitation of stroke patients. Journal of MCU Nakhondhat, 8(11), 112–125. (in Thai)
Division of Nursing, Ministry of Public Health. (2019). Guidelines for intermediate care nursing services. Sun Media Publishing Co., Ltd.
GBD 2021 Causes of Death Collaborators. (2024). Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: A systematic analysis for the Global Burden of Disease Study 2021. The Lancet, 403(10389), 2100–2132. https://doi.org/10.1016/S0140-6736(24)00367-2
Health Administration Division. (2024, February 15). Guideline for intermediate care. https://phdb.moph.go.th/main/index/detail/30103 (in Thai)
Kundi, M. K., & Spence, N. J. (2023). Efficacy of mirror therapy on lower limb motor recovery, balance and gait in subacute and chronic stroke: A systematic review. Physiotherapy Research International, 28(2), e1997. https://doi.org/10.1002/pri.1997
Kensakoo, T., Sinumpaisit, T., & Srithumsuk, W. (2020). The effectiveness of discharge planning’s clinical nursing practice guideline on activity daily livings, hospital readmission and quality of life in ischemic stroke patients. Journal of The Royal Thai Army Nurses, 21(3), 215–224.(in Thai)
Marín-Medina, D. S., Arenas-Vargas, P. A., Arias-Botero, J. C., Gómez-Vásquez, M., Jaramillo-López, M. F., & Gaspar-Toro, J. M. (2024). New approaches to recovery after stroke. Neurological Sciences, 45(1), 55–63. https://doi.org/10.1007/s10072-023-07012-3
Ngamhom, K. (2023). Development of a continuous health care model for homebound and bedridden stroke patients in Thung Fon District, Udon Thani Province. Journal of Humanities and Social Sciences, Udon Thani Rajabhat University, 12(2), 67–81. (in Thai)
Nimit-Arnun, N. (2017). Discharge planning: Concept and clinical practice guideline. Christian University of Thailand Journal, 23(3), 501–510. (in Thai)
Owolabi, M. O., Thrift, A. G., Mahal, A., Ishida, M., Martins, S., Johnson, W. D., Pandian, J., Abd-Allah, F., Yaria, J., Phan, H. T., Roth, G., Gall, S. L., Beare, R., Phan, T. G., Mikulik, R., Akinyemi, R. O., Norrving, B., Brainin, M., Feigin, V. L., & Stroke Experts Collaboration Group (2022). Primary stroke prevention worldwide: translating evidence into action. The Lancet. Public health, 7(1), e74–e85. https://doi.org/10.1016/S2468-2667(21)00230-9
Paksee, N., Srivisai, T., & Khunkaew, S. (2021). Preparation of family caregivers of patients with stroke on transitional care from hospital to home. Boromarajonani College of Nursing, Uttaradit Journal, 13(1), 47-61. (in Thai)
Phrai-in, P., Perkdetch, B., & Leelawattanagul, P. (2022). Development of a care model for stroke patients during rehabilitation. Journal of Thailand Nursing and Midwifery Council, 37(04), 73–94. (in Thai)
Pitthayapong, S. (2018). Situations, problems, and barriers of post-stroke care in the transitional period from hospital to home. Srisavarindhira Thai Red Cross Institute of Nursing Journal, 11(2), 26–39. (in Thai)
Poonvasin, T., & Arpornrat, A. (2023). Development of Continuity of Care Model for Stroke Patients. Journal of Research and Health Innovative Development, 4(2), 126–136. (in Thai)
Puangchan, K., & Jinawin, S. (2020). Effects of Using a Nursing Practice Guidelines for the Care of Acute Thrombotic or Ischemic Stroke Patients, Phrae Hospital. Journal of the Phrae Hospital, 2(28), 1-17.(in Thai)
Rushanan, S. G., Giordano, N. A., & Keim, S. K. (2024). Homeward stroke recovery: Results of a home rehabilitation program. Home Health Care Management & Practice, 37(2), 101–109. https://doi.org/10.1177/10848223241268153
Thanasirikarn, T., Boonmasri, P., & Nantana, R. (2021). Development of a continuous care model for special care patients in Mueang Loei district. Journal of Nursing and Therapeutic Care, 39(2), 127–136. (in Thai)
Theppabutr, S. (2020). Development of A Model of Care for Stroke Patients at Home. Sawanpracharak Medical Journal, 17(3), 112-124. (in Thai)
Thiamkao S. (2023). The incidence of stroke in Thailand. Journal of Neurology of Thailand, 39(2), 39-46. (in Thai)
Uangpairoj, N., Uttama, C., Kaweemuang , C. ., & Khantarak , P. . (2021). Developing Care System Network for Stroke Patients in Chiang Mai Province. Nursing Journal CMU, 48(1), 1–14. (in Thai)
Yusuwan, K. (2024). Development an operational model to address the causes of death from stroke in Suphan Buri. Region 4-5 Medical journal, 4(43), 513-528. (in Thai)
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