The development of continuing care system for patients with chronic diseases in Chumphae District Health System.

Abstract

     This action research was aim to develop the framework of continuing care for patients with chronic diseases at Chumphae’s network. The target population was the patients with chronic diseases who registered at Continuing Care Center, Chumphae Hospital during October 2017-September 2019. This continuing care system was responsible by 20 personnel from Primary Care Unit, urban health center, Chumphae’s District Public Health Office as well as the Chumphae multidisciplinary care team composing of 8 personnel with physicians, nurses, pharmacists, physiotherapists and dietician. The care system was based on the Deming cycle with 4 steps including step 1 Plan; this step was to investigate the problem, set up the meeting with related parties and review the procedures, step 2 Do; it was the execution step to follow the plan and procedures, step 3 Check; this step was to evaluate the result and check the possibility of policy implementation and the limitation and step 4 Act; this step was to develop the registration program of continuing care for patients with chronic diseases as well as the following guideline, guideline of hospital to home care pathway, the practical guideline of continuing care for network of Chumphae Hospital, the criteria for home visit by multidisciplinary team and home visit report. The descriptive statistics was employed this dataset a long the content analysis.

     The result showed that 68.2% of patients with chronic diseases had been followed up at home visit. Of those 87.4% was performed by network of Chumphae Hospital. Regarding the chronic diseases, stroke was the most found as 35.7% following by palliative care of 21.1% and general medicine of 9.5%. In addition, 141 patients with chronic diseases were visited by multidisciplinary team. It was found that the disease complications e.g. bedsore, joint addition, pneumonia and urinary tract infection was 9.5% whereas the patient’s and care-giver’s satisfactory was 85%. Moreover there was no re-admission among those patients who was discharged home. Mostly the seamless continuing care was organized using the information technology for data processing and building the guidelines for multidisciplinary team, inside the hospital and their networks.