Development of Continuous Palliative Care Model for End-of-Life Patients from Hospital to Community, Kongkrailat Hospital, Sukhothai Province.

Abstract

     This study was action research approach using the ADDIE model integrated with Meleis' Transition Theory and Wagner's Chronic Care Model. The objectives were to investigate the current situation, develop a continuous palliative care model for end-of-life patients from hospital to community settings, and evaluate the effectiveness of the developed model. The study was conducted from October 2024 to September 2025. Sample size were 34 end-of-life patients receiving palliative care services. Research instruments comprised interview guides, demographic questionnaires, palliative care knowledge assessments, care quality evaluation scales, satisfaction assessments, and operational performance recording sheets. Data were analyzed using descriptive statistics, content analysis, and paired t-tests for pre-post comparisons.

     Results showed that the developed care model consisted of six core components: holistic assessment and care planning, multidisciplinary team development, seamless continuum of care system, family and community empowerment, effective symptom management, and continuous monitoring and quality improvement. The model's effectiveness demonstrated significant improvements: nurses' knowledge increased from 69.17% to 90.83%, patient care quality improved from moderate (68.42±12.34) to high level (103.58±8.67), and patient satisfaction increased from moderate (52.35±9.87) to high level (83.50±6.42), all statistically significant at p<.001 (t = 15.68, 23.47, 18.92, respectively). Operational indicators showed continuity of care increased from 29.4% to 88.2%, Family Meeting/Advance Care Planning from 38.2% to 91.2%, and dignified death rates from 70.6% to 91.2%, all statistically significant at p<.001. Expert evaluation rated the model's appropriateness as high (82.89%).