Questions/Answers

Lamsonthi is located on the border of central and northeastern Thailand with Punghey and Khaoruak mountains in-between. The terrain is rugged and hilly. The district is 264 km with 1 day travel time from Bangkok. Among the population of 26,287, there are 343 with dependencies, elderly and people with disabilities. These groups of people suffer from fecal incontinence, urinary incontinence, bed-sores, starvation, poor diet, insufficient food, poverty, and were left with children. Their children go out to work, earn money to support the family. They need support to do their daily activities, but it is not easy to get to hospital because of the high cost it incurs. Dr. Santi Lapbenjakul, Director of Lamsonthi Hospital, was aware of his social responsibility, and so he has designed and initiated a long-term care system by using the family as a base and home as a point for delivery of care for the elderly and disabled under the concept of ‘No One Left Behind’. The integration of care from 1) Healthcare team and 2) Social care team has been evolved continuously for 10 years. The results of the initiative show no one is left behind. Today, the Lamsonthi model is an administrative innovation in community health management with simple, high achievement and low costs with only one-third of hospital costs. Since 2015, the Ministry of Public Health of Thailand has used the model as a long-term health care service policy for dependent elderly people. Hospitals all over the country are using the model with support from local governmental organizations, the National Health Security Office, and the Government. It is an international model that can be applied to countries with limited resources.

This work is a health care system that suits the single-family lifestyle of the modern age with the following purposes: 1) Improve the quality of life of dependents in Lamsonthi hospital for better health. 2) Adjust the primary care network model. 3) Engage all stakeholders in the network and people in the community. Strategy to drive 1.Use the community as a base and home of those who depend for work. Holistic Health Care by 3BBB Model: 1) Brain 2) Bone and 3) Body. The body enhances telemedicine, increase communication channels through web application groups and personal LINE. Adjust JHOS and JHCIS to HIS for real-time care and management with a single database for the whole network. 2.Create a multi-professional and community care teams by selection from the village health volunteers, siblings, relatives and community volunteers and train for social care to accomplish skills needed before go to work. 3.Create a collaborative network with local authorities, the community is accepted by all sectors with more flexibility.

Lamsonthi Model: Long-term care system for the under-privileged and dependent groups of people to help solve the problems of neglected people, reduce family expenses, and reduce disparity in access to health services among rural, urban and remote populations. Increasing access to proactive health services to home-based lifestyles, Lamsonthi Model has a unique identity with care for the underprivileged and dependent of all age groups from birth to sedentary. The cooperation between all parties in the network by the director of the hospital is to present the problems and raise awareness of the responsibility and problem solving of the public health organizations, the sub-committees and the people in the community in good governance. Under the concept of the underprivileged and those who depend on everyone in the community, care must be taken with equal quality. Life with human dignity, regardless of race, social or financial status is a basic human right.

Contribute to the 2030 Sustainable Development Goals to promote good health of the population. Improve public sector services by: 1.Health service provision by health centers, health promoting hospitals, community health teams in Lamsonthi district. The collaboration occurs in the same direction. Reduce duplication and provide solutions that meet the needs of the area. The underprivileged and the dependent on the center of the services. 2.Use technology for home visits. Increase communication channels between the underprivileged and those with dependencies/relatives with the health care and social care team. Solve problems and emergency conditions such as Telemedicine, Skype, group Line, personal Line. 3.Sharing resources between public health agencies, community organizations, facilitating common problem solving. Can mobilize resources from other sectors. 4.Create sustainability by adjusting the role of the government agency from Key Actor to Facilitator, allowing local communities to self-manage their health by the people in the community, creation of ownership and commitment. Take responsibility and expand cooperation to other sectors to collaborate as partnerships.

Lamsonthi Model: Long-term care system for under-privileged and dependent groups of people is the best practice from the design of "long-term care" developed from the concept ‘No One Left Behind’. Using the International Association for Public Participation (IAP2), from participant engagement principle with social care team and holistic approach and integrate care with care managers to supervise caregivers with the following steps: 1.Long-term care registration. Notification through hospital and the community. 2.Planning and coordination by health sector, district level, patient assessment, planning, individual long term care program, health sector and social sector. 3.Service and process by Health Sector. Follow the plan and follow the Family medicine guidelines. If there is a problem during care, the case owner will coordinate with the care manager to solve the problem. 4.Meeting and analysis by care manager with meetings, follow up, work progress, analyze data and report LTC 1 time per week.

Results reveal the community has accepted with harmony. Raising awareness of all sectors of society to care for the underprivileged and the dependent from family to the community, district to province and nationally. Since 2006, the Thai Government focused on appropriate care for dependency groups of people and allocated a 600 million Baht budget to NHSO for health promotion and disease prevention, and rehabilitation as benefit packages. The Ministry of Public Health, the NHSO and the Tambon Administrative Organizations (TAOs) jointly undertake with target of 100,000 elderly people in 1,000 tambons (sub-district) in all provinces, including Bangkok. The Ministry of Public Health has a role of preparation for long term care (LTC) by providing family care team (FCT) to assess Barthel’s Activity Daily Living Index, development of individual Care Plan, provide services according to the benefit packages, and evaluate the results with local government organizations in the country.

Lamsonthi Model: Long-term care system for under-privileged and dependent groups of people is a policy innovation for long-term care in Thailand to provide services to the underprivileged and dependency of all age groups. The Model is run under the concept of IAP2 participation and is divided into two parts: 1) public health sector and 2) social sector. It is not complicated, uses local resources and is low cost, with evident results. There are many countries from Europe, America, Asia and Japan that have visited and applied to their country contexts. The Ministry of Public Health of Thailand has adopted the model in all 77 provinces of Thailand. Later, the Ministry of Public Health has included the model in the 20-year National Strategic Plan on Public Health (2017-2036) within the Prevention & Protection Excellence Strategy and the Service Excellence Strategy to drive to the goal "Healthy People, Happy Staff and Sustainable Health System" under the mission of developing and governing a participatory and sustainable health system

It is an original innovation developed from real-life situations in Lamsonthi district with continuous quality improvement (CQI) using PDCA/PDSA cycle to ensure that the disadvantaged and their dependents have an improved quality of life. Safety & Quality of Patient Care guidelines are used to review home-based health services in accordance with hospital accreditation (HA) standards. Meetings are held by both health sector and social sector. A summary report is sent to LTC President on a weekly basis. IAP2 principle has been implemented to provide opportunities for community organizations, people in private sectors, foundations, and educational institutions to participate as Network/Joint Committee/Public Advisory and Strategic Partners. Proof of empirical innovation: Outstanding Rural Doctor Award 2011, The 7th Khon Kon Khon Award 2009 for Inspiration branch, AAAH Award 2016 for Long Term Care in Colombo, Sri Lanka, and a study visit to attendees of "Prince Mahidol Award Conference 2012 and 2015"

1. Financial: NHSO supports the budget through the district fund for 45 baht/person., every sub-district allocates 10% of public health budget for home visits in the community, Premier Group Company, Khon Thai Foundation (BKIND), Yuvabadhana Foundation and academic institutions donated money through fund raising to support the cost of materials for home improvement. The Trirat Uppathumbhothiwatana Foundation runs ‘1 to 5 Piano’ project as a special children’s program. 2. Human Resources: Lamsonthi Hospital and health promoting hospitals allocate multidisciplinary staff as a health care team. Other volunteer teams, community leaders, villagers, religious leaders, students, etc. 3. Materials and medical equipment: Other hospitals and primary care units (PCUs) support materials, pharmaceuticals, medical supplies for patients such as infusion pumps, automatic vital sign monitors, suction machines, oxygen concentrators, carts, beds, medical air mattresses, blenders, blood pressure monitors, etc.

Yes

By 2015, the Government has allocated more than 20 million Baht of the budget to the Department of Health to develop Care Managers and Care Givers in eight provinces of Health Region 4 in accordance with the policy of the Ministry of Public Health to accelerate the healthcare system for the elderly, dependents and end-of-life care. The target provinces include Bangsithong Mueang Municipality Nonthaburi, Rangsit Nakhon Municipality Pathumthani, Tharea District Ayutthaya, Wisetchaichan District Angthong, Wihandaeng, Nongdone, Muaklek Districts Saraburi, Thawoong and Lamsonthi Districts Lopburi, Pakphi District Nakhonnayok and Thachang District Singburi Province. Since 2016, the Lopburi Governor has taken the model as a prototype for all districts as "Lopburi Model" to operate within 1 year under the slogan "No One Left Behind". In 2016, the Ministry of Public Health launched the LTC policy for the elderly with dependencies as the national health security system by integrating with PCC team and was driven through the District Health Service (DHS). The model has now been applied nationwide.

Social dimension: For 10 years the problem has become a community culture of Lamsonthi to use the family as a base and home as a care delivery. The ‘No One Left Behind’ fund has expanded to the Lopburi Model under the strategy "strengthening sub-district organizations by working as a district network" under the concept of "Harmonic Concept" to improve the quality of life and health of all age groups in the province. Nowadays, the policy is titled ‘No Thai Left Behind’, using the local area as a base with people at the center of services. The Ministry of Public Health announced the policy to drive the development of quality of life in the area close to the people, namely the "District". Economy Dimension: there are revenue producing activities for every sub district in Lamsonthi and the District Governor initially supported the budget as per diems, sundries and fuel for 10 community-based caregivers. There are now 25 caregivers for 4,000–6,000 Baht per month. One caregiver is allocated per 4 patients (1-2 bed-ridden patients/day, 6-7 non-intensive care patients/day). Environmental dimension: Volunteer agencies gain resource mobilization for care and help with physical therapists, technicians, hospital car drivers, community hospitals to renovation of bathrooms, ramps, railings and installing shower faucets including building new homes. All of which contribute to a significant improvement of long-term health care. Bua Chum Lopburi Industrial College helps produce tricycles and production of physical beds for the disabled.

For 10 years, the community of Lamsonthi took care of people in the community until it became a culture of Thai society. In 2006, using its initial name, the "Care Team for the Handicapped and the Underprivileged", consisted of one hospital director, one nurse, and one physical therapist providing home visits for nursing care and rehabilitation. Between 2007 and 2010, the Health Care Team was established and provided multidisciplinary services and worked as a Care Manager for health. This stage registered more dependent groups such as breakfast project and ‘1 to 5 Piano’ for special children and increased the numbers of psychiatric nurses for psychiatric patients. Between 2011 and 2012 there were lesson learned that health care services were not enough and a social care team had been established. Tambon Administrative Organization (TAO) had been invited. Participation had 3 levels 1) District 2) Tambon or sub-district and 3) Family. Many committees had been named with District Governor as the president to align all bodies to work in the same direction. In 2013 the integration involved 4 Levels 1) District Long-Term Care Committee (LTC) 2) District Long-Term Care Coordination Team (LTCc) 3) Sub-district Working Group 4) Family level. Tambon team had been established (CLT) and coordinated through LTCc. From 2015 to the present, there are important social phenomenons from Lamsonthi to transform all areas of Thailand. Lopburi Province has expanded the Lamsonthi Model to the Lopburi Model. The Ministry of Public Health purposed a committee for District Health Board (DHB) to the Cabinet and resolution of October 3, 2017 approved the draft regulation of the Prime Minister. The goal is to increase the quality of life, reduce disability, elderly people with disabilities, child poverty, chronic non-communicable diseases, city life environmental issues, garbage management and chronic diseases.

Yes

The work has been evaluated by the Thai Health Insurance Research Office (HISRO), the Health Systems Research Institute (HSRI) on the Integration of Long Term Care Services, the "Lamsonthi Model" - Concept, Principles, Processes, and Impact of integrated long term care system between 2013 and 2014 and is based on the Barthel ADL index. The score was 0-2 points and the full 20 points. Results reveal: Group 1 social-restriction group (Mild) can be self-reliant, can help other people, the community and society and have ADL scores of 12 or more. Group 2: House-restriction group (Moderate) can take care of themselves. ADL scores are in the range of 5-11 points. Group 3 bed-ridden group (Severe) cannot be self-reliant or disabled. ADL scores range from 0 to 4 points. In addition, the work was evaluated by an external audit committee from the Office of the Public Sector Development Commission (OPDC) and won the National Public Service Award of Excellence in the year 2017 for development of excellent services.

By comparing the data between 2013-2014, the patients in the long-term care system, the underprivileged and the dependent are classified into 3 groups. 1) Severe group. In 2013, 3 patients declined, 63 patients remained the same and 34 patients improved. After care in 2014, results have improved. Decline was reduced to 0, same reduced to 11, and improvement increased to 83. 2) Moderate group. In 2013, 31 patients declined, 47 patients remained the same, 22 patients improved. After care in 2014, results have improved. Decline was reduced to 18, same reduced to 55, and improvement increased to 27. 3) Mild group. In 2013, 39 patients declined, 59 patients remained the same, 2 patients improved. After care in 2014, results have improved. Decline was reduced to 20, same reduced to 60, and improvement increased to 20. In summary, care for patients entering long-term care systems, the underprivileged and those with dependency can recover to live closer to a normal life and delayed death of home-restriction and bed-ridden patients.

1) The average life expectancy at birth (LE) of the Lamsonthi population in 2010 was 74.42 years and in 2014 was 76.44 – an increase of 2.02 years. 2) The average healthy life expectancy (HALE) of a 60-year-old man in 2010 was 22.12 years and 25.77 years in 2014. 3) Satisfaction of dependents who received home visits in 2014-2016 showed that the percentage of satisfaction of elderly in the home was 82.25, 82.66, and 87.40, for people with disabilities was 86.4%, 88%, and 90%, and for end-stage 90%, 92.86%, and 93%. 4) The expenses for home care is US$ 5 per day - $10 per day less than hospital-based care (hospital costs US$ 15 per day). 5) The target group received 100% home health services (343 persons). 6) Percentage of elderly people that received care from family, community, and public sector between 2015-2017 were 99.99%, 99.99%, 99.89%. 7) Percentage of people with disabilities receiving care from family, community, and public sector between 2015-2017 were 99.84%, 99.90%, 99.94%.

Lamsonthi Model: A long-term care system for under-privileged and dependent groups of people created a mechanism of participation by two main teams: 1) Health sector. Doctors, dentists, nurses, pharmacists, physiotherapists, occupational therapists, psychologists, nutritionists, care managers, and care givers to provide health care, receiving and assessing patients before entering long-term care. Care include nursing care, blood pressure monitors, wound care, catheter care, pharmaceuticals and medical care, providing physical therapy, nutritional care, and follow-up and monitoring care givers. 2) Social Sector. - Tambon Administrative Organization supports the cost of visiting the Care Giver's home and supports home improvement resources. Other necessary resources include: - Caregiver acts as a family doctor, caring for social care, home care, sleep, body care, clothing, food, water, care, and bathroom assistance. Environmentally friendly advisory services to each sector. - Voluntary organizations to raise funds to support resources. The cost of providing care to technicians and drivers of the hospital helps rescue the body with the equipment. Community renovation of bathrooms, ramps, railings, installation of shower railings and faucets created a new home that is conducive to long-term health care by preventing accidents and complications. Producing tricycles and specialized beds for the disabled also helped patients. Meeting and Analysis Care managers are responsible for meetings and supervising the process of conducting the improvement analysis and the disseminating the results of the operations report to the Board of Directors (LTC) every week.

Lamsonthi Model: A long-term care system for the under-privileged and dependent groups of people is a prototype of an innovative model that is not complicated and which involves the participation of all sectors in the area. By using resources within the local area, costs are slightly decreased by cost analysis. This model can be expanded to other areas of Thailand. Appreciation and engagement: Inviting every TAO to take part as lectures and act as a contributor to the concrete results. Let TAO be proud of their work and support for their own people and passion to improve performance. Essential Care: The result of using the District Health System mechanism is to build trust between the Health Care Team and the Social Care Team. The government should select issues that all people in the community agree on beforehand with the power to drive other development work. At present, the center (in statute care) has created a long-term care center for the elderly and the disabled by fund-raising rallies from volunteers.