The Development of the Coronary Heart Disease Management Model at Sakon Nakhon Province - การพัฒนารูปแบบการจัดการโรคหลอดเลือดหัวใจ เครือข่ายจังหวัดสกลนคร

Abstract

This action research was aimed at developing a model of the Coronary Heart Disease Management
at Sakon Nakhon Province by using the six components of the chronic illness management
concept. The participants included: 1) Stage I: 334 people from health care team and community
committee members; 2) Stage II: 279 people from health care team and community committee
members as well as 9,512 patients with coronary heart disease; and 3) Stage III: 354 people from
health care team. Data were collected from October 2008 to December 2012. The study composed
of three stages. Stage I: Situation Analysis with SWOT analysis and the instruments used for collecting
data in this stage were group discussion, observation, field notes, and assessment questionnaire.
The data were analyzed by using quantitative statistics with mean and qualitative analysis
with content analysis. Stage II: Developing a Model by using a model preliminary application and
reflection and Stage III: Evaluation model effectiveness with chronic illness management assessment
tool and the mortality and mobility rates of the coronary heart disease. In the Stage II and III,
data were collected by using observation, interviews and field notes, group discussion and meeting
notes, then data were analyzed using quantitative statistic with mean and proportion and qualitative
analysis with content analysis. The research findings were in three areas.
1) The significant keys for a model development were implementing the policies of coronary
heart disease management to every heath care setting, managing of service system in every heath
care setting, managing patient care service in every stage of disease, and integrating all components
of chronic illness management into health care service system.
2) The Coronary Heart Disease model at Sakon Nakhon province composed of one stop service
heath care system for all heath care system levels with multidisciplinary heath care team, patient
self-care center and cooperating among community and networks. Health care manger worked
as a coordinator.
3) The assessment score of chronic illness management was higher than those before the model
development was operated. Sakon Nakhon province had a new model of coronary heart disease
management covering all health care settings with one stop service, patient self-care center and
community participation, which lead to the reducing of mortality rate.
The study findings point that the development of coronary heart disease management model
should be initiated with the obvious policy, developed by all network cooperation with the unique
problem, and integrate all components of the chronic illness management concept.
Key words: chronic illness management, model of chronic illness management, coronary heart disease