Development of an Integrated Care Model for HIV Patients and Infected Persons through the Participation of a Multidisciplinary Team, Families, and Community Network Partners in Yang Sisurat District, Maha Sarakham Province.

Abstract

      This action research aimed to examine the situation and problems related to HIV care, develop an integrated care model, and evaluate the outcomes of the model through the participation of a multidisciplinary team, families, and community network partners in Yang Sisurat District, Maha Sarakham Province, Thailand. The study was conducted from July 2023 to September 2024 and comprised three phases: situation and problem analysis, model development through two action research cycles, and model evaluation. The model was developed by integrating the Self-Management Support concept using the 5A’s process with Creer’s Self-Management concept. Participants involved in model development included 25 multidisciplinary healthcare professionals and 42 family members, caregivers, and community network partners. In addition, 80 patients and people living with HIV who received care according to the developed model were purposively selected. Data were collected using clinical record forms, a self-management behavior questionnaire, a self-management support process checklist, a quality-of-life questionnaire, satisfaction questionnaires, interviews, and focus group discussions. Quantitative data were analyzed using frequency, percentage, mean, standard deviation, and paired t-test, while qualitative data were analyzed using content analysis.

      The developed integrated care model consisted of five key components: (1) holistic assessment and risk stratification, (2) individualized information and counseling, (3) promotion of self-management and shared goal setting, (4) integrated care coordination, and (5) continuous and proactive follow-up. After implementation of the model, the overall mean self-management behavior score increased from 30.84 ± 4.76 to 39.26 ± 3.58, with a statistically significant difference (p < .001). The self-management support process was implemented at a high level of completeness across all components. Improvements were also observed in antiretroviral therapy adherence and appointment attendance, while missed appointments and loss to follow-up decreased. Retention in care and viral load suppression increased following implementation of the model. In addition, the mean quality-of-life score increased from 78.46 ± 9.82 to 86.35 ± 8.14. Both service recipients and multidisciplinary healthcare professionals reported the highest level of satisfaction with the model.