Research Report Thai COC Program for the Quality Criteria Results of Home Visit Services : Surin Province

Research Report Thai COC Program for the Quality Criteria Results of Home Visit Services : Surin province

By Miss Pasinee Nakdee

Expertly Professional Nurse

The chief of Community Health Nursing Department Surin Hospital

Preface This research is an action research to study the effect of using the Thai COC program on the quality of the result from the homecare services in Surin Province with the research methodology as follows.

Content page Preface a Content b Table Content c Diagram Content c Chapter 1 Background 1. Introduction and objectives 1 2. Objective 4 3. Inclusion criteria 4 4. Definition 5 5. Outcomes 5 Chapter 2 Concepts, theories and related researches 1.Concepts and theories 6 2. Related researches 29 Chapter 3 Research Methodology 1. Population and Sample Group 33 2. Research Process 33 3. The Research Tools, the quality inspection of the tool, and data collection 34 4. Data Analysis 35 Chapter 4 Research Result Phase 1 Planning 36 Phase 2 Action 37 Phase 3 Observing, monitoring and supervising 40 Phase 4 Reflect/Feedback 40 Chapter 5 Research Conclusion, Discussion and Recommendation 1.Research Discussions 56 2.Recommendation 58 3.Reference 59 c

Table Content

Table No. page 1 Amount and percent of patients classified by ratio of requested and accepted cases of homecare patients 45 2 Amount and percentage of homecare patients classified by general grouping 46 3 Amount and percentage of feedback from homecare patients categorized by patient levels and report cases 48 4 Amount and percentage of dependent patients categorized by report cases and transfer time 50 5 Percent of the patients categorized by the patient levels and health conditions 51 6 Percent of the patients categorized by the satisfaction ratings 52 7 Percentage of the service provider categorized by the satisfaction ratings 53

Figure Content

Figure No. page 1. Home care nursing concept 9 2. Conceptual Frameworks for Research 32

Chapter 1 Background

Introduction and objectives In 2002 Thailand has established its universal health coverage (UHC). The scheme aims to make healthcare services accessible to all Thai citizens. In addition, the service is optimally standardized to provide the services to Thai people equally. One of the most important policies is the primary healthcare; it includes to implement a family and community health promotion, to provide primary healthcare services in the district healthcare level, so to reduce the number of patients in the tertiary hospital and to reduce the health expenses in the family and federal healthcare budget. The data from Thai Minister of Public Health (MOPH), department of policy and prevention showed that, in 2008 there were 17.5 million patients with chronic diseases. It was estimated that 308,337 million Baths in a year was spent to provide services to this group of patients. The cost of care per year is expected to rise. It is estimated to cost the government and private expenses around 335,539 million Baths per year (Department of policy and prevention, 2008). One of many strategies in meeting the primary healthcare objectives is to provide healthcare services in the patient’s own home, called home ward, because it showed to reduce the workload and healthcare cost. (Clenment-Stone, Eigsti &Mc Grire,1995, cited in Nursing Office, Thai Ministry of Health, MOPH, 2013: 3) The national health expenses (cost of medication, cost of care) per household has been rising from 71,067 Baths in 193 to 381,387.50 Baths in 2016 (http://social.nesdb.go.th/ social Stat Health 4, Public Health resources) nl thf ehT hr l ot fo thtrop ehT lpb s eT1f pb t rfh ir%i eT 1ff h 17r1ni in 2016. b p f bro h l Tr s f hr l tp e T b slh lpi 1lfhTe1 t eb pb b br1l pb pf l t f T ehTh 1lfhTe1 eetT teb pb h eb1lf e1 l teb pb (Data from 2011-2015) (4 tpf T hr ohoe1 pTt of i T ehTh 2n1 ) nleb f thf 1hTbeb T se l l f thf hr Surin hospital, increase the number of in-patient, out-patient pTt l s t h11rte t fp . SeT1 2n11, i spb f thf t lp l Tr s f hr hr -tp ieT 2

increased from 2,121 to 2,818 t p e T b per day, iT-t p e T increased from 626 to 876 tp e T b per day pTt l s t h11rtpe t fp increased from 54.74% to 105.52%. ( rfeT 7hbte poh 2n17) Continuing care at home is an important strategy, to promote self care in the 1h rTe tfhiet b s 1h rTe l po l 1pf shfe f, lp 1pT f tr1 t lhbte po o t l hr b p , 1hTb er T o f tr1 b l po l1pf 1hb r

shr eTre hr 1pf eb t reT t pb p lhoeb e1 1pf lp responding to patients needs and patients problem lp tfhiet b h tp e T s trfeTt lhbte poenp ehT l T 1hT eTr teieTt to them after discharging er 1pf eb b eoo f eref tr nl tp e T b lh eb tpf hr l healthcare facalities lp 1pT s rb t h rp1eooe p tp e T b 1pf . t l nl rp eo seoo s tfhiet eThso tt hr 1pf h pTt fpeT t h s pso h brtthf l tp e T by the healthcare team, that they can s 1hT p1 t 2 lhrfb p tp for t T1 brtthf r (ofpteT ap pTph1ff3)

nl lh 1pf b fie1 b is p tfe pf l po l1pf b fie1 that s1hoop se l o7 policy. It provides an integrated care which includes health promotion, health prevention, basic treatment and rehabilitation, to support self-care of the people and to encourage their family and community to participate in health self-management. It also enhances and expands the nurse’s authority in their roles and scope of practice in using fundamental of nursing care in home care. In the primary homecare model, the nurse acts as a case manager who collaborate with other healthcare team in transition care from hospital to homecare. This practice helps to reduce the gap of care between primary, secondary and tertiary care by providing knowledge of care and facilitate effective communication to provide effective care for the continuum. To using discharge planning can maintain continuity of care more effective.

In 2016, Surin Hospital found that the homecare services were not achieved the quality standard of home visit (set by the Department of Nursing Office, MOPH) due to the communication model between hospital and home care service. Surin Hospital, Surin Public Health Department and Data and Statistic centre in Public Health Faculty in Khon- Kaen University agreed to develop Thai COC Program. It is planned to create a database system to collect patient data, connect the network of data communication between each 3

healthcare service from tertiary healthcare centre to secondary and primary healthcare centre in Thailand. This system helps to promote faster and effective communication and interaction between healthcare providers, as a result it helps to prevent complication from delay care, hospital readmission, and it helps to promote patient recovery and wellbeing.

Since the COC has been established, it has been used extensively by the members of healthcare providers. This program and collective databases support the use of information database in the following ways.

1) Using data to analyse the causes of delaying communication and suboptimal care between every levels of healthcare providers by taking into consideration of risk and benefit of individual as followings: 1.1) Able to report a current outcome of homecare, so to follow up and reduce workload of the healthcare worker 1.2) The care workers are able to access their data in their level of care and authority, so security of data is optimal. 1.3) The healthcare index can be analysed in each disease in each geographic area. 1.4) The COC communication network creates a spot map which can be used in a smart phone, tablet and computer. 1.5) There is a survey for customer service satisfaction and quality of life of the patient in the Thai COC, provided in the link via the smart phone. 1.6) The healthcare user can add more care pathway for other disease if needed. 2) To facilitate the meeting between the programmers and users to analyse the problem and update the system if needed. 3) Use the data to develop the Thai COC under the Thai Care Cloud Platform. 4

4) The program was first tested and updated in Surin Province at Gaeyai sub- district Health Promotion Hospital. 5) The program was first roll out on the 5th of September 2016 to the user in Surin province and other provinces, the training was provided to all users inside and outside the regions. 6) Established a continuity care committee in district, provinces and regional level. 7) Created a practice guideline booklet for each disease in a hard copy and uploaded into the Thai COC. 8) Followed up and monitoring the healthcare index target achievements through the meeting at the level of province, district and sub-district. 9) Established an administrator team to monitor and update the system in each level of the healthcare provider, and established the Line group for faster and more effective communication between administrators.

Now, the Thai COC is used in 9 health region, covered 39 from 77 provinces in Thailand, by 12,005 users, 4,463 healthcare centres, and 251,166 patients and log in 321,333 times (Data from Thai COC 15th October, 2018). The author is interested in studying the effects of Thai COC to the quality of care in home visit in Surin Province. This outcome data will provide basic information to develop the care pathway for optimal homecare, seamless between each healthcare provider including private and government providers.

2. Objective To evaluate the effects of Thai COC to the quality of home visit health outcomes

3. Inclusion criteria 3.1 Patient in any ages and disease enrolled in the Thai COC. The following criteria will be included. 3.1.1 Being discharged from Surin Hospital with the home visit follow up to be delivered by the one general hospital, 16 district hospitals, 232 primary healthcare centres, 3 community healthcare centres in Surin Province. 3.1.2 Being referred from the general hospital, district hospital to the primary healthcare centre and outer region hospital. (outside Surin Province) 3.1.3 The patients reside in the primary healthcare centre service geographic area and response to healthcare worker request for home care. 3.1.4 The patient referred from outer region that required a home visit. 3.2 The outcome of achievements can be measure by 6 indices included: 3.2.1 The covered rate of patients visited by the healthcare team. 3.2.2 The rate of patient discharged from the tertiary, general, community hospital being seen by the home visit team within 14 days. 3.2.3 Numbers of working hour of each officer for home visit activity. 3.2.4 The rate of complication that occur during a homecare service 3.2.5 The patient accessing to home visit service, has essential skills for self care. 3.2.6 The referral rate of patients category 3, data was sent to the homecare provider team within five days. 4 . Level of satisfaction to homecare service, of the patient and relatives/ healthcare receivers. 5 . Level of satisfaction to homecare service, of the healthcare providers.

4. Definition 4.1. Thai COC program is an innovative software program for healthcare that was developed for healthcare networking and communication between the users. Its’ web application works under the Thai Care Cloud (http://thaicarecloud.org). It can be used in a smart phone, tablet and computer that connected to the internet provider. 4.2. The tool for evaluate the quality of healthcare service provided by the home visit team was developed by the National Nursing Office. It aims to provide the optimal care as per the UHC policy. This evaluation tool uses a working process including input, process, output and outcome, which adjusted to the homecare fundamental. 5. Outcomes 5.1. Able to use a working process to evaluate the outcome of providing care in patient’s home 5.2. Able to use the study outcomes from this group of population in developing a better care plan to meet the UHC policy.

5.3. Able to use the digital technology in providing a better care to the patient at home.

Chapter 2 Concepts, theories and related researches

1. Concepts and theories 1.1 Home health care Home health care is associated with some words in Thai language and many English words. To clarify this word, Thailand Nursing and midwifery council has defined the meaning of the words as follows: Home Health Care was widely translated into Thai language including Home care nursing, Home health care, and Home Health care services, etc. Dr. Praphan Wattanakit (1993) has defined the meaning of Home health care refers to proactively provides health services by using people homes as the services provided places. There is a health care team who supports and educates about health caring to patients and their families in their home. Also in an emergency event, there will be the staffs and their teams who stand by for help and support in constantly. Therefore, the focusing of Home Health Care is the multidisciplinary team including physicians, nurses, pharmacists, physiotherapists, nutritionists, and others work together as a team to take care of patients at home. Wholistic Caring, Dr. Rattanapan Wattanakit (2016: 6-10) explains that the term "wholistic" comes from the word "holistic", which is derived from "holy" means sacred, divine or consecrate, this word mostly recognized in term of religions and God. Therefore, she decides to create a new word by using the word "Whole" instead and changed into "wholistic" which means overall or holistic, related with the principle of good health care start from home. Also, wholistic care could be separated into two major categories of health services: 1) Caring services called "Basic Health Services". 1.1) To Promote or build a good health. 1.2) To Prevent or protect a health from disease. 1.3) Treatment and Nursing care 1.4) Rehabilitation 8

2) Sanitation and Environmental Health care service included: 2.1) Sanitation and Environmental Health care in 3 places at home are kitchen, bathroom and accommodation areas. 2.2) Sanitation and environmental sanitation care in the basement of the house, around the house, including drinking water, water drainage, standard distance between the water source and toilet in the house, Cleanliness, and pollution, including with early outbreak causes controlling and elimination. The word "Caring" comes from the word "Care" which has a clear definition in itself, brought up with the phrase "Caring more than care," added up to the scope of health services, initiated the three more standard qualifications of health care services as follows; 1) Put yourself in someone else's shoes. Pay close attention to people (Patients or any person who are receiving care) 2) Provide care and/or assistance with kindness, generous. Not because of a duty 3) Protect or prevent the spreading of disease through entire surrounding environments, concluded with bed and resting place while waiting for the treatments at home. Home Visit is an activity or strategy that is the most important for individuals and patients health caring at home. Home Ward means using a patient’s home as a patient care bed. Could be clarified as giving continuous care for the patient after discharge from the hospital by using patient’s home as the place to treat and care as same as in a hospital. These patients are patients with complex health problems who need special care from professional practitioners such as patients with chronic diseases, kidney disease, paralysis, accidentals, and end-stage lives disease. Patient care at home is a potential development of patient self-care for patients and families. In order to prevent the complications or recovering from illness and have the best health conditions according to their potential and/or build up the relationship in the family, provides families with opportunities to take care of patients closely moreover prepare all family members to be ready and accept when it comes to lost. 9

Primary care unit refers to a service unit that provides public health services. It is a primary care unit which taking care of the people with those holistic care and continuous care. These primary care units will be named after their agency, such as the Sub-District Health Promoting Hospital with City and Community Health Centers, Department of Family Clinical Practice and Community in Community Hospitals, the social medicine department in general and regional hospitals which have a home visiting care service. Home care nursing refers to providing health care services for patients, and their families by running the services at the patient’s home. The home care nursing services are for supporting, training, and instructions patients and their families able to perform self- caring, complications preventing and illness recovering. Besides to help patients live their lives within their potential also bring back good health as close as usual. Patients could be self-reliance within the context of the environments and their families. In case of the emergencies or dangers events, there is a team to contact for helping of all times. This nursing care has come along with community developing launch to a benefits source of Health care for all members. 1.2 Home Care Nursing Home care nursing is a continuous patient care service. Consist of the care activities that suit the patient's desires and maintain the quality of life for the patients and their families. According to this caring service, using the nursing care process to assess patient’s health problems during their home staying is a process that helps nurses to figure out the real problems, will effect on the plans and further nursing care. This care service is proactive care which continues caring patients from the hospital to their home. For those who have health conditions such as patients with chronic diseases, the elderly, rehabilitation needs patients, disabled patients, and end-stage live patients, the proper nursing care from the healthcare team, must be obtained. This nursing service will provide nursing caring to patients and caregivers who were lacking care skills, lacking knowledge or disability. Also, build up the confidence and encourage patients and their families to care for themselves and be able to live in society. 10

Home Care Nursing Purposes are; 1) To assess the patient's health status, Caregivers, families, the environment, health needs analysis, Discharge planning including the external factors that effect on patient's living at home. Any problems were found at home could be used as supporting information in nursing planning. 2) To guide and practice skills for patients and families to recognize and adjust behavior during patient's rehabilitation as well as perform the right Self-care. 3) To provide nursing services in which patients and caregivers are unable to perform or limited self-care. 4) To keep up with medical treatment and rehabilitation. Reduce acute symptoms and disability of illness also maintain Good health 5) To strengthen confidence and support for patients and families, to live with patients and participate in patient care for a good quality of life.

Home care nursing goal Home care nursing service is designed to meet the needs of patients and families with health problems by providing holistic care service. The services consist of Health promotion Disease prevention Medical treatment and rehabilitation. Also, support the patients and families to participate in the planning and implementation of health care plan to meet their demands and health conditions.

The benefits of home care nursing 1) Provide services to increase accessing the nursing services in the community through the home also give the equal opportunity for people with the need for discharge planning and health care services. 2) Develop people's potential for health care.

The conceptual framework of home care nursing Home care nursing services use the systematic concepts. (Department of Nursing, Ministry of Public Health, 2014) consists of Input, Process and Output and Outcome as shown in the Figure 1r 11

Figure 1 Home care nursing concept

From Figure 1 has shown the concept of home care nursing by using systematic concept. These nursing services require having resources that conducive to the operation, with professional nurses acting as the nursing team’s leader who arranges a home visit system. The system consists of these followings; 1) Inputs refer to the attributes of the staffs, the sufficiency of equipment/appliances, which is the input of home nursing service and service management system that contains with 1.1) The home visiting team including nurses, physicians, physiotherapists, pharmacists, and other health personnel who work in the primary care sector such as public health educators, governance, and other network partners both in public and private sector. The goal is to share the care of patients at home. 1.2) Nursing Linking System for Patient Care, According to the patients who are discharged from the hospital also needs a period for recovering. Moreover, patients whose disease have effected on their images and capabilities become as limited self-care persons or unable to adjust themselves to the illness. These patients are required to have 12

continued in nursing care at home. So a nurse who is responsible for the home care nursing program has to arrange the caring system as following and coordinate with the hospital. 1.2.1) Discharge Planning 1.2.2) Self-Care Support System for Patients and Families 1.3) Equipment / Appliances 1.4) Factors of Nursing supportive at home 1.4.1) Potential of community 1.4.2) Home caregiver 1.4.3) Community resources 2) Process is an interaction between home visiting team and patients include with the families considering to all nursing activities, knowledge demonstrations, and knowledge applying processes of nursing care providers to meet with health problems. The nursing process is to be used as a tool following the step of the process. Divided into three stages: 2.1) Pre-visiting phase, there are three phase of preparation: 2.1.1) Information preparations, Prepare for all the community health information, the patient or family Identity analysis of health information by studied from patient's data from the hospital and community. The nurse significantly has to study for patient’s health information in the subject area. Also, knowledge preparations and community information studying needed to be done for further use in patient health consultations and care. Therefore the basic knowledge should nurses prepared and produced some media are the significant disease that occurs in the subject area or the disease of the patient who is going for a home visit. The progress of disease, symptoms, treatment, complications, and duration of rehabilitation. Moreover, treatment such as procedures that may have been received in the future, types and usages of specific drugs, first Aid and primary care in case of emergencies during the visiting. Patient care must be continuous. There should be connected between the hospital and home nursing. The hospital discharge plan should be prepared. Nurses and home care providers need to 13

practice and follow the discharge plan continuously. By assessing health information at home and plan for nursing properly. 2.1.2) Defining the care plan, the objective of visiting is to assign the activity. Determine the type of visit by severity and clarify into three levels. As a result, nurses should help patients and families as planned. The visit plan could be adjusted and rearranged as the considerations for the most effective home nursing care plan. 2.1.3) Equipment/supplies for home nursing, for home visits appliances are essential. The team has to prepare for each patient. While performing nursing activities, patient’s Universal precaution should be taken to prevent complications from service. Moreover, the environment arrangement should be concerned. The nurse must wash/clean their hands before and after service. All garbage from the service process must be dumped in a container with a lid closed. In the case of infectious garbage or Hazardous drugs must be eliminated in the correct process. Also, to prevent the spread of infection in the community, all used appliances/ equipment must be separated from clean to prevent contamination. 2.2) Home visiting phase Nurses should assess the relationship between patients and their family members. Also assess the environment by using the nursing process as a tool for assessing and nursing provides guidelines. The nurses need to identify problems and health care desire of patients. Then make a plan for the nursing team, patients and caregivers put up to practice. The activity should base on the purpose of the home visit. Assessing the original problem included the new problems that may arise by using INHOMESSS and the Nursing Process as an assessment tool. Home Nursing Process is a process that solves the problems with scientific methods and the systematic way of thinking. (Siriporn Khamlakit, 2539 stated in the Nursing Bureau Office of the Permanent Secretary, Ministry of Public Health, 2013: 85- 90).Consisting of the procedures that more emphasized on problems solving and needs of the patients than correcting on patient's disorder or medical treatment. Therefore, nurses 14

who are using the home nursing process as an assessment tool need to follow the steps below. 2.2.1) Health Assessment is the process of collecting information. The nurse must gather the information consisting of symptoms from the pathology that effected on physical problems throughout personnel spiritual and social spiritual consider with the social, culture and lifestyle. Moreover, nurses should study the context of the community that consists of history, structure, a location of houses, economic, social, transportation, traditions, beliefs and attitudes, environmental conditions in both physical and biological, also the available resources in the community that family can use in health care. For the assessment, nurses can create tools or any evaluation forms to gathering the information within the concept or scope, whether from the personal or various data record. These will help nurses to understand the problems from both disease and social problems that effect on patient’s recovery. For example, constipation assessing in heart disease patients by using the INHOMESSS form as a guideline for health status assessment. Assessing patients’ health status is essential. Because of the information, nurses will know the causes of health problems. Moreover, this information will be a significant database of nurses to set the targets and strategies for nursing care, create health promotion plan and provide proper nursing to meet patient's needs. 2.2.2) Nursing Diagnosis, Nursing Diagnosis must be defined under empirical data support that is problematic. The good nursing diagnosis's writing should guide nursing practice. There should be supportive information as well. whether, from personnel informing or behavior observations based on people expression after service receiving. That can be corrected/assisted by using the nursing principle. This method is an analysis of the data process. The nursing diagnosis consists of two types, first is the actual nursing diagnosis and second is the risk nursing diagnosis. Health problem's prioritization is a process that categorizes patient’s health problem. Based on the urgent and violence of the problem. Considering with the following 1) what is the threat to the patient's life? 2) What is the threat to the physical and mind of the high-risk patient? 3) What is the effect on the patient’s maintaining the normal physical and mental health of patients? Nursing diagnosis is a clinical judgment about client’s responses to actual or potential 15

health problems/life processes lead the planning and practice of nursing following health conditions within the scope of nursing. Also, manage by knowledge, experience and the scope of the professional law. 2.2.3) Nursing Care Plan is the implementation of the nursing planning of care based on the assessment and diagnosis. The decision must be made to suit each individual and meet the needs of patients. Nurses have accountability to consider all the correct information which covers all nursing care plan. The care plans must be consisting with defining the objectives of the problem-solving, setting measurable and achievable short- and long-range goals, identifying activities to solve problems, determining guidelines and criteria for evaluation. Nursing care plan is a tool that represents the patient's conditions. Moreover, it provides the nursing practices guideline to solve health problems for patients. The nurse practitioner would gain the advantages from seeing nursing care plan and understand the overview of problems, including with purpose of nursing care, criteria, evaluation, nursing activities, and intervention. Proper nursing planning helps nurses to provide specialized care for each patient. The excellent quality care makes the most benefit for patients to reduce health problems. 2.2.4) Nursing Intervention According to the Nursing intervention, an important principle to consider is the involvement of patients in their health care. The nurse must provide nursing care following goals that have been set. Patient care is based on the principle of human being, linking with all personnel in every dimension. Nurses must give time to listen, pay close attention to patients, respect their native and culture. Besides, could apply folk wisdom or others philosophy to improve nursing practice. Nursing care providers need nursing skills, communication skills, management skills. Also, the ability to encourage a patient to follow the nursing plan toward short-term and long-term goals 2.2.5) Nursing Evaluation is the final step of the nursing process, which is the process of examining the results of the practice, achievement of nursing activities. The results of the evaluation will lead to re-assessment of the data for further support or revision of nursing practice. Or, set new goals according to the changing of nursing problems. 16

When visit a patient home, should start to establish a relationship and trust with the patient and family. With their trust, it would be easier to find out the real problems of patients and families. Communication skills for relationship development, problem-solving skills for patient and family are recommended. Moreover, skills in social psychology and the anthropological are required. The health care provider must know about the Explanatory Model Illness Episode Record, Family Tree, and Genogram. The visitation will rely on the objectives that set from patient and family problems. To proceed the holistic care, In each visitation, assessing of health condition of patients and families must be involved by using the Family Practice Guidelines (INHOMESSS) as evaluating tool and the practice guidelines as follows. I = Immobility is an estimation of patients capability whether they can take care of themselves or not? Or need someone to take care of daily activities such as using the phone, taking medicines, walking or moving. N = Nutrition to see the patient's nutritional status related to the disease. Including, the processing of cooking, Food storing process, Eating habits and favorite foods such as what do the elderly in the house like to eat? What are the children eat? How do people with diabetes control food? Evaluate the appropriateness of nutritional status for the disease as well as how to store finished food. H = Home Environment to see the Environment in the home and around the house. It is a factor that affects the health of patients and families, such as home conditions, congested area, industrial factories close to home, the relationship with a neighborhood. O = Other People refers to the relationship between patient and the family member or caregiver, Role of family members with the patient, Person who has authorized on a decision making for the patients. M = Medications For medical assessment, To see the use of medication, self- care, the pursuit of dependence on the health of the patient, receiving the treatment from multiple doctors, ability to cooperate with a treatment plan also the use of medicinal herbs, folk medicine, is needed to be assessed. 17

E = Examination is a health examination during home visits such as blood pressure measurement, wound care, maternity, and postnatal care. To assess the patient at that time and adjust the care plan. S = Spiritual Health is to assess the spiritual health status, spiritual well-being, beliefs, attitudes, values, cultures, traditions, and social psychological factors affecting patients and families. Moreover, to understands the health habits of patients and families, their meaning of living, Life value and spiritual anchors. S = Service is assessing nearby health care services places, relatives and family understanding. Also, need to know the linkage care between a hospital and home. What is the need for concern? What is the treatment plan? Who will contact in case of an emergency? S = Safety is a home safety assessment which assesses the environment in the home from the structure, ladders, furniture, facilities through the bathroom floor, whether it is safe for patients.

Home visiting Nursing activities could be classified as the follows The first visit was a holistic assessment of patients at home using the family health assessment form or other tools such as The Family Practice Guidelines (INHOMESSS) for assessing. In the case of referral from the hospital nurses and team should assess self-care skills based on the discharge planning or continuing problems. And provide nursing care base on the problems that were founded within two weeks after discharge. Next visit is following up the results of nursing home care in recent times. Assess new problems that arise during staying at home. Assess the nursing goals. Moreover, keep providing the nursing care base on the patient's problems until the health problems have reduced or until the patient/caregiver can take care of themselves. The behavior that nurses should have done during a home visit is using excellent communication skills to build relationships with patients and families by 1) Interested in talking and listening about the suffering and joy of the caregiver. Especially if the patient has limited self-help. 18

2) Listen carefully to the caregiver. Because listening will help the caregiver reveals their feelings and reduce some stress. 3) Provide knowledge about the disease, complications, treatment and side effects of treatment as much as the caregiver needs. Also provides information relating to the current illness and situation so that the caregiver can observe and give the correct nursing care. 4) Provide the contact number for the caregiver to contact or ask for help from the professional team. 5) Help to coordinate the assistance in the community, such as caregiver teams, the group of patients with the same disease, volunteers, social workers, community leaders, neighbors. 6) Provide Caregiver's health care. If the caregiver is ill, it can affect the patient. 7) Prepare for the loss. The death of a patient is an essential change for the caregiver. Nurses should talk to the family members. If the patient was diagnosed as the end of the disease, the family should be prepared in advance and prepared to leave the patients with honorably.

2.3) After the visiting phase After the home visiting, all the information gathered from the home visit including the info that received from the relatives and neighbors need to be addressed and concluded in the meeting to set comprehensive solutions for more holistic care. The team members must write a note on the home visiting forms or Nurse's Note in the OPD Card to communicate with the health care team about the essential information as the supportive evidence for the continuous care plan. Nursing records are the information records and clinical records writing by nurses. The Nursing records are consist of the report and activities of nursing to meet the purpose of each home visiting, the summary of all nursing activities and patient assistance provided in each visit, also the problems to follow for the next visiting. It is a significant tool that would increase the efficiency of nursing home visits. After a patient home visit, the team must summarize all issues for patients to understand. Also, All the process need to be reviewed, from the recording and planning 19

process, monitoring and evaluating process to the next home visiting process. When the visitation has finished, nurses have to summarize and analyze the records, cleaning all the bags and tools and plans for continuously care. Principles of nursing home records For the Nursing records, use the SOAP Charting as the principles of recording. SOAP Charting is a holistic approach to problem identification in physically, mentally and socially which we can thoroughly analyze the patent's problem stating by Barbara (Barbara Bates, 1995). At Office of the Permanent Secretary Ministry of Public Health, 2556: 93-94). SOAP Charting is inclusive with the following; S = Subjective Data is the information that patients tell to show their symptoms or feelings such as the chief complains, present illness, Past History of illness, underlying disease, self-Profile or Family profile. Moreover, should record only the essential information. Also, that information is related to the present illness. It could be causes, complications or comorbidity. In records should not be written in the Negative Findings or the insignificant information. Assume what is not written is something that is not in the patient's history. O = Objective Data. The information that can be check or measure such as the physical examination, X-ray, blood test results up to the date of writing must be relevant to the problem, including the patient's body language or nonverbal communication as well as the environmental information that has been detected as the cause of health problem. A = Assessment is the assessment of patient and family problems. Whether there still have the problems? How has the problem changed? For the complete assessment, there should be the sufficiency information to support. P = Plan Management is a comprehensive plan that addresses comprehensive solutions compounding with holistic care and continuous care. Especially, self-care promoting and families and social networks potential empowering for proper use. After visiting the house, all gathered information should be discussed with the team in every conference.

Things that should be on the records 20

• Changes in the behavior of patients and caregivers. • Identify current issues that need to be solved, Change of present illness • Uncommon symptoms and signs of complications. • Nursing Practice And essential daily care for the sickness • Visits by health care team. • The results of the nursing practice. • The treatment outcomes such as progressive of post-operation wound, pain, discomfort • Plan activities to be done next visit. • The importance of recording, every records count as the legal evidence. Because, the recordings reflect quality of the nursing practice of nurses and caregivers.

Evaluating nursing home visits is to review the operation, visit the patients and find better service development. All the process are A. Analyze individual data by analyzing the patient's care goals and problems. It should be analyzed after every visit with a comparison whether is better or worse. This will lead to the revision of the nursing service plan by the service team. B. Corporate Data Analysis, to evaluate the nursing process at home or to evaluate clinical care outcomes in each patient. Also reports the results to the relevant parties at least every 3-6 months. C. Restore information to family and community for nursing care is to provide opportunities for families and communities to recognize the illness and join for the care. So, there is an exchange of proper care in the community. This causes the self-reliance of the community in the long-term

3) Output is the result of a service that reflects quality of nursing care. It can indicate service performance such as service assessing, appropriateness of care such as patient home care services, self-care support services, And the home visit system. That effect on patient care at home in both the short and long-term period. So all the output that has shown represent the quality of care with the indicators such as Structural Indicators, Process Indicators, and Outcome Indicators of Home Nursing Services, Clinical quality 21

indicators, and nursing service quality indicators, only four aspects were selected. And there are Effectiveness, Continuity, Efficiency, and Timeliness. If nursing outcomes do not meet the goals. The Nurse could use the nursing process tool to gather additional information for a new diagnosis and adjust the nursing plan to be consistent with the nursing diagnosis. Then perform nursing activities as planned. Lastly, Re-Evaluation.

Classification of patients to provide home care nursing The home nursing care process is divided into three phases: pre-visit Home visits and after visit. Therefore, before providing nursing service, the nurses should know about the patient's problem and their classification. The patients were divided into 4 groups as follows: Group 1 is the group of recovering phase, stable symptoms, unused of medical equipment to close observation and control. For the patients with changed symptoms or need a strictly clinical observer from nurses and doctor will be categorized in these followings; 1.1) Patients with emergencies conditions such as unconsciousness, have cutting wounds who need immediate help. The nurse must have knowledge and skills to assist in the incidents including have first aid equipment to reduce the severity and prevent more harm, before sending to treatment as needed. 1.2) Patients with acute illness such as diarrhea, asthmatic attack etc., and nurses must detect the alarm signs, follow up the symptoms, consultation for initial treatment. Need for care to relieve the symptoms of violence and refer to receive proper treatment in time. 1.3) Patients with chronic disease. The visit will be an activity. Nursing based on hospital discharge plan to assist patients, such as prevention of aspiration in cases of dysphagia. Muscular dystrophy prevention joints stiffness protection, and follow up for treatment. Also, adapting to the disease. The home visits are focusing on assessing the progression of the disease and provide long-term care planning information. 22

Group 2 Patients who must be hospitalized such as the patient who need cesarean section surgery, the patient with dengue, the patient who need surgery, etc. after leaving the hospital. For follow-up and evaluate the symptoms after hospitalization. Or, find the cause of the patients whom loss follows up. As a result, discontinued treatment and cannot be evaluated after treatment. Group 3 Patients who have limited access to the service. However, requires the assessment to monitor health conditions such as the elderly, children with disabilities, patients with limited access to services, patients with limited Self-help, etc., nurses should be visited to assess health status. Also, the need to maintain in good health. So, assesses the ability to perform daily activities on their own. Group 4 End-stage disease, such as end-stage cancer. Chronic kidney disease etc., visit the patient to help and support the patient to get the most comfortable. By providing nursing care to reduce discomfort such as pain, tightness, abdominal discomfort. Reduce the symptoms of rash, etc. In addition to reducing the uncomfortable symptoms. Nurses need to prepare their patients and relatives to help patients stay calm and help families get ready for the loss.

Determining the duration and frequency of visiting patients at home The Duration and frequency of visiting patients at home depend on the diagnosis of the patient, self-care capabilities of patients and families. Including the context of the patient, mostly in the first week of care, there will be close monitoring of patients at home. And, will be less frequent when patients get better. Duration of care and frequency of visiting would be a schedule for the patient care plan in the nursing report. This is consistent with the interval time between each visit (Humphrey & Milone-Nuzzo, 1996). Office of the Permanent Secretary Ministry of Public Health, 2556: 75) According to, determining the duration and frequency of visiting patients at home. There is no fixed pattern for determining the frequency of visits. However, there are factors that nurses need to evaluate patient’s status to determine the duration and frequency of 23

visits as the symptoms change over time. The frequency of visits depends on the skills of the nurse in estimating. Suree Leung Mongkol (2010) has discussed the factors that determine the frequency of home visits as the following 1) Health status of patients at the recent time required to get health care at home 2) The commitment goal that defined the time between patients, Family and visiting team 3) Prognosis of the disease, Risk of complications. 4) To evaluate nursing care and to evaluate the progress achieved. 5) To monitor the achievement/results of teaching patients and caregivers. 6) Type and complexity in providing essential nursing care. 7) The mental status of Patients and the understanding of nurses on condition also knowledge of patient’s illness. 8) Accommodation/patient's home environment 9) The ability of patients and caregivers to follow the instructions.

The nurse who is the head of the home care nursing team has to follow and assess patient care in the subject area. For planning , and organize visits based on health problems and care needs. Therefore determining the duration for a visit is depends on the nursing diagnosis, symptoms of the patient and Self-care ability of patients and relatives/caregivers. Also, Nurses need tools to assess the patient's condition, such as ADL, INHOMESSS, diabetic foot examination form, Nursing Process, etc., then use the data from the tool to consider the severity which the Nursing Office (2556) has classified as follows. Level 1 refers to the initial stage of illness. From Chronic Disease There is a slight change in lifestyle. No complications or comorbidity. Patients can help themselves. However, lack of knowledge, Understanding and skills to adapt to disease and adjusted the behavior. 24

Level 2 is defined as the number of patients affected by the disease affecting the ordinary course of life. There is little or no ability to help their self. Insufficient in self-care and requires caregivers/helpers to do some activities. Level 3 refers to the patient with pathology of the disease causes of disability/limitation of self-efficacy. Or put medical tools to support the living. Also need caregivers to help with their daily activities.

1.3 Criteria Standard of home visits The Criteria Standard of home visit It is a tool to evaluate the quality of the practice at home. It is designed by the Bureau of Nursing (2557), with the goal of providing qualified home care nursing. According to the primary care development policy the criteria standard of home visit uses the systematic approach consists of input, process, and output outcomes, which correspond to the patient's home care nursing practice. For evaluation, the rating will give you 1 point if "Yes" and if "No" is 0 points. All criteria must be assessed in each of the criteria, and then all the scores will be summed. Compare the score levels as follows Input / Process score is 1-30 points. Overall Outcome (Output) Process Topic Minor topics Indicators supportive information Input System work system 1. There is a linkage - CUP Continuing Care system from the hospital Handbook / Manual to the home that - Continuing Care Flow supports self-care of chart patients. 2r There is a database of - Patient Information patient home visits. Register classified Easy to use and up to by severity follows date. the target group. - Referral Form 3. There is a system to - Community health create community network’s report 25

Process Topic Minor topics Indicators supportive information support networks. - Community health network name lists Home visit Home visit r Home visiting by - Job assignment team team of professional nurses based on care primary care needs. center 5r Home visiting by - The documents in the primary health care flow chart in no. 1 center team 6. Home Visiting by - Describe the order Primary Care Team for the commission / members together with a working committee at team of network partners the district / province from other agencies, both level. public and private. - home visit records Work as a 7. Interdisciplinary teams - assignment teamwork are responsible for - home visit records of (Both inside visiting the home and each and outside) working following their interdisciplinary professional scope, teams. working in a systematic pattern. %r There is a professional - appointment order / nurse manage the goals assignment statement of Patient’ home Visits, Planning for discharge and distribution the home visit team. fr Planned for discharge/ - Discharge plan adjust plan according to 26

Process Topic Minor topics Indicators supportive information the patient's condition and evaluation of the care team's visiting Team 10. Have knowledge about - Home visiting performance medications / records complications, can be - Interviewing of home early detected, visit team screened and refer patients for the proper treatment in time. 11r Choose to use or - Documentation of the create a specialized appropriate used tool which suit for the instruments for each patients such as ADL, patient PPS, 2Q, fQ etc. 12r Social Cost Analysis - home visit recording - Information, illness and community / patient / recovery information for relative inquiries empowerment for About the restoring cooperation information Creating 13. Develop a network of - Documents / photos Involvement government agencies. showing the And the private sector cooperation of the to involve in the home network partners. visit. 14. Build strength and - Document / Photo expand the network of Activities Public people to join in the relations home visit team. - Funds 27

Process Topic Minor topics Indicators supportive information - Committee 15. There is a system of - Documents / photos instruction that allows the to teach the team volunteer know how to how to home visiting work as the home visit for general people team. materials and 16. Have fully available -home visiting bags Tools Home visiting equipment. Support 17. Management of - daily equipment factor for materials and usage records such service equipment to be as home visiting bag effective and adequate for use. 18 Apply the device in the - Documents/ Photo home / community to suit each patient. Process Target groups 1fr The standard Criteria - The standard Criteria for Screening for for Screening Targeted group of Patients Home visit 20. Has the patient - Information system service information system up used to date 21. There is a prevalence - SPOT MAP map of target groups in the area based on severity. Home visiting 22. Home visits according - Guidelines for the 28

Process Topic Minor topics Indicators supportive information process to plan and frequency care of patients in of visits to home in each diseases groups / individual. - Home visit plans The goal is to promote Including home visit self-care of patients. records Note: Within the CUP, find out how to cope with the disease. And create home visits plan 23r Emergency home - Emergency home visits in case of acute visiting method complex/ severe illness occur. Notes; within the CUP. Find out how to emergency visit patients home in case of acute illness occur. 2 r Monitoring, con trolling - Interviews the and evaluating the supervisors and nursing performance. home visits teams - Summary report and evaluation. Home Nursing 25. Follow up the - Home visiting Activities essentials treatment / records procedures / prevent - Random Home visit complications. 26. Provide nursing care to reduce discomfort. 29

Process Topic Minor topics Indicators supportive information 27. Coordinating in providing Initial treatment / referral / help the patient and family receive help and care as appropriate. Continuing Continuous 28. Having a - Communication care Care communication channel system Coordination channel to coordinate - Phone call record and adjust plan following the patient’s conditions with the effective network services. 29. Having the - Assignment reports responsible service sector who mainly support of all services 30. Having an information - Evidence of system, information communication technology, channels. communication - Line forwarding information between record or the other the centers services communication that appropriate with channels. the context. - Data from 21 files Continuing of 31r Having a discharge - Evidence of care Care Center planning, and coordination (COC) information - Evidence of referrals 30

Process Topic Minor topics Indicators supportive information management. Also, Continuing care services, coordination with various care centers. 32. Having a team and - Networking potential network Development development to taking care of patients at home. 33r Having a network of - Evidence of medical equipment for equipment home using supporting by the Center service in case of the absence of the agency itself Coordinate of 3 r Having a coordinative - Evidence of the Multidisciplina process of home care coordinated home ry team in visit, in case of visiting record Home visiting complicated referral 35r Having a shared discharge planning between the health care service centers even in the different levels. 3ir Having the mentoring - Evidence of system for the mentoring system consultation in Tertiary 31

Process Topic Minor topics Indicators supportive information /Secondary and Primary level 37r Having the recording - Home visiting Home visit every time of home records records visiting 3%r Having the information on Health problem and care changing to meets the needs. 39. Having a record of the use of nursing process to determine the problems and care plans, in according to patient conditions. Total Input + Process (Full score 39) Out put Home visiting 1. Number of the visiting - Home visiting results hours per each staff indicators must not less than 6 Note : hours / week. output 2. The coverage rate for The home visiting criteria of home visits is not less indicators should be home care than 80%. determine within the visiting CUP Quality of 3. The occurrence of home visit having complications at home is not more than 5%. 32

Process Topic Minor topics Indicators supportive information r Rate of patients who was home visited, can control the disease and provided the self-care more than %nir The 5. Team satisfaction is not effectiveness less than 80% of home visiting providers with Seamless 6. Satisfaction of the care service’s recipient is not performance less than 80%. 7. Rate of patients returned from Sub- district Health Promoting Hospital, primary care hospital, secondary care hospital. Received home visit within 14 days 100% %r The rate of inform patients information within 5 days is %nir Total Out put (Full score 8) Total Input + Process + Out put (score = 47)

1.1 Output criteria of home care visiting The standard indicators can measure the successful outcomes. Including inputs indicators, Process indicators, and standard Home care nursing indicators. Therefore in this research, are determine into 6 indicators as follows: Indicator 1 : Coverage rate for visiting patients at home is not less than 80%. Indicator Type Provider - Process Objective To evaluate the effectiveness of home care nursing practice which is a significant activity leading to the continuation of nursing care follow-up from the hospital discharge to the patient's home. Definition the definition of coverage rate of visiting patients at home, means the proportion of each target population, such as patients with chronic diseases, psychiatric patients, elderly, etc., in the area of responsibility who received the home visits for home care nursing providing following to the criteria in each target group. Formula = Number of patients in each target group who receiving home visits X 100 Number of patients in the same target group with the same disease

Indicator 2 : The rate of patients who returned form the Tertiary care /Secondary care /Primary care hospital and had received home visits within 14 days, 100% Indicator Type: Setting-Outcome-Process Objective: To evaluate the effectiveness of time spent on helping patients and caregivers to practice self-care/adjust themselves according to their potential. Definition: the patients who returned from the Tertiary /Secondary /Primary care hospital means the patient who was admitted and undergoing for inpatient treatment. Then, doctors are allowed to discharge but required to have continued nursing care at home. These patients need to be visited within 14 days since the discharged date. Formula = Number of patients returned from the Tertiary care /Secondary care / Primary care hospital and had received home visits within 14 days in 1 month X 100 Number of patients returned from the Tertiary care /Secondary care / Primary care hospital in the same period

Indicator 3 : Complication rate of patients at home is not more than 5%. 34

Indicator Type Setting - Outcome Objective To assess the effectiveness of home nursing practice. Planning and providing patient care, counseling, and evaluation of comprehensive treatment plans, as well as evaluating the patient and relative environment to prevent potential complications. Definition Complications at home means that patients at home are placed in a group where they have to have the home visiting, such as patients with bedsore, infection from surgical wounds, the patient who has the equipment insertion for treatment, the patient who need suction, etc. These conditions are due to the inadequate advice/ instruction/skill training provided by the visiting team. So this can cause complications.

Formula = Number of patients who received home visit and has complications x 100 Number of patients who received home visit in the same target group

Indicator 4 : Transmission rate of patients information, level 3 to the destination care center within 5 days for 80% Indicator Type Setting - Process The objective is to evaluate the effectiveness of the period that all information about the current illness of the patient in level 3 who needs continuing care, past to the Sub- district Health Promoting Hospital. Definitions the transmission rate of patients' information refer to the information of patients who were allowed to discharge and was classified as the level 3 patients. Those patients need effective continuing care. So, the referral hospital must sent all the information of the patient to the destination care center within 5 days Formula = Amount of data that sent within 5 days x 100 Number of level 3 patients who were discharged at the same time

Indicator 5 : Satisfaction of service recipients not less than 80% Indicator Type Client - Outcome 35

Objective To assess the effectiveness of home care nursing for the Patient/family who was received the service. Definition of Service Satisfaction refers to the opinions of patients/clients and families regarding nursing services that received at homes such as the Introduction to health care resources, nursing and care of the staff. By answering the questionnaire (Appendix 4) Formula = Sum of satisfaction scores of patients who received home nursing services x 100 Total score of the questionnaire

Indicator 6 : Satisfaction of team visiting home Not less than 80%. Indicator Type Provider-Outcome Objective To evaluate the effectiveness of the management process related to job satisfaction which affects the quality of services providing. Definition of team home satisfaction means the opinion of Nurses Public health clinicians includes home delivery service providers who have full time working hours in the service care center about job satisfaction on Homecare/home visits. Use the questionnaire in Appendix 5 to measures.

Formula = sum of rated scores x 100 Total score of all evaluation forms

2. Related researches There are the study of the model and the development of the home visit model, as reported by Penisiri Atthawong and colleagues (2560), found that after using Home Nursing Care which the program was developed for patients with Bed ridden status type 3. By apply the patient care process in a ward at Songkhla hospital to practice in the home care systems. Use the community health center as a Nurse Station, use the patient House as a Ward, community nurse as the Case Manager, Caregiver as the Nursing Assistant, and the Network Associate including multidisciplinary team. Providing care In patients with the pathological disease, the patients with disability / limited ability to do their activities or have 36

medical equipment to help in living. In conclusion, after using the home visit method HNC results were passed through the quality assessment criteria more than before the use of home visit HNC. Statistically significant at the 0.05 level. In addition, each procedure will allow all participants to plan, co-operate, monitor and evaluate the HNC, which is an important part of encouraging the ongoing care process by families, communities and networking parties to strengthen self-sufficiency in healthcare. The research of Manthana Jariangwan and Sirirat Chantra. (25i1: 7n-%3)r The study by the World Health Organization In conjunction with Watson's Human Caring Theory To develop a patient care model for palliative cancer patients. And study the results of model development. Studies in patients with stage 5 cancer. There are 5 steps, including; 1) Analyze the problems and situations 2) Develop the drafted care model 3) Take the drafted care model to trial and improve 4) Apply the improved care model and 5) Analysis and conclusion The results of this study conclude that caring for patients with advanced parenchymal cancer has improved with the efficacy in caring for patients with terminal cancer and have good results in patients, caregivers and service providers under the context and limitations of Sisaket Hospital. The research on the factors affecting the caregivers and patients is the research of Wilairat Sansuk and colleagues (2558: 27-131) studies the effectiveness of ambulation of the volunteered stroke patients in the 36 rural communities with an average age of 60 years, whose surviving the stroke for more than 5 years and living with the families but staying alone in a daytime, 3% can walk inside their homes, 10% can walk to the parking space or post office and 34% can walk out to the neighborhood. The three groups were unable to walk in the community. The rest (53%) were able to walk to their friends' homes, temples, markets, farm shops and community health centers. The study of Pavanee Brahmaput and colleagues investigated factors related to stress in caregivers of stroke patients at home (2557: 82-96) who found that stress was negatively correlated with perception, Self-efficacy of caregivers, the ability to perform daily activities of patients, relationships between patients, relatives, caregivers and families, and social support from the family. The results of this study suggested that community nurses provide care for relatives, caregivers, stroke patients. Particularly, in patients with lesser 37

capacity for daily activities by evaluate stress, perceived self-efficacy of caregivers as well as family relationships and social support from family. For Nursing Home Research Nursing Office Office of the Permanent Secretary Ministry of Public Health (2556) presented the results of the study: Anna Sumano (2007) research found that helping patients and families to recognize the risks, violence, benefits, health problems at home with addition to continuous social support, give results that the pulmonary tuberculosis patients are more cooperate with the health care plan. The results of research of Suchada Pradipvanich (2007) was found that patients with hypertension of unknown cause, Group Health Care at Home by Health Team Knowledge and self-care behaviors are better than before receiving home health care. And better than the usual service group at the hospital, which is consistent with the results of the research by Ratree Maneekhat (2007), finding that home visits of a nursing home can promote appropriate behavior in hypertensive patients and the research of Maleechit Chained(2009) shows that family involvement in caring for patients with COPD after visiting the house is better than before visiting the house. Research results related to the home care nursing can be used as a home care nursing approach. The research was applied to the context of each patient. To be able to self-help and adapt in living in the house and community according to the potential of the patient. The results of the study will be found that nursing visits to home care or home visits are beneficial to patients and families. It encourages people in the community to take care of themselves and their families. Emerging family and community health networks. This can lead to health, family and community development. Patients who are discharged from the hospital will feel comfortable with nursing care at home. Relatives will have an understanding of illness, pay attention to more patients, patients and families cooperate in the treatment, quick recovery and the treatment is effective so the patients will have better quality of life. Thus, nurses who provide home care nursing must be a knowledgeable person, highly skilled in direct nursing practice as well as a coordinator between the health team and the patient. The conceptual framework for research is as follows.

Diagram 2 Conceptual Frameworks for Research

results Input 1. Home visiting Coverage Rate

1. Home visit 2. rate of Patient returned from primary care /secondary/tertiary care hospital received team and process network home visits within 14 days. Program partners. 3.before The -incidenceduring-after of complications at home is no home care nursing Thai COC more than 5%. 2. Materials /

Vehicle 4 Transmission rate of patients level 3 ‘s Equipment information to the destination within 5 days.

3. Supporting 5. Satisfaction of the recipients. factor Patients 6. ความพึงพอใจของทีมเยี่ยมบ้าน 1.illness

2.socioeconomic status

3.caregiver

4. community

Chapter 3 Research Methodology

This research is an action research to study the effect of using the Thai COC program on the quality of the result from the homecare services in Surin Provinces with the research methodology as follows. 3. Population and Sample Group 3.1 Population in this study select the home care patients of all disease and age groups who submitted their data through the Thai COC program. 3.2 Sample group uses purposive sampling method to select home care patients from 24,796 patients of 23 disease group who submitted their data through the Thai COC program between October 1, 2016 and September 30, 2017 from every home care service and response in Surin Province as: 3.2.1 The patients distributed from Surin Hospital onto 1 general hospital, 16 community hospitals, 232 primary care units, and 3 community heath care services within Surin Province. 3.2.2 The general and community hospitals submitted their data to primary care units and community health care services within and outside of the area. 3.2.3 Patients are within area of primary care units and response to home care service. 3.2.4 The patients are redistributed to home care services in Surin Province by services outside of Surin Province.

4. Research Process This research follows the action research model of Kemmis & McTaggart (Kemmis & McTaggart, 1988 : 10 ref. Werayut Chatakan, 2015) which explained that the action research model is a form of research model that does not technically differ to any other research models but is different in its methods. The methods involve the spiral of self- reflecting practice which is broken into phases of planning, acting, observing, and reflecting which require the collaboration of the subjects or patients in order to develop the better improvement effectively. The phases in this model are broken into 4 steps as follows:

Phase 1 Planning is conducted through the meetings of Service Provider Boards of the Continuity of Care (COC) of Surin Province to provide the home care service comprehensively and efficiently by utilizing home care and home ward guideline of the Region 9 Health Care Office. Phase 2 Acting is utilized through the use of Thai COC program by all health care services in Surin Province to the home care patients of every disease and age groups which include setting up group chat of Line application to connect between the patients and the servicer providers within the provincial area. Phase 3 Observing is supervised through monitoring of group chat of Line application, meeting of Public Service Audit & Evaluation Committee, and meeting of District Health Coordinating Committee in evaluating the results from Thai COC program with the quality criteria by the Home Care services of nursing department including the data collections of issues and solutions. Phase 4 Reflecting is the results and reports of the improvement and regulation of nursing, the development of Thai COC program’s effectiveness to the objective, and results of the Home Care which include the coverage and complication rates of the home care, home care patients’ and service providers’ satisfaction, patient return rates from primary, general, community hospitals and health care units within 14 days of service, and 41

Level-3 patient 5-days transport rate as per the home care criteria of the nursing department.

5. The Research Tools, the quality inspection of the tool, and data collection The tools used in the research of the Thai COC program for home care services in Surin Province are quality inspected in 2 steps as follows: 5.1 The researchers received the assistant from the experts which include provincial hospital managers and statistics analysis specialists from Health Service Center faculty of Khon Kaen University, to conduct program inspection together with handing out evaluation forms to 5 experts, and are collected by the researchers. 5.2 The researchers asked for the permission from the Board of Directors of Surin Hospital to conduct the trials of the program. The doctors, nurses, and computer specialists are handed out the assessment forms to evaluate the trial results of the program for the patients of 24 disease groups, and the data are then collected by the researchers. The data collections from the Thai COC program include: 1) Personal records of home care patients including gender, age, marital status, occupation, medical rights, medical severity classification 2) Records of response from home care patients per disease including primary caregiver, care given, complications, and the followed up home care result 3) All reports from Thai COC program including long-term care (LTC), continuity of home care, disease group classification, the disease development report, general data report, patients’ and service providers’ satisfaction reports, and quality of life reports.

6. Data Analysis The researchers analyzed the data as follows: 42

6.1 Verifying the completion of the evaluations received and selecting the finalized and completed data to analyzed 6.2 Quantitative analysis is conducted by utilizing descriptive statistics in distributing average percentage and analyzing textual data using quality data analysis methods such as the data from each distributed assessment form to find the frequency percentage from the collected of personal data of home care patients, and their response per disease classification. All the reports from Thai COC program and home care patients followed up reports received from community nurses, multidisciplinary teams, sub-district health promoting hospital, and social medial network team, are analyzed into frequency and percentage value which are the home care coverage rates, complication rates of the home care, home care patients’ and service providers’ satisfaction, patient return rates from primary, general, community hospitals and health care units within 14 days of service, and Level-3 patient 5-days transport rate as per the home care criteria of the nursing department.

Chapter 4 Research Result

The action research of Thai COC program and its effect on the quality criteria of the homecare in Surin Province can be categorized into 4 phases as follows:

Phase 1 Planning 1.1 By studying in the real life situation; for instance, the patients’ data were previously sent from the primary healthcare center to the community hospital in traditional handwritten paper forms and sent through the post office which are slow and unreliable, the patients were thus receiving the homecare services in an untimely manner, and sometimes inaccurate which further the difficulty for proper analysis and diagnosis, and was reflected upon receiving only 20% homecare feedback, low quality of responses, and were the only communicating method in use between the primary hospitals, community hospitals, and sub-district health promoting hospitals. 1.2 By collecting the past reports from the meetings of nurses from the Community Health Nursing department, Surin Hospital, Community Hospital, and the Sub-District Health Promoting Hospital, several issues can be addressed as follows: - The communication and information systems between the primary hospital and the other healthcare services did not cover every levels of services. - The data recorded in the program were insufficient and do not meet the quality standard of the homecare services. - The data were outdated. 1.3 To utilize the plan in managing the continuity of care (COC) for every healthcare services in Surin province by connecting the information of every services and cases through the Thai COC program developed by applying technology with the Thai COC program to connect the information over all areas of the country including district, sub-district, and local level. In implementing the “spot map”, the application in Smartphone, Tablet, and PC, adding the function for receiving the feedback entry through the link, and 44

adding more report cases as needed from the policies or demand of each area, the program should be designed to serve the needs in coordinate from all levels of services such as the care giver, care manager, the homecare nurses, and the security in accessing of the data and information of each healthcare services. Phase 2 Action by exercising the policy and resource into action as follows: 2.1 Appointing the responsible agents to take parts in the development of the services and assigning their duties in the project

Agents Roles / Duties 1r Data Management and Technology and Development of Thai COC program in Statistical Analysis Center, accordance with the needs of patients and service Faculty of Public Health of Khon policies. Kaen University, and Data Center - Thai COC is developed under the data management of Surin Hospital and electronic health record system named “Thai Care Cloud" - Its web application is developed by Khon Kaen University under the memorandum of understanding with Department of Health Services of Ministry of Public Health - Developed mainly by PHP and MySQL languages on the Yii Framework. - Use database server of Department of Health Services of Ministry of Public Health - All data, codes, IDs, names, and addresses are encrypted with SSL 512 bit, and password protected by the agents responsible. - Only the agents responsible can access the encrypted data. 2r Community Health Nurses 2r1 Design the content of the feedback submission and data entry with the Service plan/Patient Care Team 45

Agents Roles / Duties for each report case 2r2 Design the content to meet the quality criteria of the homecare service and satisfy the needs of the patients. 2r3 Develop the content of the feedback and data entry to meet the needs of the policies 2r Continuously improving the program by listening to users’ feedbacks and comments 2r5 Create program guides and supports 3r Surin Provincial Health 3r1 Supervising the project to achieve the goals. Office 3r2 Holding provincial conferences, and district meetings periodically r Community Hospital r1 Precisely, on time, and completely send the data to sub-district health promoting hospitals in the network r2 Continue to complete the tasks and goals. 5r District Health Office 5r1 Continue to complete the tasks and goals 5r2 Holding provincial conferences, and district meetings periodically ir Sub-district Health ir1 Send/Receive the data of homecare patients Promoting Hospital accurately, on time, and completely by the criteria of the homecare services ir2 Analyze the report cases to further develop the proper treatments 7r Related network units Support the homecare patients such as caregivers are to care for the patients with his/her family. And the care manager, and the sub-district administrators take action with the patients who required further supports economically and socially. 46

2.2 Conferences and Meetings 2r2r1 The committees of Surin Hospital, and the Data Management and Statistical Analysis Center of Faculty of Public Health of Khon-Kaen University in analyzing the issues and developing Thai COC program are the incorporating of information technology to data and communication network to creating streamline nationwide coverage connection, and continuity of care and services to the homecare patients. In accordance with the quality criteria homecare services, allowing thoroughly and up-to-date control, reducing the workload of the agents in all parts and levels, creating dynamic, secured, and precise analysis of report cases and data entry and assessment to all levels of commands from sub-district, district, provincial, and country levels. Implement of Spot Map, and allow feedbacks and comments on the quality of services and life, allowing the adding of report cases as needed from the policies or demand of each area. 2.2.2 Service plan meeting amongst all groups, and wards to develop continuously by improving the connecting with the patients from the hospitals and all primary healthcares of 23 report cases which are pregnant, post-partum, pediatrics, underweight pediatrics, complications and incurrent report cases such as diabetes, abnormal blood pressure, stroke, COPD, CAPD, Asthma, TB, STEMI, psychiatry, post operative patients, orthopedics, trauma, general surgery, URO, ENT, geriatrics case, the disability case, and end stage patients.

2.3 Form the council to the Continuity of Care (COC) for the Thai COC program into regional, provincial, district, sub-district levels to 2.3.1 Consult and counsel on any issues, and difficulties faced from the homecare services of the homecare patients in Surin province 2.3.2 Oversee the tasks and courses of actions to take to each report case for the homecare patients 2.3.3 Follow up and manage the results to meet the quality criteria of the homecare services through the provincial conferences, district and sub-district meetings 47

2.3.4 Conclude the results and reports of the homecare services from the provincial conferences, district and sub-district meetings with the hospital managers and committees, hospital councils, Service Plan committees, PCT committees, etc. 2.4 Assigning administrators of the program in provincial and district level to administrate the information and coordinate with the management and issues in the field responsible 2.5 Create the guidelines and regulations to the homecare services and home ward of region 9, and courses in taking care of the homecare patients for each report case. 2.6 Exercising the plan to continuously work with the tertiary nursing services and teams whom emphasizes in homecare and bedridden patients with complications and complex report case, and medical equipment installed at home. Coordinate with the primary and secondary healthcare services and networks, and other healthcare professionals through the use of group chat in Line application to communicate and manage the services between the patients and the health care service providers.

Phase 3 Observing, monitoring and supervising Through the use of group chat of Line application for the conferences, and meetings of the Provincial Health Office, District Health Office and Sub-districts Health Promotion Hospitals.

Phase 4 Reflect/Feedback In accordance to the action approach to allow any feedbacks and comments from the participants by streamlining the information exchange to develop and improve with 2 followings aspects: 4.1 Formative evaluation to assess and manage the task flows to improve and develop the nursing and Thai COC programs in supporting the tasks and create efficiency in the work flows in using Thai COC program to connect between main or host hospitals and the community hospitals and other primary healthcare services. By entering the information into the Thai COC program, the data are accessible with complete report cases to match the proper diagnosis and treatments required without barriers or technical issues such as incomplete or inaccurate information. The information will be accessible and easily analyzed by all levels of commands from national, regional, provincial, district, and sub- district levels. Accessibility of information in real time and two-way communication between the recipients and the senders, and if in case of error or uncompleted data, the issues can be solve through the channel of Line group chat. The patients are thus efficiently streamlined with better quality healthcare, reduced complications, reduced re-admit, and better quality of life and health. From the research, the Thai COC program helps in 2-way connections of the information and feedback to be more efficient and streamline. The performances from the homecare services can be analyzed, assess, and evaluated in real time with better quality criteria of the homecare services and continuity of care for each patient in each field of services, and helps reduce paper usage. Furthermore, the Thai COC program is the administrating tool for the supervisors to supervise, control, manage, and monitor the tasks and courses in real time, and also allow adding indefinitely more data to the existed 49

segments such as assigning new report case for continuity of care, more coverage usage of the program, accepting the patients of the Royal Medical Units, covering more of f regions 3f provinces. The Thai COC program will technological enhance the quality healthcare services to fulfill the policies of the Service Plan development, the services of the primary and community healthcare and homecare services to patients of all report case and age group from pregnant, postpartum, pediatrics, underweight pediatrics, complications and incurrent report cases such as diabetes, abnormal blood pressure, stroke, COPD, CAPD, Asthma, TB, STEMI, psychiatry, post operative patients, orthopedics, trauma, general surgery, URO, ENT, geriatrics case, the disability case, and end stage patients. And also the development to respond to any existed homecare policies such as One Day Surgery (ODS), Intermediate care (IMC), the first 1,000 days plan, etc. while also allowing all new policies of all levels of illnesses such as Acute Care, Intermediate Care, Long Term Care, Palliative Care, etc. The Continuity of Care of the Thai COC program will allow flows of information from the patients to the service providers to be efficient, on time, and complete to meet the standard quality criteria of the homecare services with reduction in paper usage, complications, readmission, and better quality of care, health, and life to the homecare patients. Allow analyzing of data to be updated, reduce workload and operating session and time which can be used to review of the data and solve any error should it occurred from all report case upon all level from national, regional, provincial, district, and sub- district levels amongst the healthcares services, and hospitals. The analysis from the supervision and management of the healthcare and homecare service providers will be accounted and developed for further academic development to improve the healthcares academically. From the reports of the complications or incurrent report cases, the patients who are in these categories include orthopedics, disability, stroke and geriatrics patients which are in the continuity of care by the community nurses through case manager of the categorized as CAPD, Psychiatry, Geriatrics, Stroke, Trauma, Pediatrics, etc. and report case management for the report cases of patients such as CVT, etc. 50

The development of the homecare services and patients transfer systems to join all the systems and create the united services structure to be seamless and streamline between the primary hospitals, community hospitals, sub-district health promoting center, and other healthcare services in reducing service gap and help supporting the sufficiency of the medical equipments, tools, and vehicles with the support of the economical and social assistances. The highlights of the research and success factors - The Thai COC program of the web application on the Thai Care Cloud platform(http://www.thaicarecloud.org) as agreed under the Memorandum of Understanding with Department of Health Services of Ministry of Public Health is used jointly together with the resources of Khon Kaen University and Ministry of Public Health - The Memorandum of Understanding (MOU) agreed to the development of Information Technology between the Home ward of Region 9 and Khon Kaen University enable the stability, standard, completion, and precision to the Thai COC program. - The results of using the Thai COC program to the quality criteria of the homecare services in Surin province create an outstanding empirical results and effects which are rewarded with awards as follows.  “ICT Innovations for eHealth & mHealth” national award by Information and Communication Technology Center of Ministry of Public Health, 2017, to the Thai COC program, in providing continuity of care for homecare services.  No.1 Presentation Poster, The Effect of Thai COC program to the Continuity of Care for homecare patients, awarded by the Social Medical Nursing Association of Thailand, 2017  The Success story from Nakhonchaiburin Regional Health No.9 of using the Thai COC program for Continuity of Care by the official inspector of the District Health to the Ministry of Public Health, 2017 51

 Management and innovation development achievement (Innovation base) for Thai COC program in Continuity of Care to homecare patients on nationwide level, 2017  The achievement of Thai COC program in Continuity of Care in receiving site visit from the Office of the Public Sector Development Commission on June 6, 2018, and the commendation for the Public Sector Excellence Awards (PSEA) of 2018 for the Top Services Innovation

4.2 The Summative Evaluation 4.2.1 Summative evaluation is assess for the reports of the homecare services in monthly, quarterly, and annually terms which demonstrate the results are indicated into 2 traits to meet the desirable criteria as the coverage rate of the homecare, satisfaction ratings of the patients, complication rate of the homecare patients, 14-day return rates within from primary, general, and communal healthcare, and level-3 patient 5-day transfer rates as under the quality criteria of homecare Nursing Division. Because data entries before the use of Thai COC program are inaccurate, incomplete, and do not meet the quality criteria of the homecare services, the reports before use of the program are only valid for 20% while other data are missing. After the use of the Thai COC program, the data entries gone up to 97.42% validations which more than meet the quality criteria of the homecare services which in turn significantly improve the overall services, creating real time updates, and collaboration between all services in the provincial levels under the quality criteria of homecare services. Create network of patients and healthcare providers in all levels flawlessly with the better quality criteria of healthcare services quantitatively (Home visiting rate) and qualitatively (Rates of complications, and readmission), and seamless Continuity of Care (14-day return rates within from primary, general, and communal healthcare, and level-3 patient -5-day transfer rates as under the quality criteria of homecare Nursing Division) with 52

which all reports and information can be monitored, accessed, and tracked in real time. There are already users of Thai COC program in 9 regions, 39 provinces, and 2,607 serving units, 7,309 staffs, and 187,139 patients which connected through the broadcasting of public relations, Innovation expos, Invention fairs, etc.

The conclusion can be summarized into 2 parts as follows

1. General Information In the fiscal year 2017 (October 1, 2016 to September 30, 2017), the data entries of requisition for the homecare services from the Surin hospital, primary hospitals, community hospitals, and all sub-district health promoting hospitals accounted for 232 healthcare providers over 17 districts in Surin province with 24,808 patients / 28,995 cases. The district with the most homecare records is Muangsurin district for 4,876 patients (19.66% of total patients), followed by Prasat district, and Sangkha district, 14.56% and 10.32% respectively. And the accepted homecare services accounted for 28,226 cases (97.49% of all districts) which are more than 90% of the requisition received. The district with the highest accepted rated is Non Narai district for the highest homecare accepted rate of 100% followed by Khwaosinarin district, and Sangkha district, with 99.88% and 99.02% respectively.

And the type of patients can be broken down into 4 levels as follows Level 1 Patient (self-manageable patient) – found in 2 districts with 100% accepted homecare services which are Khwaosinarin district and Nonnarai district, followed by Sangkha district and Samrongthap district (99.18% and 99.11% acceptance rate respectively). Level 2 Patient (Partially self-manageable patient) – found in districts with accepted homecare services which are Nonnarai district with 100% acceptance rate, followed by Khwaosinarin district, Thatum district, and Sangkha district, 99.67%, 99.38%, and 99.02% respectively. 53

Level 3 Patient (Dependent patient) – found in 4 districts with 100% acceptance rate of homecare services which are Nonnarai district, Khwaosinarin district, Chumphonburi district, and Buached district, followed by Thatum district, and Prasat district with 99.39% and 99.08% acceptance rate respectively. Level 4 Patient (Palliative care patient) – found in 4 districts with 100% acceptance rate of homecare services which are Nonnarai district, Khwaosinarin district, Chumphonburi district, and Lamduan district, followed by Sikhoraphum district, and Prasat district (96.63% and 96.49% acceptance rate respectively). Details as follows in Table 1 54

Table 1 Amount and percent of patients classified by ratio of requested and accepted cases of homecare patients Requisition case and percent Accepted case percent Acceptance rate per level of patients District in percent Unit % Unit % Level 1 Level 2 Level 3 Level 4 Kapchoeng 880 3.55 852 96.82 98.14 95.90 90.48 76.47 Khwaosinarin 829 3.34 828 99.88 100.00 99.67 100.00 100.00 Chomphra 932 3.76 842 90.34 88.60 91.87 96.15 83.33 Chumphonburi 828 3.34 810 97.83 97.95 97.00 100.00 100.00 Thatum 2,278 9.18 2,240 98.33 98.51 99.38 99.39 84.81 Nonnarai 360 1.45 360 100.00 100.00 100.00 100.00 100.00 Buached 810 3.27 798 98.52 98.97 97.93 100.00 95.45 Prasat 3,613 14.56 3,567 98.73 98.93 98.13 99.08 96.49 Phanomdongrak 442 1.78 425 96.15 97.02 95.60 100.00 80.95 Muangsurin 4,874 19.65 4,694 96.31 96.36 96.21 98.04 93.01 Rattanaburi 1,194 4.81 1,137 95.23 92.00 96.71 96.81 92.41 Lamduan 697 2.81 682 97.85 98.04 97.58 98.11 100.00 Srinarong 860 3.47 821 95.47 95.83 96.95 88.06 90.48 Sikhoraphum 1,823 7.35 1,782 97.75 98.17 97.34 96.53 96.63 Sanom 573 2.31 557 97.21 97.54 97.76 97.01 88.89 Sangkha 2,561 10.32 2,536 99.02 99.18 99.02 98.50 94.64 Samrongthap 1,254 5.05 1,240 98.88 99.11 98.87 98.63 95.83 Total 24,808 100.00 24,171 97.43 97.69 97.44 97.80 92.67

Most patients who sent the homecare service data are women (66.91%), are older than 60 years old (47.07%), are agriculture (24.35%), have applied for medical gold card (77.26%), have been sent from Surin hospital (65.06%), are self-manageable patient (59.92%) as shown in the following Table 2. 55

Table 2 Amount and percentage of homecare patients classified by general grouping 56

General data Amount Percent Gender Male %h21n 33rnf Female 1ih5f% iirf1 Age (year) 0-5 294 1.18 6-14 248 1.00 15-19 1380 5.56 20-59 11,209 45.18 60 years or more 11,677 47.07 Occupation Agriculture 6,041 24.35 Freelancer 2,044 8.24 Merchant 182 0.73 Officials 325 1.31 Politician 5 0.02 Priest 122 0.49 Housekeeper 276 1.11 Student 267 1.08 Others 102 0.41 Not stated 15,444 62.25 Medical rights Local insurance 384 1.55 Officials 2,001 8.06 Social Disability Insurance 217 0.87 Social Security 2,587 10.43 Medical Gold Card 19,167 77.26 Others 452 1.82 Agency admitted to Surin Hospital 16,139 65.06 Prasat Hospital 6,392 25.77 Community Hospital 1,556 6.27 SHPH 720 2.90 Homecare Patient type Self-manageable 14,864 59.92 Partially self-manageable 7,333 29.56 Dependent 1,785 7.19 Terminal 827 3.33 57

When considering the 29,298 cases of patients of each report case, the cases with the most requisitions are from the postpartum case, followed by geriatrics case and stroke case (30.21%, 20.23%, and 7.29% respectively). For the homecare cases, the cases with the most requisitions are from the asthma case, followed by geriatrics and postpartum cases (100.00%, 98.94%, 98.17% respectively). The level of patients that received and feedback to the homecare services can be categorized as follows.

Level 1 All report cases accounted for more than 93.6% of feedback from the homecare services, and are found in the 3 highest rated (100%) cases of PC, Asthma, and Trauma cases, followed by disability case, STEMI case, and geriatrics case (99.29%, 98.73%, and 98.73% respectively) Level 2 All report cases accounted for more than 87.80% of feedback from the homecare services, and are found in the 3 highest rated (100%) cases of asthma, ANC, and URO cases, followed by geriatrics case, disability case, and postpartum case (99.36%, 98.92%, and 98.66% respectively). Level 3 All report cases accounted for more than 83.33%% of feedback from the homecare services, and are found in the 8 highest rated (100%) cases of PC, asthma, postpartum, cancer, COPD, CAPD, ENT and underweight pediatric cases. Level 4 All report cases accounted for more than 50.00% of feedback from the homecare services, and are found in the 6 highest rated (100%) cases of psychiatry, surgery, orthopedics, STEMI, trauma and URO cases. Detail as in Table 3

Table 3 Amount and percentage of feedback from homecare patients categorized by patient levels and report cases

Requisition Percentage to Percentage to feedback Percentage to Report sent (times) total patients received patients homecare Cases Level Level Level Level received 1 2 3 Postpartum 8,828 30.45 98.13 98.66 100.00 0 98.16 Geriatrics 5,872 20.25 98.73 99.36 99.03 92.11 98.96 Stroke 2,107 7.27 97.63 97.66 98.8 93.94 97.82 HT 1,700 5.86 97.27 95.87 97.69 91.67 96.71 Psychiatry 1,464 5.05 97.04 95.44 84.38 100.00 95.83 DM 1,390 4.79 97.8 96.01 96.88 81.82 97.05 TB 970 3.35 95.8 98.57 90.00 87.5 95.88 Disabled 896 3.09 99.29 98.92 97.08 77.78 97.99 Disability 859 2.96 96.44 92.91 100.00 90.1 93.25 PC 784 2.70 100.00 97.87 100.00 95.86 96.17 Surgery 769 2.65 98.04 94.7 98.08 100.00 97.40 Orthopedics 568 1.96 97.56 97.63 91.67 100.00 97.54 Others 555 1.91 97.14 94.94 96.38 92.86 96.22 COPD 450 1.55 96.4 95.68 100.00 87.5 96.00 CKD 424 1.46 93.46 94.39 96.97 91.67 94.10 CAPD 360 1.24 93.13 98.64 100.00 75 96.39 STEMI 213 0.73 98.73 98.33 90.91 100.00 98.12 Pediatrics 214 0.74 98.13 91.49 96.3 83.33 95.79 Underweight 142 0.49 94.05 87.8 100.00 0 92.96 Pediatrics Asthma 130 0.45 100.00 100.00 100.00 0 100.00 ANC 127 0.44 93.6 100.00 0 0 93.70 Trauma 80 0.28 100.00 93.55 97.73 100.00 96.25 ENT 50 0.17 94.44 92.86 100.00 50 92.00 URO 38 0.13 93.75 100.00 83.33 100.00 94.74 HD 5 0.02 0 0 0 0 0.00 Total 28,995 100.00 97.72 97.55 98.05 93.19 97.49 2. Results of the Homecare 2.1 The transfer and homecare The transferred and home cared patients are found to be dependent patients (Level 3 and 4) for 3,755 names with 68.97% to receive feedback within 5 days which are mostly patients from URO case, followed by pediatric case, and surgery case (85.71%, 85.00%, and 84.21% respectively). 59

Homecare patients with feedback within 14 days are 81.04% of all cases and are found highest (100%) in Asthma, and postpartum case, followed by geriatrics case, and the disability case (90.10% and 82.53% respectively). Complication cases are accounted for 16.75% and are found mostly from orthopedics case, followed by the disability case, stroke case, and geriatrics case (28.57%, 26.71%, 21.73%, and 20.64% respectively). Re-admit cases are at 3.46% and the cases with no re-admit are underweight pediatrics, STEMI, CAPD, asthma, trauma, and postpartum cases while the cases with highest re-admit rate are ENT, COPD, and URO cases (25.00%, 20.00%, 14.29% respectively). Detail as in Table 4.

2.2 The change in health conditions of the patients After the homecare and feedback are served to the patients for 28,226 report cases, most patients’ health conditions remain unchanged (88.15% rate) followed by improved health conditions, declined health conditions, and fatality (8.09%, 3.21% and 0.55% respectively), and the improved health condition cases are found from 2 groups which are Level 2 (Partially self-manageable) and Level 3 (Dependent patient) for 20.34% and 16.35% rate respectively. And the fatality cases are found highest in Level 4 (Terminal patient) with fatality rate of 13.40% as detailed in Table 5.

2.3 The satisfaction of the homecare patients from the Continuity of Care The satisfaction of the patients is of 2,637 cases. The highest satisfaction rating of high to highest of more than 80.00% rating are found most from satisfaction from the manners shown from the service providers, followed by the interested and dedication shown from the service providers, and the openness of the staffs in answering medical and decision-making questions that are vital in choosing the right treatments for the patients (42.11%, 37.26%, and 37.18% respectively), as detailed in Table 6.

Table 4 Amount and percentage of dependent patients categorized by report cases and transfer time.

Dependent Transferring Within 5 Days Within 14 Days Complications Re-admit report cases (times) Times % Times % Times % Times % Post-Pregnant 1 0 0 1 100.00 0 0 0 0 Geriatrics 1,182 804 68.02 1,065 90.10 244 20.64 25 2.12 Underweight 17 13 76.47 11 64.71 0 0 0 0 Pediatrics Pediatrics 60 51 85.00 45 75.00 5 8.33 5 8.33 DM 86 68 79.07 68 79.07 11 12.79 4 4.65 HT 154 120 77.92 117 75.97 12 7.79 6 3.90 COPD 15 12 80.00 10 66.67 0 0 3 20.00 Stroke 451 335 74.28 369 81.82 98 21.73 11 2.44 STEMI 14 3 21.43 11 78.57 2 14.29 0 0 CKD 57 37 64.91 45 78.95 3 5.26 4 7.02 CAPD 9 7 77.78 7 77.78 0 0 0 0 Asthma 4 3 75.00 4 100.00 0 0 0 0 Trauma 45 35 77.78 27 60.00 7 15.56 0 0 Orthopedics 21 17 80.95 17 80.95 6 28.57 1 4.76 Surgery 57 48 84.21 38 66.67 9 15.79 3 5.26 Psychiatry 34 26 76.47 22 64.71 2 5.88 3 8.82 Cancers 352 217 61.65 253 71.88 52 14.77 15 4.26 Disability 292 226 77.40 241 82.53 78 26.71 16 5.48 Tuberculosis 18 14 77.78 13 72.22 1 5.56 1 5.56 PC 723 473 65.42 562 77.73 76 10.51 26 3.60 ENT 4 3 75.00 3 75.00 0 0 1 25.00 URO 7 6 85.71 3 42.86 1 14.29 1 14.29 Others 152 72 47.37 111 73.03 22 14.47 5 3.29 Total 3,755 2,590 68.97 3,043 81.04 629 16.75 130 3.46

Table 5 Percent of the patients categorized by the patient levels and health conditions

Patients Total Health Condition Levels Amount Improved Unchanged Declined Fatal Level 1 (Self-manageable) 16,250 15,788 449 12 (97.16%) (2.77%) (0.07%) Level 2 (Partially self-manageable) 8,948 1,820 6,840 269 20 (20.34%) (76.44%) (3.01%) (0.22%) Level 3 (Dependent) 2,189 358 1,745 76 10 (16.35%) (79.73%) (3.45%) (0.47%) Level 4 (Terminal) 839 106 508 112 112 (12.62%) (60.58%) (13.40%) (13.40%) Total 28,226 2,283 24,882 907 154 (100.00%) (8.09%) (%%r15%) (3r21%) (nr55%)

Table 6 Percent of the patients categorized by the satisfaction ratings. Services Satisfaction Highest High Medium Low Lowest 1. Regular home visit from the staffs 29r16 53r32 16r75 0r64 0r13 2. Good manners and services from the 42r11 51r60 6r03 0r13 0r13 staffs 3. Proper attention and concern from the 37r26 56r98 5r63 0 0r13 staffs 4. Equality and orderly services from the 33r67 59r15 7r04 0r13 0 staffs 5. Public announcements and updates from 27r18 58r59 13r85 0r38 0 the hospital and healthcare services 6. Medical and treatment explanations from 33r67 57r62 8r45 0r26 0 the staffs. 7. Preventive and health promoting advices 36r12 57r07 6r43 0r26 0r13 from the staffs 8. Staffs’ skills and expertise in diagnosing 27r14 63r64 8r96 0r13 0r13 9. Staffs’ proficiency in the services 34r49 54r74 10r38 0r26 0r13 10. Staffs’ openness to your questions and 37r18 56r54 6r03 0r26 0 answers Total 33r79 56r93 8r96 0r24 0r08

2.4 The satisfaction of the staffs to the continuity of homecare The satisfactions of the staffs and service providers indicate that most high to highest rate of over 72.00% rating are found most from the satisfaction with homecare servicing, followed by the satisfaction in doing their best and fullest in servicing, and the 63

satisfaction to the policies and goals of the homecare services (22.60%, 18.64%, and 18.64% respectively) while the low satisfaction rate are found from the satisfaction of the budget, supplies, and equipment required for the operation, and the satisfaction of the workforce contribution to the homecare services of agencies (2.26% and 1.13% respectively) as detailed in the Table 7

Table 7 Percentage of the service provider categorized by the satisfaction ratings Service provided satisfaction Highest High Medium Low Lowest 1r Satisfaction to the policies and goals of 18r64 67r23 12r99 0r56 0r56 the homecare services 2r Satisfaction to the workforce 6r21 40r68 38r98 12r99 1r13 management for the homecare services and agencies 3r Satisfaction to the freedom of choice 13r07 66r48 18r18 1r70 0r57 from the task assigned r Satisfaction to the agents who support in 12r50 56r25 27r27 3r98 0 teaching and developing the staffs’ knowledge and skill to the job 5r Satisfaction to the information on the 10r73 62r71 23r73 2r26 0r56 development of homecare services ir Satisfaction to the support of the using of 13r56 67r23 16r95 2r26 0 staffs’ knowledge in developing the quality of the assigned task 7r Satisfaction to the support in budget, 8r4 40r11 41r81 7r34 2r26 supplies, and equipment for the jobs %r Satisfaction in fully working with your skill 18r64 64r97 14r69 1r69 0 talent fr Satisfaction in homecare servicing 22r60 62r15 14r69 0r56 0 Total 13.84 58.64 23.26 3.71 0.57

Chapter 5 Research Conclusion, Discussion and Recommendation Research Conclusion This research is an action research to study the effect of using Thai COC program in evaluating the home care services of Surin Province. The population sampled within this research includes every disease group of all age group that have submitted their data to Thai COC program. The purposive samplings include the data of the patients and their responses from the home care services of all health care units within Surin Province through Thai COC program during October 1, 2016 to September 30, 2017 collected from 23 disease group for 24,796 patients. The research instruments used are the reports of the home care services of the Surin Province from Thai COC program. The qualities of research instruments are checked by the experts and trial tested before the data are collected from the reports of Thai COC program, and analyzed through descriptive statistics method to distribute into average and percentage rate. The action research conclusions are broken into phases as Phase 1 Planning is conducted by studying the actual situation, analyzing the reports that do not meet the home care standards, collecting report data during research by conducting the subgroup meeting of the nurses involved in the local health care services from Surin hospital, the community hospital, and the sub-district health promoting hospital. These data received are then analyzed to plan to create the continuity of home care for all the health care units in Surin province and create the network of continuity of care services for every disease group and age group through the Thai COC program developed by applying the uses of information technology to promptly exchange information over nation wide and feedback of the home care patients to increase the disease analysis leveling from national level, provincial level, district level and sub-district level, together with the increasing of spot map and access to Smartphone, Tablet and computers, increased quality of life feedback records through links, and to add more disease group for the home care as needed from the policies or demand of each area. Phase 2 Acting is applied by implementing the plan and the resources into practice which include the determining the involved participants in developing the services 65

and in participating in the projects, meetings, and conferencing the home care committee by using the Thai COC program in provincial, district, and sub-district level from the provincial and district level program administrator in examining, coordinating, managing and solving the issues in the field responsible. The home care and Region 9 Health Care Office guides are outlined to the disease groups of home care patients for the continuity of care guidelines to be followed. The community nurses who are tertiary care level units will emphasize on the home care and bedridden patients afflicted with complex disease that have medical equipment installed at home, by collaborating through the use of Line application group chat with primary, secondary, professional, and network health care teams. Phase 3 Observing, tracking, and supervising through the use of Line application group chat, committee meetings and planning, and provincial evaluation by District Health Coordinating Committee. Phase 4 Reflecting on the performance and results by allowing the participants to evaluate the process of the operation to develop and further improve including the 2 assessments as follows. 4.1 Formative evaluation is used to evaluate and supervise the operation continuously and the received data are developed to improve the medical nursing model and the Thai COC program to support the operation continuously. The research of the Thai COC program provides faster connection and response rate by applying 2-ways connection and analyzing the reports of the home care services, creates the continuity of care to the home care patients, and also help minimizing the use of paper resources and materials. More ever, the Thai COC program allows the administrators to control and track the current supervisions effectively. In addition, the program can be improved and developed to meet further needs without limited such as expanding the area of services, adding disease groups of the continuity of care, accepting the patients of the Royal Medical Unit, and covering more of 9 Regional Health Office covering 39 from 77 provinces in Thailand. The highlights of the research have been rewarded, and recently praised by the Site Visit of the Office of Public Sector Development Commission (OPDC) dated June 6, 66

2018, and commended for the Public Sector Excellence Awards (PSEA) of 2018 for the Top Services Innovation. 4.2 Summative evaluation is assess for the reports of the home care services in monthly, quarterly, and annually terms which demonstrate the results are indicated into 2 traits to meet the desirable criterias as follows. Trait 1 The coverage rate of the home care patients is not less than 80% (In 2017, rate is 97.49%) Trait 5 The satisfaction ratings of the patients are not less than 80% (In 2017, the ratings at high-highest rating at 90.72%) Traits that do not met the standards are 4 traits as follows Trait 2 The home care patient 14-day return rates within from primary, general, and communal is at 100% (In 2017, the rate is at 4.53%) Trait 3 Complication rate of the home care patients is not higher than at 5% (In 2017, the rate is at 23.00%) Trait 4 Level-3 patient 5-day transfer rate is 80% (In 2017, the rate is at 16.75%) Trait 6 Satisfaction ratings of the home care providers are not less than 80% (In 2017, the ratings are at high-hest rating at 72.48%)

Research Discussions From the action research model, the 4-steps of planning (acting, observing, tracking supervising, and reflecting of the operation) and systemically problem solving consist of the factors of input, process, and output to achieved the expectation in desirable medical and nursing service. Even though the first implement of the Thai COC program only had demonstrated to meet 2 traits of desirable criteria, the results show improvement compared to the year 2017; the Level-3 patient 5-day transfer rate is increased by 16.75% to the total of 68.97%, the home care patient 14-day return rates is increased by 4.53% to the total of 81.04%, the complication rate is reduced by 23.00% to the total of 16.75%, the Re-admit rate is reduced by 19.76% to the total of 3.46% (ref. Thai COC program reports filed during October 1, 2016 and October 1, 2017) 67

The satisfaction ratings of the patients and recipients at high-highest ratings are at 90.72%; rated by the good manners, services, cares, and dedications received from the health service providers, and the opportunities to comment and ask questions in regards to medical care and nursing for the patients to choose and decide the most proper services based on the competencies and skills of each community health nursing teams which are the community assessment skill, teamwork, coordination skill, communication and captivation skill, motivation skill for the patients, his/her relatives and neighbors, promoting family and social supports in properly health management by the Thai COC program (Health Office Region 9, 2017: 49-50; Wirairut Sansook and affiliates, 2015: 27-131; Pawinee Phrombhut and affiliates, 2014: 82-96). With the probable from home care service, the data evaluation, the participation, the continuous tracking to the patients and caregiver which emphasize the comprehensive analyzing, and the focus on the planning of the patients discharge process from the hospital, can whether decrease the re-admission rate of the patients. (Manthana Jirakangwarn and Sirirat Chantree, 2018: Amphaporn Theeranut and affiliates, 2016) As for the service providers, the satisfaction ratings are low in regards to the supporting budgets, instruments, and materials to operate the health care services and personnel management to the home care services which are due to the newly establish facilities with many home care patients discharged from the hospital in contrast to the small amount of medical personnel and staffs available and the limited of patient care technicians and transport vehicles. The operation continued in 2018 is operating by the 4-steps in effectively improving the continuity of care service by emphasizing the medical process which is the major factor in setting the standards of the medical care. (Nursing Division - Ministry of Public Health, 2012) To satisfy the patients or recipients in accordingly with the Home Health Care idea of Nursing Division (2014) and the research of Phensiri Athawong and affiliates (2017) who have implemented the Home Nursing Care model and found the results to better meet the standard criteria of the Nursing Division than before implementing the Home Health Care model which in each steps allow all participants to plan, act, monitor and evaluate the results to be the vital factor in creating continuity of care service with which families, communities, and networks would become self-sufficient and sustainable. 68

Recommendation 1. To develop the disease management, such as the group of highly cost disease, highly complex complication diseases, disease group with high re-admission, chronic disease group that need sustaining support, providing necessary health care to reduce cost and promoting better quality of life or health. 2. To develop and update the programs cooperating with provinces using the program by the committee and administrators at all level, province, district and sub-district level of supervisions, and establishing of Line application group chat to communicate and publicize the use of the programs covering 39 from 77 provinces in Thailand. 3. The low satisfaction ratings due to the supporting budgets, instruments, and materials to operate the health care services of the service providers and the satisfaction rating to personnel management should be emphasized and supported more by the administrative officials in regards to the resource and transport vehicles to deliver home care patients sufficiently along with the efficiency in home care equipments to reduce the rate of in-patients and re-admission patients in the hospital which would also reduce the cost of the medical treatment in hospital.