The development of a homebound bedridden and palliative care patient care model led by a community nurse team
Keywords:
Homebound patients, bedridden patients, palliative care patients, community nurse team, community participationAbstract
This mixed-methods action research aimed to develop and evaluate the effectiveness of a care model for homebound, bedridden, and palliative care patients led by a community nurse team in Kut Chum Sub-district, Kut Chum District, Yasothon Province. The study was conducted from March to November 2025, totaling 9 months, and divided into two phases. Phase 1 involved model development using the Participation Technology (TOP Model) through focus groups, workshops, and A-I-C participatory planning with 224 network partners. Phase 2 evaluated the model's outcomes in 40 patients. Data were analyzed using descriptive statistics and Pair t-test.
The developed care model consisted of four main plans: (1) homebound patient care system development, (2) bedridden patient care system development, (3) palliative patient care system development, and (4) management and evaluation system. Key activities included establishing a sub-district medical equipment lending center, developing a discharge planning system with the community hospital, establishing a specialized palliative care team, and setting up a 24-hour telephone consultation hotline. After implementing the care model, patients consisting of 34 homebound patients, 3 bedridden patients, and 3 palliative/end-of-life patients showed significant improvements.) The mean ADL score increased (p = 0.013). The mean Morse Fall Scale score decreased (p < 0.001). The mean Braden Scale score decreased (p < 0.001). The mean ESAS score decreased (p < 0.001). The mean Pain Score decreased (p < 0.001). All differences were statistically significant at the .05 level.
The participatory care model developed through collaboration with health networks and community partners effectively and sustainably improved the physical functional status of patients, reduced the risk of complications, and alleviated symptoms. It should be expanded to other areas with similar contexts.
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