Abstract
Background and Rationale
The number of patients receiving continuous ambulatory peritoneal dialysis (CAPD) in Thailand has steadily increased. Most are frail older adults with comorbidities and polypharmacy. At present, CAPD patients are managed according to standard care through hospital-based peritoneal dialysis clinics. However, patients remain at risk of dialysis-related complications while performing CAPD at home. Continuous care is therefore required, extending from hospitals to community-based care. The transfer of primary care service responsibilities from the 60th Anniversary Commemorative Health Centers (SHPH) and Subdistrict Health Promoting Hospitals (SHPH) to local administrative organizations presents an opportunity to reform the health service system to improve access to essential medical and supportive services.
Research Objective
To develop a primary care service system for transferred Subdistrict Health Promoting Hospitals to support community-based continuous care for older adults receiving CAPD.
Methods
This mixed-methods study included literature review; quantitative and qualitative data collection; interviews; focus group discussions with stakeholders; and patient journey mapping to identify patients’ service and support needs and to analyze gaps in service and support systems. A participatory process was used to develop a framework and guidelines and to design a CAPD Co‑Care prototype involving transferred SHPHs, local administrative organizations, and community stakeholders. The health information system component included a gap analysis of existing information systems and the design of data architecture, informed by the WHO Health System Framework, Donabedian’s model for quality assessment and monitoring, and the Zachman Framework for information systems architecture. Participants comprised 45 older CAPD patients, 25 caregivers, and 73 administrators, providers, and stakeholders in the provinces of Chiang Mai, Chiang Rai, and Phayao.
Results
The findings indicate that the main gap in community-based care for older CAPD patients stems from fragmented work across service levels (hospital–primary care–local government–community). This fragmentation results in discontinuities in symptom monitoring, risk assessment, polypharmacy management, and caregiver support—especially for cases requiring proactive care (home visits/close follow-up) and management of social determinants of health. Another major finding is the “information system gap” that disrupts continuity of care, including discontinuous data across facilities, low interoperability, insufficient data content for home-based care, and lack of key outcomes data (e.g., some clinical indicators and patient‑reported outcomes [PROs]). This is because current data structures are designed primarily for reimbursement rather than for clinical monitoring and follow-up. The proposed framework and prototype service model for continuous community-based care for older CAPD patients, “CAPD Co‑Care,” consists of: Home visits and continuous follow-up mechanisms to monitor complications; assess home environment, patient and caregiver readiness, and socioeconomic factors; delivered by transferred SHPH home-visit teams and village health volunteers to screen and refer patients at risk of CAPD complications; identify medication-use problems and promote adherence; and reinforce patient/caregiver self-care knowledge and skills; capacity building for primary care staff and community networks through a standardized knowledge package and tools for caring for older CAPD patients in the community; strengthened collaboration with tertiary nephrology clinics to enable bidirectional referrals (to and back to transferred primary care units and local administrative organizations) using standardized referral processes and interoperable referral information; development of a local administrative organization CAPD information system containing essential data on health status related to aging and peritoneal dialysis, as well as needs for economic and social support, transportation, infectious waste management, and home modification, along with dashboards for monitoring and evaluation of service delivery; and use of digital tools to support home-based monitoring, including Patient‑Reported Outcomes, to track health status and detect early warning signals for CAPD-related complications in a timely manner. For primary care health information systems, the study proposes reforming data architecture under the concept of Data‑Centric Primary Care and Seamless Service Integration, shifting the paradigm from reactive treatment of complications to proactive prevention and holistic well-being. Regarding standardization of health and social welfare datasets, the study proposes developing a standardized dataset for home-based peritoneal dialysis care (Thai Home‑Based Renal Care Data Set) including clinical data and PROs, geo-location data for logistics management, and functional status data (ADL/Barthel Index) to support accurate assessment of basic needs by relevant agencies; developing a provincial digital health data ecosystem using the Provincial Administrative Organization area as a pilot, testing cross-agency data linkage through modern data exchange standards to enable real-time data flow between health facilities and local agencies, allowing local administrative organizations to plan patient transport routes, organize infectious waste collection, and allocate budgets for home improvements targeted to the appropriate groups; and shifting the paradigm of holistic care from using data as reimbursement evidence toward using data as a tool for quality-of-life management through alert and health status monitoring systems that connect health and social dimensions, in order to reduce inequities in access to basic services and sustainably improve the quality of life of older CAPD patients in the community.
