Continuity of Care for Postoperative Patients Across Hospital and Community Settings in Thailand: A Qualitative Study

Background: Postoperative recovery following major surgery in neurosurgery, orthopedic surgery, and abdominal surgery significantly impacts the quality of life of both patients and caregivers. In Thailand, although various strategies including referral systems, postoperative care plans, home follow-up, and patient and caregiver education have been developed to support recovery and ensure continuity of care from hospital to home, challenges remain, particularly in community health service models, access to care, and the provision of welfare and benefits.Purpose: This research aimed to explore the continuity of care for postoperative patients in hospitals and community healthcare services in Thailand.Methods: This qualitative study using an ethnographic approach involved 86 informants, including 57 key informants consisting of postoperative patients (n = 7), caregivers (n = 8), healthcare providers (n = 35), and executives of relevant agencies (n = 7), and 29 general informants who contributed additional perspectives. Data were collected from April 2023 to March 2024 in southern Thailand. Participants were recruited using non-probability sampling methods, including purposive sampling followed by snowball sampling. Qualitative data were collected using participant observation, in-depth interviews, focus group discussions, field notes, and document analysis. Data were validated through triangulation and analyzed using Creswell’s thematic analysis approach.Results: Continuity of care for postoperative patients was organized into three themes: (1) organization of healthcare services, describing coordinated hospital and community systems that support rehabilitation, referral processes, discharge planning, home visits, long-term care, and emergency support; (2) support for postoperative patients, highlighting integrated mechanisms such as capacity building for patients and caregivers, shared information systems, and welfare, social, and financial assistance after discharge; and (3) management and coordination, which enabled community-based postoperative care through integrated data systems and shared governance arrangements.Conclusion: Continuity of postoperative care in Thailand is facilitated by the integration of hospital and community services, caregiver support, and coordinated management systems. Nurses play a central role in ensuring follow-up, information sharing, and patient support across care settings. Strengthening organizational integration, support mechanisms, and coordination processes can enhance continuity of care and address gaps identified in current postoperative services.