Results of home visits to elderly diabetic patients with hyperglycemia and stage 3 chronic kidney failure in Kudnamsai Subdistrict, Chaturat District, Chaiyaphum Province.

Abstract

     This action research aimed to study the context and problems of caring for elderly patients with diabetes mellitus and uncontrolled blood glucose levels combined with stage 3 chronic kidney disease, develop a home visit follow-up model, and evaluate the outcomes of the model implementation in Kudnamsai Subdistrict, Chaturat District, Chaiyaphum Province. The study was conducted from January to April 2025, over a period of 5 months, using the PAOR process according to Kemmis and McTaggart's concept for 2 cycles. The sample consisted of 12 multidisciplinary team members and village health volunteers, and 35 elderly target group participants. The research instruments included focus group discussion guidelines, general information questionnaires, knowledge assessment forms, self-care behavior assessment forms, clinical data collection forms, appropriateness assessment forms, satisfaction assessment forms, and the home visit follow-up model. Data were analyzed using descriptive statistics and inferential statistics (Paired t-test).

     The results showed that the developed model consisted of 7 main components: a 10-step clinical practice guideline, role definition for 7 professional disciplines, 4 data recording forms, 8 media and documents, guidelines for health education and self-care promotion in 6 domains, a capacity building plan with 4 courses, and a monitoring and evaluation system with 6 indicators. Experts rated the appropriateness at the highest level (mean score 4.73). The results of model implementation showed that elderly participants' knowledge increased from 14.86 to 22.31 points (p<.001), self-care behaviors increased from 78.29 to 109.43 points (p<.001), HbA1c decreased from 8.45 to 7.24 percent (p<.001), eGFR increased from 46.71 to 48.26 mL/min/1.73m² (p=.039), complete appointment attendance increased from 68.57 to 94.29 percent, complication incidents decreased from 7 to 1 time, and satisfaction was at the highest level (mean score 4.58).