Abstract
Primary care service development to improve quality of life for stroke patients in the community is considered a major service activity for promoting health, reducing body impairment and disability along with promoting good quality of life. Several models for providing primary care services and care for patients are used in Bangkok communities where the factors promoting quality of life differ from rural societies. Furthermore, no clear assessments have been conducted to assess the effects of primary care service models on quality of life in Bangkok. This study was aimed at studying model of care, personal factors, social networks influencing quality of life, test causal correlations of service provision models with quality of life and discover problems and needs of associated persons in order to modify and improve the service provision model before testing model as a pilot study in Bangkok for functional recovery and quality of life. The sample was 450 patients who had survived ischemic or hemorrhagic stroke for no more than two years and were discharged from the hospital to return to the community along with primary care unit service providers. This study used quantitative and qualitative research methods. Data were collected by using questionnaires, focus groups and implementation of appropriate primary care service models. According to the findings, stroke patients in Bangkok (68.2%) were found to have not recovered after being discharged and returning home with medium-level quality of life (Mean + SD = 3.40 + 0.93). Most of the patients had access to care at home provided by Registered nurses (RN), followed by physical therapists and community nurses with social network support from village health volunteers or Care Givers (CGs) trained care of bedridden patients by Nursing Division Public Health BMA Department at 3 9 .6 percent. Patient’s factors most an effect on quality of life (QOL) was high functional disability score (ß = .57, p = .000), followed by depressive (ß = -.22, p = .000) cognitive impairment (ß = .20, p = .000) unable return to work after stroke (ß = -.12, p = .000) and hours to care for stroke patients (ß = -.07, p = .000), respectively. The results showed that 4 model of care such as Continuing care with nurse expert model provides the best recovery and quality of life for patients, followed by the Bangkok Metropolitan Administration (BMA) Home ward was a primary care service that can serve a large group of patients in community and use the most of community's resources for benefit of care. Continuing care from hospital to home was occurred by family management, and received necessary equipment of care which supported from the hospital. While family care has family supported and provided care to patient. The causal relationship model of the factors influencing functional recovery and quality of life among stroke patients was consistent with the evidence-based data (χ2 = 4.688, df = 6, p value = .584, χ2/df = .78, GFI = .997, RMR = .014, RMSEA = .025). Stroke patients’ quality of life was most influenced by functional impairment (ß = -.79, p = .000), followed by the continuing care model with nurse experts (ß = .13, p = .000) and the BMA home ward model (ß = .10, p = .008). Patients who received care support from only family members and community members were unable to reduce disability and improve quality of life. Concerning healthcare service needs and barriers, the recovery goals of patients and healthcare providers were found to be inconsistent. Patients looked at the destination and chances of survival, while healthcare providers looked at the process on the way toward self-management, stabilization of control over complications and comorbidities. Therefore, the services provided for stroke patients in the community were care for bedridden patients rather than care to stroke patients with neurological impairments return to a condition similar to before illness. Accurate recovery processes are needed for the development of clinical nursing practice guidelines for stroke patient in community and trial implementation with selective models. Synthesis new model of care by nurses and health personnel involved in trial implementation of the home ward for stroke care which has clinical nursing practice guidelines for stroke patient in community, patients were found to have less physical impairment and higher quality of life with statistical significance. Therefore, community nurses can implement service provision models and care guidelines for stroke patients in the community to improve quality of life among patients in the community for positive health outcomes. In the future, primary care services for Bangkok will be faced with population structure changes, different social determining factors from rural societies, few family care roles and distant social networks. Nurses are the crucial health personnel as consultants, help and take role play closely of nursing care at home. Meanwhile Bangkok Metropolitan Administration is unable to resolve shortage of nurses to support patients in hospitals and communities. Freelance nurses can provide solutions in promoting health among patients in communities to meet needs by developing freelance nurses and implementing good practice guidelines in communities to create quality care practices and support correct decision-making with stroke patients. Moreover, supported by volunteers in place of patients with family caregiver whose relatives have no time or readiness to provide care and volunteers who serve as patients’ family members with nurses while maintaining close relationships and care consistency can help reduce disability and improve quality of life. Therefore, policy-makers need to develop volunteer with knowledge and readiness to care for patients with complex conditions disease in the community in addition to creating new volunteers to replace old volunteers.
