Care Management Model for Older Adults with Chronic Diseases in Community

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Pramote Thangkratok
Raphatphorn Petchsuk
Thitaporn Keinwong
Winai Trainattawan
Pondvadee Thatdee
Prissana Boonpradit

Abstract

           Many Thai older adults are living longer but with increasing levels of disability from chronic illnesses in the community. Registered nurses play a vital role in providing care management for older adults with complex chronic diseases, frailty, and comorbidities. This article studied on the definition and conceptual framework of the following: 1) identification of members who need care management, 2) comprehensive needs assessment, 3) care plan development, 4) implementation of care plan, 5) analysis of the effectiveness and appropriateness of care plan, 6) modification of care plan based on the analysis, and 7) monitoring of the outcomes. This study also demonstrated the successful key of care management in community as follows: 1) appropriate patient selection, 2) person-to-person encounters, 3) trained care managers with low caseloads, 4) multidisciplinary teams including physicians, 5) informal family caregivers, and 6) use of coaching technique, and applying the care management model to older adults with complex chronic diseases in the community. This article contributes to understanding care management concepts and identifying an action guideline for providing care management that has improved the quality and reduce the costs in health care services.

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Section
Academic Article
Author Biographies

Pramote Thangkratok, School of Nursing, Srisavarindhira Thai Red Cross Institute of Nursing

School of Nursing, Srisavarindhira Thai Red Cross Institute of Nursing, Bangkok

Raphatphorn Petchsuk, Faculty of Nursing, HRH Princess Chulabhorn College of Medical Science

Faculty of Nursing, HRH Princess Chulabhorn College of Medical Science, Bangkok

Thitaporn Keinwong, Faculty of Nursing, Suan Dusit University

Faculty of Nursing, Suan Dusit University, Bangkok

Winai Trainattawan, Boromarajonani College of Nursing Changwat Nonthaburi

Boromarajonani College of Nursing Changwat Nonthaburi, Nonthaburi Province

Pondvadee Thatdee, San-Chao-Pho Subdistrict Health Promotion Hospital

San-Chao-Pho Subdistrict Health Promotion Hospital, Nakhon Ratchasima Province

Prissana Boonpradit, Sap Poep Subdistrict Health Promoting Hospital

Sap Poep Subdistrict Health Promoting Hospital, Phetchabun Province

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