Effects of A Nurse - Led Integrated Care Model for Older Adults with Uncontrolled Chronic Diseases in Bangkok Metropolitan
Keywords:
Nurse-led integrated care, Older adults, Uncontrolled chronic diseases, Self-managementAbstract
Background: Uncontrolled non-communicable disease is a significant challenge for older adults, who have multimorbidity. In Bangkok, older adults with multimorbidity have difficulties in self-management due to fragment health services and continuing care, leading to poor control. Objective: This two-group pretest-posttest quasi-experimental research was conducted to evaluate the effects of a Nurse-led integrated care model for older adults with uncontrolled chronic disease, living in Bangkok. Methods: A total of 60 older participants with uncontrolled chronic disease were recruited from two public health centers and allocated by sites to an intervention group (n=30) or a comparison group (n=30). The intervention group received the 12-week Nurse-led ICM program, consisting of 1) a comprehensive geriatric assessment; 2) health education and skill training; 3) monthly home visits by multidisciplinary team; 4) bi-weekly self-management support by a nurse case manager using self-monitoring application; and 5) two group sharing sessions. While, those in a comparison group received usual care. Results: According to Paired t-test and Independent sample t-test results, the mean score of self-management, functional status, blood sugar, and blood pressure within the intervention group were significantly improved and better than the comparison group (p < 0.001) at week 12th. Conclusion: Findings suggest that this integrated care model is feasible and effective for older adults with uncontrolled chronic diseases in primary care context. Thus, it could be applied to those older adults with chronic diseases, living in other community in Bangkok. In addition, self-management support competency of public health nursing should be strengthened to promote quality of care and patient outcome.
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