Developing a Care Model for Stage 4 Chronic Kidney Disease Patients at Kosumphisai Hospital.

Abstract

     This action research aimed to: 1) investigate the situation and problems in the care of patients with stage 4 chronic kidney disease (CKD); 2) develop a care model for patients with stage 4 CKD; and 3) evaluate the outcomes of the developed care model. The study was conducted at Kosum Phisai Hospital, Maha Sarakham Province, Thailand, between March 1 and December 1, 2025. The participants were 17 newly diagnosed stage 4 CKD patients receiving care at the CKD clinic, selected through purposive sampling. The developed care model was based on the empowerment concept combined with health coaching techniques. A specialized nurse served as an individual health coach, providing health assessment, collaborative goal setting, motivation enhancement, health education, follow-up evaluation, and support from family members and community networks. In addition, a salt meter for measuring sodium content in food and a home blood pressure monitor were used as tools to support patient self-management. The intervention was implemented for three months with follow-up monitoring for nine months. Data were collected using a demographic questionnaire, a self-management health behavior assessment, an awareness questionnaire on salt and sodium consumption, records of food salt measurements, and glomerular filtration rate (GFR). Data were analyzed using descriptive statistics and paired sample t-test.

     The results revealed that after implementation of the care model, patients had significantly higher self-management health behavior scores compared to the pre-intervention period (t = 4.21, p < .05). Awareness of salt and sodium consumption also significantly improved (t = 11.20, p < .001). Moreover, kidney function, as measured by GFR, significantly improved after the intervention compared with the baseline measurement (t = 2.31, p = 0.034).