Abstract
To develop a stroke-care model for the outpatient department, Thoen Hospital in
Lampang Province, 32 patients were studied in the period February -July 2007 (six months)
by a multidisciplinary team. The method of study was a three-dimensional framework.
The first dimension was to strengthen the health-care team, focusing on control of comorbid
conditions and risk factors. It was found that, in the DM-patient group of 13
cases, the results of risk control as the compliance levels of blood pressure, plasma fasting
glucose, TG and LDL were about 23.08, 30.77, 69.23 and 23.08 percent, respectively. In
the group of 14 cases without DM but having other risk factors, we found that the levels
of blood pressure, TG and LDL were under control at 64.29, 57.14 and 14.29 percent, respectively.
By monitoring for new risk factors, we could detect such factors in 24 cases
(75%), for whom we controlled both their previous and new risk factors purposely in
order to reduce stroke recurrence. The second dimension was to encourage self-care
behavior in the patients and their caregivers; we could empower 30 cases (93.75%) to
achieve successful rehabilitation. For evaluating the quality of life, we used the Barthel
Index of Activity of Daily Living; we found that the score had statistically significantly
increased (p = 0.005). The stroke patients could pass their post-test in the topics of nutrition,
domestic vegetables and traditional Thai medicine; the increase was significant (p =
0.005). The last dimension was for providing competency for the partnership of the community
health-network. The local government and a volunteer-group participated in
home health-care activities for stroke patients in the villages. For improving the quality
of life for the stroke patients, many community plans have been implemented, such as
the screening activities among the population at risk for stroke prevention and fostering
health promotion in the Thai style. In conclusion, there is a limitation on stroke care in
the outpatient department of the community hospital, but with such a model, using the
concept of a multidisciplinary team, the effectiveness of integrated health care for stroke
patients could definitely be improved.
