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Continuous care is an important in people with chronic illnesses. As it connects the health care gap between the hospital and the home. The use of information programs increases the efficiency of care.
This study was quasi-experimental. Two groups were compared before and after the experiment. The purpose aimed to evaluate effects of an integrated continuous health care model using information program in chronic disease patients, Yasothon Provincial Health Office Network. The participants were chronic disease patients and divided into two groups. The first group received only conventional care. The another group received an integrated continuous health care model using information program consisted of development the continuing care team, Forwarding data with Thai COC, Proactive services for joint assessment and care planning based on the context of each patient, and Supervision. The duration of data collection was 6 months. Evaluated by using the satisfaction score of chronic disease patients, and the continuing care team with Cronbach's alpha coefficient equal to .90 and .93 respectively and home visit evaluation form. The data were analyzed using descriptive statistics, chi-squares and independent t- test.
The results showed that the group that uses the integrated continuous health care model by using the information program had home visit coverage rate, Patients can control and take care of themselves rate, Rate of patients returning from the hospital was home visits within 14 days, and Data of patients level 3 sent to the destination service unit within 5 days increased than before using the model with statistical significance at the level of .05. The incidence of complications at home was not different but tended to decrease. In addition, chronic disease patients and the continuing care team were satisfied with the use of the integrated continuous health care model by using the information program at a high level in the process/service steps, Data completeness, Communications, and quality of service.
Summary and recommendations: Integrated continuous health care model by using information program to increase quality of care for chronic disease patients. The format should be adjusted to suit the context of the department.
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