Development of an Integrated Home-Based Continuum of Care System for Stroke Patients in the Phrom Khiri District Health Network, Nakhon Si Thammarat Province

Abstract

This research and development study aimed to develop and evaluate the effectiveness of an integrated home-based continuum of care system for stroke patients in the Phrom Khiri District Health Network, Nakhon Si Thammarat Province. The study was conducted in four phases: 1) exploring the context and analyzing care-related problems; 2) developing a participatory care model under the PHROM KHIRI Model, based on House’s social support concept; 3) implementing the model using a one-group pretest–posttest quasi-experimental design over 20 weeks among 38 stroke patient–primary caregiver dyads; and 4) evaluating, refining, and expanding the model. Data were collected using interview guides, focus group guides, caregiver care assessment forms, community support assessment forms, quality-of-life assessment forms, and satisfaction questionnaires. Data were analyzed using descriptive statistics, paired t-tests, and content analysis. The results showed that, after implementation, the mean scores for caregiver care, community support, and patients’ quality of life increased significantly, with mean differences of 0.28 points (95% CI: 0.21–0.35), 0.63 points (95% CI: 0.47–0.79), and 0.55 points (95% CI: 0.42–0.68), respectively (p < 0.001). Stakeholders’ overall satisfaction with the developed model was at a very high level (81.43%). In conclusion, the PHROM KHIRI Model strengthened the linkage among health services, families, and communities, resulting in improved caregiver practices, social support, and quality of life among stroke patients.