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

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.