Continuity of care model for Intermediate Care in stroke patients of Kalasin Hospital, Kalasin Province.

Abstract

     This research is participatory action research. Aim to develop and implement a continuity of care model for stroke patients in the rehabilitation phase at Kalasin Hospital, Kalasin Province. Sample consisted of a multidisciplinary team and 87 stroke intermediate care patients phase. Research tools instruments included a general and clinical data collection form, an ADL assessment form, and an MRS Score assessment form. Data were analyzed using descriptive statistics, percentages, medians, inferential statistics, t-tests, and qualitative content analysis.
     Results of the study Stroke patients in the rehabilitation phase Most of them were male (54.02%), 33.33% were under 60 years old (Mean±SD = 58.46±1.67, Min=52, Max=75 years old), 36.78% were general laborers, 100% were Buddhists, 40.23% were primary school education, 82.76% were ischemic stroke, 32.18% were comorbidities,97.70% were diabetes, and 42.53% were diabetic. Most of the patients had difficulty walking and weakness in their arms and legs. The ability to perform daily life was mostly independent, 42.53%. The development of the model consisted of 5 important processes: 1) Develop guidelines for referring patients for continuous care at home, 2) Evaluate and prepare for discharge according to standards, 3) Update problem information before discharge, 4) Develop a symptom tracking system with modern technology, and 5) Have a patient health record book for rehabilitation care. After the development, it was found that the ability to perform daily life, the average ADL score increased significantly at the statistical level of .05 (t = 3.12).