Development of community-based Home Visit Guidelines for Patients with Complexity Problem Suksamran Health Promoting Hospital Dongmaung Sub-district Yangsisurach district, Mahasarakham province

Abstract

     The objective of this research was to develop a community-based approach to home visits guidelines in patients with complex problems within the Suksamran Health Promoting Hospital , between October 2017 and March 2019. Developed according to the Kemmis & Mc Taggart action research which consisted of 4 steps: planning, acting, observing, evaluating and applying the concept framework of Holistic Nursing and Home visit. Sampling that divided into 2 groups 1) group that developed guidelines for the care of patients with complex problems, including public health workers,multidisciplinary teams, caregivers and community network partners ; 202 people. 2) 31 patients with complex problems. Research tools were included with INHOME-SSS, ADL assessment, PPS –score assessment, observation form. Data Analysis by qualitative are triangulation data and content analysis and quantitative data are descriptive statistics such as mean and percent .

     The results of this study were :

     1) The home visit guidelines that, (1) development the sub-district cooperation center for connecting the data of complexity health problem patients, ( 2) appointment of working group members for setting the role and responsibilities for the community, (3) setting up the community participatory action combining with the nursing process, (4) l home visit hand book (5) development the home visit innovation; the wet wound prevention bag (6) setting up the “friend support friend fund”.

     2) Interms of clinical outcomes, there were the better changes in; (1) the number of the patients who could control HbA1C<7 was increasing from 40% to 50%, (2) the disease complications related to eyes, kidneys, and feet was decreased from 40% to 25%, Hypo-Hyperglycemia symptoms was decreased from 20% to zero. (3) Moreover, the number of good dead patients in palliative group was increased from 50% to 100% (4) the success rate was 100% in of TB patients, the number of disease recurrence in psychiatry was decreased from 20% to zero (5) the bedridden patients was being to patient at home increasing from zero to 100%.