การประเมินเชิงพัฒนาการเข้าถึงและคุณภาพบริการดูแลระยะกลางการปฏิรูประบบบริการสุขภาพปฐมภูมิในกรุงเทพมหานคร

Vijj Kasemsup; Maturin Juntongsree; Pawin Sriwichian; Tanaporn Chandharohit; Phusit Prakongsai

Authors

Vijj Kasemsup Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University
Maturin Juntongsree Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University
Pawin Sriwichian Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University
Tanaporn Chandharohit Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University
Phusit Prakongsai Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University

Keywords:

intermediate care, stroke, home rehabilitation, health policy, accessibility

Abstract

Intermediate care (IMC) is defined as the specialized care provided to patients who have transitioned out of the acute phase. While these patients are medically stable, they often retain physical impairments that limit their daily activities and social participation. This is particularly evident in stroke patients who require intensive rehabilitation. This study followed 139 stroke patients during the first six months after hospital discharge across five hospitals. The participants consisted of 65 females (46.8%) and 74 males (53.2%), with an average age of 70.6 years and one-fourth of the cases were hemorrhagic stroke. There were four channels of IMC in this study: 1. IMC ward (31 cases, 22.3%), 2. IMC outpatient (27 cases, 19.4%), 3. IMC home rehabilitation (21 cases, 15.1%), and 4. self-home rehabilitation (45 cases, 32.4%). Improvements in Barthel index (BI), Euro-quality of life (EQ-5D-5L), and World Health Organization-five well-being index (WHO5) were observed across all groups in every type of IMC services. In conclusion, intermediate care services represent a vital strategy for enhancing the recovery and quality of life for stroke patients. Notably, IMC home rehabilitation emerged as an effective alternative that yielded outcomes comparable to IMC ward care, leading to a statistically significant improvement in patients' BI scores after a 14-week period.

References

Sirindhorn National Medical Rehabilitation Institute. Guideline for intermediate care for medical personnel according to the service plan, revised edition 2024. Nonthaburi: Sirindhorn National Medical Rehabilitation Institute, Department of Medical Services, Ministry of Public Health; 2024. 73 p. (in Thai).

Bureau of Non-Communicable Diseases, Department of Disease Control. National plan for the prevention and control of non-communicable diseases (2023-2027), Thailand. Nonthaburi: Department of Disease Control, Ministry of Public Health; 2023. 98 p. (in Thai).

Bureau of Elderly Health. Guidelines for the operation of elderly and intermediate care in the community. Nonthaburi: Department of Health, Ministry of Public Health; 2020. (in Thai)

National Health Security Office (NHSO). Intermediate care for 4 disease groups: 4 years of continuous development, expanding services outside healthcare units and into the community [press release]. Press Release, National Health Security Office; 2023. (in Thai)

National Health Security Office (NHSO). Notification of the National Health Security Office on the Reimbursement of Health Service Expenses for Intermediate Care Services [internet]. 2025. [cited 2026 May 30]. Available from: https://www.nhso.go.th/th/docman-document/nhso-payment-condition/nhso-payment-medical-services-fees-per-person/2568-2/54767-5-1/file. (in Thai)

The Active. The Director of Chulalongkorn Hospital recommended establishing a network of hospitals to restore public confidence in the quality of healthcare services provided at the primary care level. Meanwhile, the Director of Siriraj Hospital emphasized that the public needs to adopt a new mindset toward health and self-care. The Director of Rajavithi Hospital proposed rebranding Bangkok Metropolitan Administration (BMA) Public Health Centers to enhance their image and strengthen public trust in primary healthcare services [internet]. 2023 Jun 7 [cited 2026 May 30]. Available from: https://theactive.thaipbs.or.th/news/public-health-20230607. (in Thai)

Kwakkel G, Veerbeek JM, Wel BCHD, Wegen EV, Kollen BJ, Early Prediction of functional Outcome after Stroke (EPOS) Investigators. Diagnostic accuracy of the Barthel index for measuring activities of daily living outcome after ischemic hemispheric stroke: does early poststroke timing of assessment matter? Stroke 2011;42(2):342-6. doi: 10.1161/STROKEAHA.110.599035.

Laohaprasitiporn P, Jarusriwanna A, Unnanuntana A. Validity and reliability of the Thai version of the Barthel Index for elderly patients with femoral neck fracture. J Med Assoc Thai 2017;100(5):539-48.

Department of Family Medicine Ramathibodi Hospital. Working with family of the elderly. [internet]. [cited 2026 Apr 2]. Available from: https://www.rama.mahidol.ac.th/fammed/sites/default/files/public/pdf/WWFelder.pdf (in Thai)

Sonsa-ardjit N, Sakthong P. Reliability and validity of the Thai version of EQ-5D-5L questionnaire on patients with chronic disease. Chula Med J 2015;59(5):489-501.

Phattanaphesat J. Health-related quality of life questionnaire EQ-5D-5L. Continuing Pharmaceutical Education Articles 2017;1-9. (in Thai)

Saipanish R, Lotrakul M, Sumrithe S. Reliability and validity of the Thai version of the WHO-Five Well-Being Index in primary care patients. J Med Assoc Thai 2009;92(2):249-54. (in Thai)

Department of Psychiatry, Ramathibodi Hospital. WHO-Five Well-Being Index (1998 version) [internet]. [cited 2026 Apr 2]. Available from: https://www.rama.mahidol.ac.th/ramamental/sites/default/files/public/pdf/WHO-Five%20Well-Being%20Index%2C%20Thai%20version.pdf. (in Thai)

Devlin N, Parkin D, Feng Y, Janssen MF, Herdman M, van Hout B, et al. Analysis of EQ-5D values. In: Devlin N, Parkin D, Janssen MF, editors. Methods for analysing and reporting EQ-5D data. Cham: Springer; 2020. p. 61-86.

Gu H, Ren D. Prevalence and risk factors of poststroke dysphagia: a meta-analysis. Cerebrovasc Dis 2025;54:236-59.

Ghoreyshi Z, Nilipour R, Bayat N, Nejad SS, Mehrpour M, Azimi T. The incidence of aphasia, cognitive deficits, apraxia, dysarthria, and dysphagia in acute post stroke Persian speaking adults. Indian J Otolaryngol Head Neck Surg 2022;74(Suppl 3):S5685-95.

He A, Wang Z, Wu X, Sun W, Yang K, Feng W, et al. Incidence of post-stroke cognitive impairment in patients with first-ever ischemic stroke: a multicenter cross-sectional study in China. Lancet Reg Health West Pac 2023;30:100605.

Musa KI, Keegan TJ. The change of barthel index scores from the time of discharge until 3-month post-discharge among acute stroke patients in Malaysia: a random intercept model. PLoS One. 2018;13(12):e0208594. doi:10.1371/journal.pone.0208594.

Duncan PW, Bushnell C, Sissine M, Coleman S, Lutz BJ, Johnson AM, et al. Comprehensive stroke care and outcomes: time for a paradigm shift. Stroke 2021;52:385-93.

Harvey DY, Parchure S, Hamilton RH. Factors predicting long-term recovery from post-stroke aphasia. Aphasiology 2021;36(11):1-22.

Oosterveer DM, Wermer MJH, Volker G, Vlieland TPMV. Are there differences in long-term functioning and recovery between hemorrhagic and ischemic stroke patients receiving rehabilitation? J Stroke Cerebrovasc Dis 2022;31(3):106294.

Tsiakiri A, Plakias S, Vlotinou P, Terzoudi A, Serdari A, Tsiptsios D, et al. Predictive markers of post-stroke cognitive recovery and depression in ischemic stroke patients: a 6-month longitudinal study. Eur J Investig Health Psychol Educ 2024;14(12):3056-72.

Nam JS, Heo SJ, Kim YW, Lee SC, Yang SN, Yoon SY. Association between frequency of rehabilitation therapy and long-term mortality after stroke: a nationwide cohort study. Stroke 2024;55(9):2274-83.

Rroji O, Mucignat C. Factors influencing brain recovery from stroke via possible epigenetic changes. Future Sci OA 2024;10(1).

Anwer S, Waris A, Gilani SO, Iqbal J, Shaikh N, Pujari AN, et al. Rehabilitation of upper limb motor impairment in stroke: a narrative review on the prevalence, risk factors, and economic statistics of stroke and state of the art therapies. Healthcare 2022;10(2):190.

Gangwani R, Cain A, Collins A, Cassidy JM. Leveraging factors of self-efficacy and motivation to optimize stroke recovery. Front Neurol 2022;13.

Zahra AA, Imran Y. The use of NIHSS as an assessment of acute stroke severity. Journal of Society Medicine. 2024;3(2):31-4.