Community Caregiver Center CCC
Donkaew Community Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The proportion of the elderly in Thailand increased at a rapid rate during the year 1980-2000, from 6.3 percent to 9.5 percent. In addition, National Statistical Office of Thailand predicted that during the years 2010-2030, the proportion of the elderly will increase from 11.9 percent to 25 percent, or more than 2 times. Moreover, common health problems found in the elderly are chronic diseases: stroke: 1.6 percent, high blood pressure : 51.1 percent, dementia syndrome leading to dependency and disability:13.1 percent. In the economic view point, it was found that the cost of individual care was 10-29 percent of the total revenue. According to the visits in the area, the elderly were neglected at home alone. They were trapped in the house. Many of them suffered and were stressful and would like to die. Bed-ridden patients were not taken care of. They also lacked of the right to medical care and did not have Disability Smartcard. They did not get the allowance. The elderly were sent back home after hospital discharge as soon as possible to reduce costs. When they were at home, it was like they await death. Children cannot take care of them because they lacked of knowledge of care. They would rely on the health care close to their home. However, it appeared that there were only two nurses providing nursing care for all residents in Tambon Donkaew which were 15,477 people (1: 7700). The average rate set by the Ministry of Health is 1: 5000. So, the nursing personnel were not sufficient to provide care for the patients at home because there were 384 cases and 54 people were the disabled.There were 165 health volunteers in the community but they did not have knowledge and skills in caring of complicated symptoms. Moreover, there were the poor disabled who were in difficult conditions. Their body was not recovered. They did not have Orthotics, career, and income. For some families, the family members had to leave their jobs or move to work near home although the salary was less. This caused economic problems in the family which led to severe stress on both patients / people with disabilities and their family members or caregivers. If we had a better system of care, the people experiencing these problems would not have died early nor had multiple disabilities. In addition, they may not have been a burden to family and society in the long run.

B. Strategic Approach

 2. What was the solution?
The problem was solved by creating innovation which was a special care center providing care with the mechanism of the involvement of community. The community owned the center under the principle of “no one in the community is left behind”. It produced the professional volunteers with the integration of the government agencies, community organizations and the networks.

 3. How did the initiative solve the problem and improve people’s lives?
Community Caregiver Center (CCC) was set with the main objectives to increase the access of the disadvantaged to the services with equality, to change the form and the mechanism of the management system, to reduce costs and increase service quality and to establish the involvement of the public in the design, implementation and evaluation. The main target groups were the disadvantaged (the elderly, the bed-ridden patients and the disabled). According to the health management system of Thailand, the medical expenses were paid with lump sum payment per individual. As a result, the district hospitals and the provincial hospitals hurried to discharge patients into the community as quickly as possible to reduce costs regardless of the potential of the caregivers (CG) and the service units in the community. The adequacy of the service units, medicines, medical devices and medical supplies were not considered. They did not consider if it would increase the spending in the households or not. According to this problem, CCC was established. The working system of the government was reformed by using the following four strategies. Creating people having potential to work as the government officials:Health workforce was planned for establishing home health care team including,1)multidisciplinary team (doctors, nurses, pharmacists, physical therapists, psychologists, social workers and nutritionists),2)caregiver team, including volunteers who had been trained (420 hrs.) and nurse case of care manager (CM) monitoring care standards and 3)community long term care coordination CLTC coordinating among communities, SAO and hospitals in order to be able to provide care for the target groups with 100 percent. Creating a new system:It was a three-pole system which included the locality (SAO), the unit (hospital) and the community. The services were provided covering all phases steadily and continuously. It started from the family which was the smallest unit to the village and the sub-district. It focused on the groups that were dependent and abandoned. Additional service channels were added, including expressway and special expressway as well as the alternative services, such as a blood bank service, emergency services for 24 hours in order to allow the target groups to receive care equally and thoroughly. Creating networks: The space for knowledge-sharing among networks was provided. Tambon Hospital was the center for knowledge-sharing. The local government organization supported for resources,budget and personnel. For the community, volunteers provided knowledge to the networks in other sub-districts across the country. Creating revenue: Vocational training for the disadvantaged and their relatives who were jobless was administered. The selling of products was promoted through One Tumbon One Product (OTOP). The coordination with the private sector was also done to provide jobs and employment. Household economy was also created to reduce stress on the disadvantaged and their families. The coordination with the private companies for employing the disabled was also done.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Previously, health care was only the responsibility of the sub-district hospital. Later, Transferred the Public Health Center and public health mission to the Local Government Organization for better self-management, faster administration, better quality, and integrated working with the community. The prominent points of the innovation were volunteerism and community power. Service system: It aimed to work to restore the health in order to reduce reliance to everyone. It focused on primary care unit which was strong and continuous. It was set as the rehabilitation center in the community which was the state welfare. Service provider system:It had enough manpower with an appropriate proportion (1:25 people: households) . Technology system: Line and Videoconference were used to communicate among Health team as well as EMS for 24 hour emergency assistance. Access to essential medicine system: It was the center connecting to the medicine stores and doctors directly in order to consider the needs for specific drugs, especially drugs that are costly. Financial and fiscal system:There were the health insurance system and the patent system. The cost of government and individuals was reduced through fundraising and the community helped to pay for medical expenses.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
CCC innovation is the new innovative healthcare services increasing more channels of access to health services to the public, especially the disadvantaged. The groups using this innovation based about 15,477 people on the role in taking care of people in the sub-district were as follows. Donkaew Hospital: It had a role of designing courses, giving advice and controlling services according to the professional standards, coordinating with multidisciplinary team and providing caregiver training with Caregiver (CG) course of 70 hours and 420 hours of Care manager(CM) course prepared stage to listen to the opinions of all sectors for finding solutions. DonKaew Sub-district Administrative Organization that had a role in setting health care policy, guidelines for the care of the target groups and also supported the development of capacity of the caregivers. Determine management measures based on good governance, set health care policy and support for budget and be the main organization in creating engagement. Caregiver Center consisted of multidisciplinary and Caregiver: Its role was to find someone who was ready to learn to become professional volunteers. There was the program of CM provided. It also designed activities and synthesized data.
 6. How was the strategy implemented and what resources were mobilized?
The main objectives were to increase the access of the disadvantaged to the services with equality, to change the form and the mechanism of the management system, to reduce costs and increase service quality and to establish the involvement of the public in design, implementation and evaluation. There were four main target groups, including the disadvantaged (the bed-ridden elderly and the dependent disabled).Four strategies, including creating people, creating a new system, creating networks and creating revenue were employed. The experiences were used for the development in three phases. 1. The developing phase (2006-2008): The strategy of creating people was used as the base of the development. It focused on the development of quality people by searching for volunteers and community leaders who were the main driving force in the coordination of development and learning. All processes were integrated with the center of volunteering caregivers at home. They worked with the multidisciplinary team in the center of volunteering at home. They worked without getting paid. 2. The integration phrase (2009-2013):The strategy of creating a new system was employed to modify the service system in the primary care. The Public Health Center had been transferred to DonkaewSAO. The community helped with designing, joint management, seeking for equipment and health supplies. The modern technology was also used to access to information and communication. The potential development of the volunteers was done through CG course and CM course that changed their roles from practitioners to care managers. The coordination with the networks and the multidisciplinary team to prepare for care conference was also done. CCC was established with the structure of the local government organization, the public health unit and the public sector. 3. Developing professional CCC phase (2014-2017): The strategy of creating networks was used to step towards to a professional in order to plan system for searching for patients, care, refer and quality of life. All patients were taken care of as efficiently as possible under the participation of all sectors in the community. The orthotics bank was established. The disadvantaged people and their families were supported with jobs. Then it was the model of the learning center at the national level. It also provided community healthcare courses. Four guidelines; for the establishment of a rehabilitation center for the disabled and the elderly in the community, for care of the disabled, the elderly ,the children with intellectual disabilities were also created. Resources consisted of 1)Human capital was divided into two parts: “those with a direct role”, including 2 personnel of the hospital and 3 officials of the local administrative organization and “volunteers” who wanted to develop their own community such as 887 volunteers for development of the disabled and the elderly leaders. 2)Budget capital was from three sources: the grants from the Department of Local Government, the budget according to the provision of Donkaew Sub-district Administrative Organization and budget from the Health Security Fund and the budget from the contributions of the public sector. The total was 1.5 million baht. 3)Groupand organizational capital: There were 87 groups, such as public health volunteers, volunteers for development of the disabled, the elderly club, and the rehabilitation center for the disabled and elderly, the home health care center, temples and hospitals. 4)Community wisdom capital: There were 60 people. The knowledge available in the community was used in operations, such as using herbal compresses, herbal steam baths, aromatherapy, Thai massage/traditional massage and homeopathy. 5)Social capital: It consisted of 48 groups, such as career groups, children and youth groups and housewife group.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The organizations in the community did not work together, so there was a problem with the services provided to the targets as they were redundant and some were not taken care. As a result, people cannot access to care services. After that, the three sectors started to corporately design the operation with the same goal that was building a community of “no one in the community is left behind”. Everyone must be given with the opportunity to receive care and access to the services equally. Their roles were as follows. Volunteers: Their roles were to survey the area, collect data, design activities and raise funds for the collaboration. External government agencies: These included Boromarajonani College of Nursing, Provincial Hospital, Institute of Child Development and Prostheses Foundation. They played an important role in supporting the academic information for decision on problem solving approaches, designing activities for the development of community caregivers and sending community care personnel to join the activities. Private organizations: They helped develop the group of children with cognitive development problems, promote careers for the disabled and inform alworkers and provide financial support and academic knowledge. These organizations consisted of the Healing Family Foundation, PH-JAPAN, JILAF, Thai health Promotion Foundation and P.M FOOD CO.LTD Groups of public health volunteers, volunteers for development of the disabled, the elderly club, the disabled and the elderly rehabilitation center, the health center, temples, and hospitals: They played an important role in offering solutions by focusing on the integration of collaboration in the area. In addition, the community leaders had an important role in providing information and facilitating when the team worked in the area.

 8. What were the most successful outputs and why was the initiative effective?
1.Getting CCC model which was from the four sectors, including volunteers, people, local government organization and hospitals with strengthening for sustainable development: It also enhanced and benefited the health care service of all age groups. Everyone can access to the services 100 percent and no one was abandoned. 2. Having 112 professional volunteers providing care to 100 percent of the target groups: 77 of them passed a-420 hour course. There were 10 CMs. They can provide care for all patients. The supporting teams were 25 relatives of the patients (1 relative person per 1 patient) who had been developed with the knowledge to promote the well-being of all citizens in the area. 3. Accessing to health services from CCC quickly with quality, and fairness according to the principles of human rights: 100 percent of the disadvantaged were provided with care. There were 384 disadvantaged people. In addition, 323 people did not have to rely on others while 50 of them can partly take care of themselves and the symptoms of 11 people remained the same. No one had suicidal thoughts. Previously, 25 people had suicidal thoughts. The family expense, which was paid for caregivers, travel expenses for medical equipment and orthotics, was reduced as of 7,000 bath: 1 month (the average monthly income per household was 15,000 baht which was than the average income of the country as of 10-29 percent.). 4.Having the curriculum and guidelines for health management system by the community: There were networks of knowledge sharing in 110 sub-districts with 3,500 people nationwide.Also, 4 guidelines providing knowledge to people, including the guidelines for care of the elderly, the guidelines for the establishment of a rehabilitation center, the guidelines for care of the disabled and for the disabled and the guidelines for care of children with intellectual disabilities were made to strengthen and build the power of a collaborative partnership . 5. Having 3 volunteering funds to help the disadvantaged from fund raising and donations and grants from local administration organization with the proportion of 50:50, including 1)The Fund was the non-profit fund helping the disadvantaged, and did not meddle in politics:150,000 baht, 2) 3 Poles Sub-district Welfare Fund (the government + the local community + the people) which supported the welfare, careers and orthotics support: 300,000 baht 3) The Fund which promoted rehabilitation: 1,000,000 baht.

 9. What were the main obstacles encountered and how were they overcome?
1. Refusing to use the service from CG because they did not believe in the potential of CG.This was solved by establishing multidisciplinary team to work in the CCC in order to establish standards and recognition. The events and the stage for understanding the work of the CCC were provided to the citizens in order to allow them. 2. The poor patients did not access to the rights. This problem was solved by establishing the volunteer fund for helping the disadvantaged. Fund raising and donations from the community were done by using the mechanism of multidisciplinary team-based care according to the human rights. 3. Many patients did not have orthotics for physical therapy. It was solved by establishing orthotic sand supply bank. It was established from the involvement of the partners in the sub-district and outside the sub-district such as air, the crutches and oxygen tanks. There were 12 types with 96 pieces of orthotics and supplies. 4.Patients and relatives were stressful and did not cooperate with a team of volunteers. These problems were solved by using stress assessment and providing the counseling on mental health by psychologists and planning for care to relive stress. 5.Patients’ relatives lacked of skills and knowledge of care. It was resolved by providing patient care training by the mentors from CG to practice skills and provide knowledge and establish planning and guidelines for emergency care together with the patients in the family. 6.The patients' relatives were worried about the cost of treatment. It was solved by cooperating in making care planning, creating opportunities, promoting career at home. The patients' relatives can spend the rest of time from taking care of patients to make money to relieve their worry about the medical bills.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Reducing time and procedure of treatment: Previously, moving patients was difficult and it took at least 6-8 hours every 1-2 months to wait for service at the provincial hospital. After CCC had been established in the community, it allowed people not to spend time much time traveling and waiting for services. The services were provided at home and there was fast channel for referring patients. Reducing severe illness with complications in patients: With CP services, patients could receive constant care. In case of patients with severe symptoms, the team can consult online with the specialist physicians or the patients can sent to get treatment by EMS. Reducing stress, anxiety, stress: Patient’stress was assessed with 2 Q (2 Question) by psychologists. It was the result of the services based on family medicine covering physical, mental, social and environmental dimensions. People felt that they can rely on someone and access to advisory services at any time. Reducing expenses and increasing revenue: It can reduce the family expenses for hiring caregivers, medical supplies and necessary orthotics as well as the loss of revenue of the relatives who had to quit job at least 7000 baht / month. Increasing revenue was done by promoting careers for the disabled and the patients’ relatives. Increasing the access to comprehensive services:The survey conducted by the volunteers revealed that no one was left behind. All of them had the right to health security to access to the service with equality and justice by the volunteer system. The caregivers, CG multidisciplinary team and the community leaders approached to the patients with the proactive home health services. The individual care plan was administered by the multidisciplinary team in order to allow the patients to receive appropriate care for individual. The disadvantaged can access to essential public services. There were social services, orthotics and medical supplies bank providing thoroughly and sufficiently. Patients had been promoted with health, physical rehabilitation and development of wellbeing in four dimensions (physical, mental, social, intellectual dimensions) so that they can be employed and they can earn for themselves and their families.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
CCC innovation was transparent and it created participation in the operation. It gave the opportunity for people to work as the working team at CCC. The people can join the operation in the design process, implementation and evaluation. The proportion of the people working in the team was one in three of the committee of the center. The management of the volunteer fund to help the disadvantaged was the operation of three sectors: the public sector,the government sector and the network sector. It aimed to help the disadvantaged in the sub-district resulting in a participatory and monitoring process of the work through the Open System which created transparency in monitoring and accessing to information in all channels, especially technology, Internet and Website. People can access to the health services quickly and conveniently by reducing the complexity of the services and everyone can receive the services equally. Proactive delivery services to the home were also provided. This helped improve the responsibility of the government in providing the community an opportunity to evaluate the performance and establish equality.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The good health system should recognize the value and the dignity of humanity of everyone. It should adhere to the ethics and morality in action for the benefits of all groups of people. CCC had mechanisms in taking care of children and women which focused on equality in service without discrimination. Special channels for women and children were created such as having counseling center for children and women at Donkaew Sub-district. The counseling service was also provided via Hotline and Line of CCC. There were the surveillance system and the transfer system of children and women at risk of violence.There was the multidisciplinary team with expertise on women and children. Two of them had a professional license of Child Protection Act, B.E. 2546 and Domestic Violence Victim Protection Act, B.E. 2550. There were creation of jobs and career promotion for children and women with disabilities. There was the cooperation with private companies to employ 10 children and women with disabilities.The loans fund for career promotion was also administered to create revenue for children and women with disabilities.

Contact Information

Institution Name:   Donkaew Community Hospital
Institution Type:   Local Government  
Contact Person:   Dr.Sutta Praesi
Title:   Director of Donkaew Community Hospital  
Telephone/ Fax:   +6653121573
Institution's / Project's Website:  
E-mail:   sutta.ps@gmail.com  
Address:   53/3 Donkaew District
Postal Code:   50180
City:   Maerim
State/Province:   Chiangmai
Country:  

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