Continuity of care coordination system development in Yasothon Hospital

Abstract

This cooperative action research aimed to develop and study effect of a system for continuity of care coordination based on the concept of Kemmis & McTaggart (Kemmis & McTaggart). Thirty-three co-investigators were selected, consisting of one person responsible for continuity of care at the Yasothon Provincial Public Health Office, 16 staff from nursing department of Yasothon Hospital, 8 staff from district hospitals, 8 staff from district public health offices. The study was conducted 2 cycles of 4 steps: 1) situation assessment 2) action planning 3) action 4) evaluation and reflection of results. Data were collected by means of group discussions, inquiries, and brainstorming sessions. Research tools included instruments for conducting research and tools for evaluation findings. Study period was from 1 August to 31 December 2018.  Quantitative data were analyzed using descriptive statistics, including frequency and percentage. Qualitative data were analyzed by using content analysis.

Results of the study showed that: a. analysis of continuity of care situation 1) Inputs, including no discharge planning with the community. The personnel were not continually developed knowledge and skills for patient care. 2) Process, there was no mutual coordination guideline for continuity of care. 3) Output, there was no database of continuity of care at home, leading to unable to follow up and summarize data, which resulted in patients not receiving standard home visit and responses to home visit results were lower than standard (15.79%). b. the system for continuity of care coordination comprised of: 1) Inputs: established a continuity of care coordination committee, developed a guideline for discharge planning in patients with complicated diseases by case manager, and organized training to promote community personnel’s capacity in taking care of patients with complicated diseases. 2) Process: established a mutual guideline for continuing care, and coordinated of continuing care through the Thai COC program. 3) Output: summarized continuing care, presented in a network meeting, and exchanged knowledge of continuing care of Yasothon Province every month. Evaluation of the system for continuity of care coordination found that there was an increase of home visits according to home visit criteria and patient severity rating (70.52%), and an increase of home visit responses (70.52%). Personnel had the highest level of satisfaction towards the system (Mean = 4.61, S.D. = 1.17).