Development of a Post-Discharge Care Model for Patients with Substance Use Disorders after the Detoxification Phase to Prevent Relapse, Soi Phisai Hospital, Bueng Kan Province

Abstract

This research and development study aimed to (1) examine the situation and problems of post-discharge care for patients with substance use disorders after the detoxification phase, (2) develop a post-discharge care model to prevent relapse, and (3) evaluate the outcomes of the developed model at Soi Phisai Hospital, Bueng Kan Province. The study was conducted from January to September 2026, a total of 9 months, in four phases: situation analysis, model development, model implementation, and evaluation. Participants were purposively selected and comprised 30 patients discharged after detoxification, 30 family caregivers, and 15 members of the multidisciplinary team and community network. Instruments included a semi-structured interview guide, a relapse prevention self-efficacy questionnaire, a follow-up record with urine drug test results, and a satisfaction questionnaire. Quantitative data were analyzed using descriptive statistics, paired t-test, and Fisher's exact test, and qualitative data were analyzed by content analysis.

          The main problems of post-discharge care were missed follow-up appointments, lack of a continuous hospital-to-community follow-up system, families having limited time for supervision, and return to environments conducive to drug use. The developed model, "Soi Phisai Seamless Care Model," consisted of five components: 1) individualized discharge planning and relapse risk assessment, 2) preparation of family members as primary caregivers, 3) seamless technology-assisted follow-up, 4) home visits by the community network, and 5) management of warning signs and re-entry into treatment. After implementation, the 3-month relapse rate decreased from 43.33% to 16.67% (Fisher's exact test, p-value = 0.047), and the treatment retention rate increased from 63.33% to 86.67% (p-value = 0.072). The mean relapse prevention self-efficacy score increased significantly (mean±S.D. 2.85±0.52 to 4.12±0.41; t = 11.24, p-value <0.001), and overall patient satisfaction was at the highest level (mean±S.D. = 4.46±0.48), with 86.67% of patients reporting high to very high satisfaction. Seamless care linking pre-discharge preparation to the community, together with family participation and technology-assisted follow-up, was associated with reduced relapse and improved treatment continuity. The model should be adopted as standard practice in the drug clinic, and further studies with larger samples and concurrent comparison groups are recommended.