The Need for Discharge Planning in the Continuity of Care among Stroke Patients in a Rural Area of Thailand: A Qualitative Study

Continuity of care for stroke patients in rural areas is critical, as its absence is a major source of disruption and ineffectiveness in post-discharge support. This study aimed to explore the needs for discharge planning of stakeholders to inform a context sensitive continuity of care for stroke patients in rural Thailand. A qualitative descriptive study was conducted in Nang Rong District, Buriram, involving 20 purposively selected participants, including healthcare professionals and community stakeholders such as Village Health Volunteers (VHVs) and caregivers. Documentary research and secondary data from hospital records (2022-2024) were also analyzed to triangulate findings. Analysis of hospital records revealed 170 stroke cases and 545 survivors living with residual disabilities in the community database, highlighting a high demand for long term support. Qualitative findings identified four critical prerequisites for improving care: structured discharge planning, clearly defined interdisciplinary roles, efficient data transfer systems, and planned community home visits. Stakeholders emphasized that current care is fragmented, with caregivers often lacking necessary technical skills despite hospital training. To bridge the gap in rural stroke care, a model coordinated by community nurses is vital. By establishing structured pathways and seamless data sharing, healthcare providers can better support recovery and reduce long term disability, transitioning from hospital centric to a participatory community based care model.