Development of a Seamless Chronic Care Support System Based on Design Thinking through a Community Digital Network to Enhance Nursing Outcomes.
Keywords:
seamless nursing care, case management, nursing process, nursing outcomesAbstract
This research and development study examined care needs and developed a seamless care system for patients with type 2 diabetes and/or hypertension in Muang Tao Subdistrict, Phayakkhaphum Phisai District, from November 1, 2023, to September 30, 2024. Ethics approval was No. 43/2566, dated October 30, 2023. Participants included 38 informants, 25 co-developers, and 239 patients. Four development phases and a one-group before-and-after assessment used content analysis and descriptive statistics. The system linked seven service steps to the nursing process, with nurse case managers. Orem’s theory explained assistance provided. Planned care increased from 77.20% to 91.60%; missed appointments decreased from 22.80% to 7.60%. Mean HbA1c decreased from 8.60% to 7.50% in 118 paired patients. Blood pressure control increased from 66.28% to 81.40% in 172 patients; highest-category satisfaction increased from 79.64% to 96.83% in 221 respondents.
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