Development of the nursing service system for the Continuing Care Center (COC), Chaturapakphiman Hospital.

Abstract

     This study was action research 1) study the service system situation of the Continuing Care Center (COC) nursing services at Chaturaphak Phiman Hospital, 2) develop a COC nursing service model, and 3) evaluate the outcomes. This study employed the conceptual framework of Kemmis & McTaggart, consisting of four stages: Planning, Acting, Observing, and Reflecting. The informants included professional nurses, health-promoting hospital nurses, multidisciplinary team members, and PCT committee members, totaling 27 participants. Research instruments included questionnaires, data recording forms in the Nemo Care system, and performance evaluation forms. The study was conducted from October 2023 to September 2024. Data were analyzed using descriptive statistics.

     Research results indicated that the development of a nursing service system for a Continuity Care Center through three cycles of action research resulted in an integrated continuity care model, the “CTRPM Smart Continuity Care Model.” The model consists of five key components: (1) Collaborative Care Network – establishing health collaboration networks; (2) Technology-Enhanced Care – applying digital technology to continuity care; (3) Referral and Care Transition – providing systematic referral and transitional care; (4) Professional Nursing Competency – developing nursing personnel competencies; and (5) Monitoring and Quality Management – continuous monitoring and quality improvement. The model enhanced the effectiveness of continuity care. One hundred percent of patients received home visits within two weeks after discharge, the home-visit feedback response rate was 87.7%, complications were found in only 0.48% of cases, and both service recipients and service providers reported high levels of satisfaction.