ผลของโปรแกรมการดูแลผู้ป่วยสูงอายุโรคหลอดเลือดสมองและผู้ดูแลระยะเปลี่ยนผ่านจากโรงพยาบาลสู่บ้านต่อความสามารถในการปฏิบัติกิจวัตรประจำวัน การกลับมารักษาซ้ำ และความสามารถในการดูแลผู้ป่วยของผู้ดูแล โรงพยาบาลทั่วไปแห่งหนึ่งของภาคใต้

Abstract

This quasi experimental research aimed to examine the effects of a transitional care program for elderly patients with stroke and caregivers on patients activities of daily living, readmission, and caregiver’s ability. Purposive sampling was used to select elderly patients with stroke and caregivers who were admitted at a general hospital of the south. A total of 60 dyads of elderly patients with stroke and their caregivers were recruited into this study. The first 30 dyads of elderly patients with stroke and caregivers were assigned to the control group, receiving a usual care. The other 30 were assigned to the experimental group, receiving a transitional care program for 4 weeks, which was divided into 2 phases: (1) in–hospital phase, and (2) home visiting and telephone follow-up phase. The instruments used for the intervention consisted of (1) the transitional care program, (2) need assessment form for elderly patients with stroke and caregivers, (3) transitional care planning for elderly patients with stroke and caregivers, (4) teaching plan for the transitional care of elderly patients with stroke, (5) power point presentation, (6) handbook for elderly patients with stroke and caregivers, (7) identification book of elderly patients with stroke, (8) home visit tracking record, and (9) tracking phone record form. The data collection tools included (1) General Information Record Form for Stroke Patients and Caregivers, (2) Activities of Daily Living Questionnaire, (3) Readmission Records, and (4) Caregiver’s Abilities Questionnaire. All research instruments were verified by three experts for content validity. The reliability testing of the Caregiver’s Abilities Questionnaire showed a Cronbach’s alpha coefficient of .81. Data were analyzed using descriptive and inferential statistics. The study results revealed the following: 1. The mean score on the activities of daily living in the elderly patients with stroke after receiving the transitional care program was significantly higher than that of the pre-intervention (t = -6.45, p < .01) 2. The mean score on the activities of daily living in the elderly patients with stroke after receiving the transitional care program was significantly higher than that of the control group (t = -2.09, p < .05) 3. The readmission rate of the elderly patients with stroke was not significantly different between the two groups. 4. The mean score on caregiver’s abilities after receiving the transitional care program was significantly higher than that of the control group (t = -9.09, p < .01) The results of this study showed that a transitional care program for elderly patients with stroke and caregivers could improve the patients’ activities of daily living and caregivers’ abilities. Therefore, this program should be implemented for patients with stroke and caregivers during the transition of care.