Development of Continuing care Model for Elderly People with Chronic Illness of, Nongkungsri Hospital, Kalasin Province

Abstract

This action research aimed to develop a continuing care model for the elderly with chronic illnesses of nongkungsri hospital. Key informants included 20 elderly patients with chronic illnesses and 20 patients’ caregivers ,as well as 15 health personnel acting as a multidisciplinary team. The study was conducted during January 2016 - April 2017. This study comprised of three phases. Phase 1 was a situational analysis conducting to assess problems associated with the continuing care of elderly people with chronic illnesses. In this phase the data collection was done through observation, interviews and focus groups with the patients and their caregivers and multidisciplinary team. Phase 2 was a developing a continuing care model for the elderly with chronic illnesses. The newly developed continuing care model had needed on three main issues, including;. These issue were 1) developing discharge planning documentation for the elderly with chronic illnesses; 2) developing clinical information system and referral system; and 3) developing  continuity care and home health care provided by multidisciplinary team. Phase 3 was a monitoring and evaluating the developed model. ,3

            The results revealed that the developed model illustrated the continuity of care for the elderly patients with chronic illnesses in terms of hospital care and also home care. The patients and  their caregivers satisfied 100 % about the model and had no complication after  discharge from the hospital. The multidisciplinary team also satisfied 100 % about this model because of its convenience and suitability to apply, and also satisfied 95.55% regarding their understanding about the referral system for the elderly with chronic illnesses. It could be concluded that the developed model was effective yielding benefits for the patients and also health personnel for caring the elderly with chronic Illnesses. Therefore, this model could be employed for caring other patients with chronic Illnesses.