Development of a continuing care model for patients with special needs population at Mueang Loei District
Keywords:
a model development, continuing of care, special needs population, discharge plan, thai COC programAbstract
This action research aimed to develop a continuing care model for patients with special need population (SNP). The participants included 1 physician, 30 nurses from the in-patient department and primary care unit, 2 physical therapists, and 3 computer technical officers. The duration of the study was 8 months (July 2020-February 2021). The participants shared and reflected on their experiences to gain mutual awareness of the problem leading to the development of a model. The research was 2 cycles on a continuing care model development and improving model as a nursing care routine, each cycle conducted 4 phases, 1) Planning: situation analysis through in-depth interview and focus group, plan for newly developed continuing care model through reflection and brainstorming, 2) Action: care model utilization, 3) Observation: evaluation the outcomes through Thai COC program and medical record and 4) Reflection: review the system and plan for changes leading to the next cycle.
The results lead to a model and guideline for continuing care with SNP. The patient’s data was sent within 5 days, which significantly increased (p< 0.001). The patient care through home health care within 14 days was significantly increased (p= 0.001). The patient’s sign improvement was significantly increased (p= 0.025). In conclusion, the continuing care models enable engagement from preparation within discharge plans and setting an environment to supporting self-care at home, helping families to be confident and able to take care of them at home. Using the Thai COC program as a communication channel, the network that provides continuing care at the home in the timeline and comprehensive care coverage.
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References
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