Development of a Home Visit and Continuity of Care System for Stroke Patients at Non Sung Hospital, Nakhon Ratchasima Province

Abstract

     This study was quasi experimental research aimed to develop a home visit and transitional care system for stroke patients at Non Sung Hospital, Nakhon Ratchasima Province. Conducted from November 30, 2024, to September 30, 2025. The sample, selected through purposive sampling, consisted of 35 healthcare team members and 15 subacute stroke patients undergoing rehabilitation. The research process was divided into 4 phases: Phase 1: Situation analysis and literature review with the 35 healthcare team members; Phase 2: Development of the home visit system; Phase 3: Action research trial with the 15 rehabilitation stroke patients to refine the system; and Phase 4: Implementation of the newly developed home visit system and evaluation of its effectiveness. Research instruments included pre- and post-test knowledge assessments regarding home visits, satisfaction questionnaires, the Barthel Index scale, focus group discussion guidelines, and in-depth interview guides. Data analysis involved content analysis for qualitative data, and descriptive statistics (percentages and means) for quantitative data. The Friedman test and Wilcoxon signed-rank test were utilized to compare Barthel Index scores across three distinct time periods.

     Results: The results revealed that the Barthel Index scores showed a continuous upward trend from admission, at discharge, to 6 months post-transitional care. The Friedman test indicated a statistically significant difference in scores across the three time periods (p < 0.05). Pairwise comparisons using the Wilcoxon signed-rank test between admission and discharge, discharge and 6 months post-care, and admission and 6 months post-care all demonstrated statistically significant differences (p < 0.05). Regarding the satisfaction of patients and caregivers, the mean scores were at the highest level (mean ≥3.41), reflecting high satisfaction with the developed home visit system and innovation. Key success factors noted by the system developers included multidisciplinary team collaboration, clear roles of community healthcare staff, and a well-connected care network between the hospital and the community. Recommendations: Long-term follow-up (> 6months) should be conducted to evaluate the sustainability of the system. The trial should be expanded to other areas or different patient groups.