Development of a Stroke Care Model for the Prevention of Recurrence and Complications

Abstract

Purposes:To develop and evaluate the effectiveness of a care model in improving patients’ ability to perform activities of daily living, reducing disability, enhancing stroke-related knowledge, and improving the knowledge and rehabilitation skills of family members or caregivers.             

Study design: Action Research.

Materials and Methods: The study was conducted from October 1, 2024, to September 30, 2025, divided into three phases: preparation phase, implementation phase encompassing two action research cycles, and evaluation phase. The research participants consisted of 5 physical therapists and 7 multidisciplinary team members. The sample group comprised 30 intermediate-stage stroke patients and their family members or caregivers. Data were collected using interview forms, assessment forms, knowledge and skill tests, and questionnaires. Quantitative data were analyzed using frequency, percentage, mean, standard deviation, Wilcoxon Signed Rank Test, and content analysis.

Main findings :  The "PT Selaphum Stroke Model" comprises 7 key components: 1) Medical consultation, 2) Initial assessment, 3) Goal setting in collaboration with patients and relatives, 4) Rehabilitation within the Stroke Unit ward, 5) Evaluation of rehabilitation outcomes, 6) Discharge planning with the multidisciplinary team, and 7) Transfer of care information to community health teams and continuous home visits. Following the implementation of the model, scores for the ability to perform activities of daily living significantly increased, while disability levels decreased (p < .001). Overall knowledge scores regarding stroke among patients and relatives significantly increased (p < .001). Frozen shoulder complications were found in 6.6% of the cases. Patients, relatives, and multidisciplinary team members reported the highest level of satisfaction, with average percentages of 95.25% and 96.75%, respectively. In addition, a handbook and educational media set entitled “Care Close to Home, Close to Heart” (Klue Mue Doo Lae Klai Ban Klai Jai) was developed to support continuous care in the community.

Conclusion and Recommendations: To maximize widespread benefits, this model should be scaled up alongside the “Care Close to Home, Close to Heart” handbook to other hospitals and health networks, emphasizing integrated collaboration among the multidisciplinary team, relatives, and the patients themselves, which is considered the key to success. Furthermore, for future research and development, the sample size should be increased, the study areas expanded, and long-term follow-up conducted to gather empirical data verifying the sustainability of this care model, ultimately leading to the establishment of efficient and sustainable standards of stroke care.