การพัฒนาระบบการดูแลผู้ป่วยโรคหลอดเลือดสมอง ภายใต้บริบทของโรงพยาบาลตติยภูมิ

Abstract

        This action research aimed to develop care system for stroke by nurse case manager  In the context of Chaiyaphum hospital, Participants were stroke ,caregiver, health care providers, Multidisciplinary team leaders and health care from a secondary care hospital. Data were obtained through participatory observations, in-depth interviews, focus group discussion, and document analysis, during 15, January, 2016-16, January, 2017. Quantitative data were analyzed using descriptive statistic’s. Qualitative data were analyzed by using content analysis. Results in 3 Phases were: 1) Situational analysis, it was found that stoke do not have access to timely, standardized treatment services. Multidisciplinary team could not sustainable development as well as of Lack of continuing care and participation from family and community. 2) Development phase, 1) decision making support for care providers was improved by the practice guideline and effective referral system; 2) self-care knowledge and the skills of patients and their caregivers were improved; 3) Nurse case manager had coordinator between multidisciplinary teams to solve complex problems of stroke. 3) Evaluation, the developed care system had benefits for stroke their can accessed one stop services. However, the care at home from health and social care providers were still needed.