Effectiveness of a Transitional Care–Based Home Visit Program on Functional Recovery and Caregiver Competency Among Stroke Patients in a Community Hospital Setting

ประสิทธิผลของโปรแกรมการดูแลต่อเนื่องโดยใช้แนวคิดการดูแลระยะเปลี่ยนผ่านร่วมกับการเยี่ยมบ้าน ต่อการฟื้นฟูสมรรถภาพและสมรรถนะของผู้ดูแลในผู้ป่วยโรคหลอดเลือดสมองในโรงพยาบาลชุมชน

Abstract

This experimental research employed a one-group repeated-measures design to evaluate the effectiveness of a continuity of care programme integrating transitional care and home visits for patients with stroke in a community hospital setting. The sample comprised 15 primary caregivers and 15 patients with stroke, selected through purposive sampling. The intervention was implemented in two phases: (1) a hospital-based preparatory phase focusing on enhancing caregivers’ knowledge and caregiving skills, and (2) a home visit phase providing continuous follow-up and support in the community. Research instruments included
a caregiver knowledge questionnaire, caregiver skill assessment tools (promoting activities of daily living and complication prevention), the Barthel Index of Activities of Daily Living (ADL), and a complication monitoring form. Data were analysed using descriptive statistics and repeated-measures ANOVA.

               The results showed that patients’ ADL scores significantly improved over time (F = 268.374, p < .001, partial η² = 0.950), increasing from a mean of 9.20 at baseline to 18.27 at two months post-intervention. Caregivers’ skills in promoting activities of daily living and patient safety also significantly improved (F = 68.070, p < .001, partial η² = 0.829). Similarly, skills in preventing complications showed a significant increase over time (F = 42.082, p < .001, partial η² = 0.751). However, caregivers’ knowledge of stroke did not show
a statistically significant change (F = 2.940, p = .104, partial η² = 0.174).

               In conclusion, the continuity of care programme demonstrates strong potential to enhance caregivers’ skills and promote functional recovery in patients with stroke. The integration of transitional care and home visit approaches may represent an appropriate model for strengthening continuity of care in community hospital settings.