Development of a Home Nursing Care Model Combined with Tele-nursing Services for Intermediate Care (IMC) Patients in Primary Care Units Network under Songkhla Hospital in Songkhla Province
Keywords:
Home Nursing Care, Tele-nursing, Intermediate Care Patients, Self-ManagementAbstract
This research and development study aimed to analyze the current situation, develop a Home Nursing Care (HNC) model combined with tele-nursing services for intermediate care (IMC) patients in primary care units network under Songkhla Hospital in Songkhla Province, and then evaluate its effectiveness. The study was conducted in three phases. First was the situation analysis, using descriptive statistics, including challenges and needs, using data from 20 participants through questionnaires and focus group discussion. Second was the model development and pilot testing. The HNC model was developed based on the Goal 3S self-health management framework. It was tested with 5 participants, and validated by 5 experts. Third phase was effectiveness evaluation, using a quasi-experimental design with one-group pre-test post-test method. The sample included 32 intermediate care patients. Data were analyzed using descriptive statistics and a paired t-test. The key findings were as follows.
1. Current situation analysis found that the number of intermediate care patients has steadily increased, from 1,812 in 2019 to 2,020 in 2020, and to 2,595 in 2023. From the 330 patients referred for home visits via the Continuity of Care (COC Link) program, there were limited tele-nursing services and no integration to promote patient self-management.
2. This new HNC model includes a) the first nursing visit (onsite) that followed the ADPIER nursing process (A for Assessment, D for Nursing Diagnosis, P for Planning, I for Implementation, E for Evaluation, and R for Record), and b) subsequent visits (online), delivered via tele-nursing, focusing on the Goal 3S self-management framework.
3. After implementation of the model, patients showed statistically significant improvements (p-value < .05) in daily living activities and quality of life. No complications were observed in three key disease groups. Patient, caregiver, and nurse satisfaction were rated as "very high", with satisfaction rates of 86.25% and 92.38%, respectively.
Per findings, the model reduces healthcare personnel workload, integrates digital technology for seamless services, and aligns with the policy for continuity of care. For patients, it improves accessibility, reduces costs, and enhances convenience. This model is recommended for expansion to primary care units in other health regions.
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