8

24 2555

(.)



(.)

(.)

. . . 13170
02-4419040-3 15-18
02-4410163
Website: www.aihd.mahidol.ac.th,
www.thaiichr.org

(.)



(.)

(.)

. . . 13170
02-4419040-3 15-18
02-4410163
Website: www.aihd.mahidol.ac.th,
www.thaiichr.org

. .



.
(..)

.


.
(..)

.

.



(. - )

(.) (..)
..
| 

. .



.
(..)

.


.
(..)

.

.



(. - )

(.) (..)
..
| 



(.)



.
(..)

. .

 |

1) 2) 3)


1)
Activate 2)
3)

Appreciative approach (
)
..



(..)

| 



(.)



.
(..)

. .

 |

1) 2) 3)


1)
Activate 2)
3)

Appreciative approach (
)
..



(..)

| 





20-30

2
1


2











-

(..) .

 |

| 





20-30

2
1


2











-

(..) .

 |

| 

 1 :


.

(..)

20

1 4

4

1

10 |

(Population
structure) ..1990 (..2533)



..2020 (..
2563)



(Estimates of Elderly Population) 60
..2010 (..2553) 11.5
| 11

 1 :


.

(..)

20

1 4

4

1

10 |

(Population
structure) ..1990 (..2533)



..2020 (..
2563)



(Estimates of Elderly Population) 60
..2010 (..2553) 11.5
| 11

 7 ..2020 (..2563)
8 15 20
1 4
4 1


2552
68.5

75
20 80




(Projection)
2539-2540
60 4-6
2545 2550 65 80 (
2 ) 2545
8-12 ( 65 ) 5-6 ( 80 ) 2550

6-10 ( 65 )
5-6 ( 80 )

12 |

2547-2567

2552 2567

20




2550
100
15.3
9.7 17.5
2




60
80
(Social
Support) (Health Care Service)
(Acute illness)
(Disable) (Death)
(Hospital) (Home) (Hospice)
| 13

 7 ..2020 (..2563)
8 15 20
1 4
4 1


2552
68.5

75
20 80




(Projection)
2539-2540
60 4-6
2545 2550 65 80 (
2 ) 2545
8-12 ( 65 ) 5-6 ( 80 ) 2550

6-10 ( 65 )
5-6 ( 80 )

12 |

2547-2567

2552 2567

20




2550
100
15.3
9.7 17.5
2




60
80
(Social
Support) (Health Care Service)
(Acute illness)
(Disable) (Death)
(Hospital) (Home) (Hospice)
| 13


(Housing)
(Home Adaptation)
(Money Saving/Income)
20
(Knowledge) (Attitude)
(Activity for Health)
(Concern)

.

30-40


3

1



2



(Interaction)




3

14 |

3




...








/


3

1)

28,000

| 15


(Housing)
(Home Adaptation)
(Money Saving/Income)
20
(Knowledge) (Attitude)
(Activity for Health)
(Concern)

.

30-40


3

1



2



(Interaction)




3

14 |

3




...








/


3

1)

28,000

| 15

2) 2



80
5-10

16 |

3)











(

..2554)

60
10
70

| 17

2) 2



80
5-10

16 |

3)











(

..2554)

60
10
70

| 17



2552
/
3
(.)



:
/
- /
- /
-//
// 1A4C -
-
-
-

- /


- /
//
- / /

-


-
-

-

: 2552

18 |

| 19



2552
/
3
(.)



:
/
- /
- /
-//
// 1A4C -
-
-
-

- /


- /
//
- / /

-


-
-

-

: 2552

18 |

| 19

 2 :

(1)

20 |

(Long-term care)



7 73 .. 10
53,000 14.24 (7,665 )

7 180





3 1


75.54 (5,790 ) 2
21.12 (1,619 ) 3
3.34 (256 )
| 21

 2 :

(1)

20 |

(Long-term care)



7 73 .. 10
53,000 14.24 (7,665 )

7 180





3 1


75.54 (5,790 ) 2
21.12 (1,619 ) 3
3.34 (256 )
| 21



.

2552

-

1) 2)
3)
4)

22 |

Home Health Care (HHC)
HHC



HHC
..

/




..

| 23



.

2552

-

1) 2)
3)
4)

22 |

Home Health Care (HHC)
HHC



HHC
..

/




..

| 23




UNFPA
(United Nations Population Fund -
)
(.)

-
(Ambulatory care) (Acute care)
(Intermediate care) (Long-term care)

- (Ambulatory care)

- (Ambulatory care)
..
Geriatric Syndrome 1

HHC (Refer) F/U
(Follow Up) (Fast Tract)
80

(Geriatric Syndrome)

(http://www.
si.mahidol.ac.th/sidoctor/e-pl/articledetail.asp?id=799)

24 |

| 25




UNFPA
(United Nations Population Fund -
)
(.)

-
(Ambulatory care) (Acute care)
(Intermediate care) (Long-term care)

- (Ambulatory care)

- (Ambulatory care)
..
Geriatric Syndrome 1

HHC (Refer) F/U
(Follow Up) (Fast Tract)
80

(Geriatric Syndrome)

(http://www.
si.mahidol.ac.th/sidoctor/e-pl/articledetail.asp?id=799)

24 |

| 25










.


One stop service (
)

HHC

..

..

(Acute care)

26 |

(Discharge - )

(Discharge plan)

HHC





(ADL: Activities of Daily
Living) ADL
, (Bedsore), (Delirium),
, (Nutrition),
/ (Polypharmacy)







| 27










.


One stop service (
)

HHC

..

..

(Acute care)

26 |

(Discharge - )

(Discharge plan)

HHC





(ADL: Activities of Daily
Living) ADL
, (Bedsore), (Delirium),
, (Nutrition),
/ (Polypharmacy)







| 27

 1 3

(, , )

20
D-METHOD 2 20



2

D-METHOD M (Medication)

/ E (Environment & Economic)


/ T
(Treatment)
/
/ H
(Health)

/ O
(Outpatient Referral)

/ D (Diet)

(http://www.sk-hospital.com/HA/lesson2.htm)

28 |

(Intermediate Care)

(Intermediate Care)

HHC

HHC

HHC







| 29

 1 3

(, , )

20
D-METHOD 2 20



2

D-METHOD M (Medication)

/ E (Environment & Economic)


/ T
(Treatment)
/
/ H
(Health)

/ O
(Outpatient Referral)

/ D (Diet)

(http://www.sk-hospital.com/HA/lesson2.htm)

28 |

(Intermediate Care)

(Intermediate Care)

HHC

HHC

HHC







| 29

 80 ADL 50

(CVA:
Cerebrovascular accident, Paralysis or Hemiplegia)

(Admit)

(.)
(.)

. .



..



--

..



(Insulin)
30 |

(HHC:
Home Health Care)





..

HHC (Case)

HHC


CUP (Contracting
Unit for Primary Care)

| 31

 80 ADL 50

(CVA:
Cerebrovascular accident, Paralysis or Hemiplegia)

(Admit)

(.)
(.)

. .



..



--

..



(Insulin)
30 |

(HHC:
Home Health Care)





..

HHC (Case)

HHC


CUP (Contracting
Unit for Primary Care)

| 31

 ..




HHC
. . ..






..




HHC
(HHC Center) HHC ..

-
32 |

(Long-term care)

(Long-term care)








2





| 33

 ..




HHC
. . ..






..




HHC
(HHC Center) HHC ..

-
32 |

(Long-term care)

(Long-term care)








2





| 33

HHC

..

34 |

2





3
3
1
2 3






..







| 35

HHC

..

34 |

2





3
3
1
2 3






..







| 35

-









.

36 |

2 :

(2)

..



..
.. .

..


10


-
(Order)
| 37

-









.

36 |

2 :

(2)

..



..
.. .

..


10


-
(Order)
| 37

38 |

..






3 /


/ .


(.)

.


(Activity Daily
Livings: ADL)

| 39

38 |

..






3 /


/ .


(.)

.


(Activity Daily
Livings: ADL)

| 39


. .


/

..







3





2

40 |

4 1)

2)
3)
4) /

.. 1)

2)

3) ..
(Teamwork)
10



4)

| 41


. .


/

..







3





2

40 |

4 1)

2)
3)
4) /

.. 1)

2)

3) ..
(Teamwork)
10



4)

| 41

 1669 EMS (Emergency

Medical Services) 5)
..


..
PCU (Primary Care
Unit)
(Home Ward)
(Home Visit) (HHC: Home Health
Care)
..

..
70



(Data Center)
(Point to Point - 2
1 )


..
1)

24 .

2)
42 |

4 1


3) 4)

..
(Case)

73 5
2 2

22
..

.




| 43

 1669 EMS (Emergency

Medical Services) 5)
..


..
PCU (Primary Care
Unit)
(Home Ward)
(Home Visit) (HHC: Home Health
Care)
..

..
70



(Data Center)
(Point to Point - 2
1 )


..
1)

24 .

2)
42 |

4 1


3) 4)

..
(Case)

73 5
2 2

22
..

.




| 43

1


943 11.80 .
69 .

.

.

1
827 87.7 2
82 8.7 3
34 3.61
-


1
(Health Promotion)




2


.

3

44 |

. .

.

..


.




2

..









.

3



| 45

1


943 11.80 .
69 .

.

.

1
827 87.7 2
82 8.7 3
34 3.61
-


1
(Health Promotion)




2


.

3

44 |

. .

.

..


.




2

..









.

3



| 45

 50-59







4 /

..

46 |

75
..




..
.

.








70



4-5 .

| 47

 50-59







4 /

..

46 |

75
..




..
.

.








70



4-5 .

| 47



80

..
1 - 1.30

1
.. 1 . 2 4-5


-




..
4
---

..

48 |

..
2-3 10



3
2 5
3 1
..

| 49



80

..
1 - 1.30

1
.. 1 . 2 4-5


-




..
4
---

..

48 |

..
2-3 10



3
2 5
3 1
..

| 49

 2 :

(3)

3
/

50 |

(.) ..

5,000 3,000
900 1 3


.. . .. .
. . /

| 51

 2 :

(3)

3
/

50 |

(.) ..

5,000 3,000
900 1 3


.. . .. .
. . /

| 51



6 1)
2)

3)

4)
5) 6)
35










/

/

52 |

( )



(Integration)

()

( ,

)

| 53



6 1)
2)

3)

4)
5) 6)
35










/

/

52 |

( )



(Integration)

()

( ,

)

| 53

..

..

. +

.
.

(
)

, ,
, .
.

(Model)

(Model)


..
/


()

54 |

( )



( )
()



..

.




()







6
2

(.)
| 55

..

..

. +

.
.

(
)

, ,
, .
.

(Model)

(Model)


..
/


()

54 |

( )



( )
()



..

.




()







6
2

(.)
| 55

-
..

56 |

| 57

-
..

56 |

| 57

..

.
3

(http://doctor.or.th/node/
5859)
58 |

| 59

..

.
3

(http://doctor.or.th/node/
5859)
58 |

| 59

..

..









.

60 |

..
.

2



.
.
| 61

..

..









.

60 |

..
.

2



.
.
| 61


. 40

5,300 40 200,000
..
..

.
.


3



40



. 9,000




.


62 |

..

4

1 (Cut
off) 60 65

(Drop)


2


3


4



3 ..

2-3-4

2 3 1

| 63


. 40

5,300 40 200,000
..
..

.
.


3



40



. 9,000




.


62 |

..

4

1 (Cut
off) 60 65

(Drop)


2


3


4



3 ..

2-3-4

2 3 1

| 63


(Success Story) .


4

4

Hospice









..

64 |

..

103

1) 2)




7

3


| 65


(Success Story) .


4

4

Hospice









..

64 |

..

103

1) 2)




7

3


| 65








.
--...


(Cloning) .

& (TCIJ)

60

66 |

(..)




2554

80
60






60 ..


60

2



(Fact Finding)
| 67








.
--...


(Cloning) .

& (TCIJ)

60

66 |

(..)




2554

80
60






60 ..


60

2



(Fact Finding)
| 67


.

30

(Entry Point)

3 ../

(Mobilize
Resources)
..

(.)

3

1 ..

68 |

..




.


..


2

HHC

3 Hospice



Hospice

..
| 69


.

30

(Entry Point)

3 ../

(Mobilize
Resources)
..

(.)

3

1 ..

68 |

..




.


..


2

HHC

3 Hospice



Hospice

..
| 69

( . )

1






2
.
. 10

.

70 |

.



.

. 2 1) 2)

(Click)

| 71

( . )

1






2
.
. 10

.

70 |

.



.

. 2 1) 2)

(Click)

| 71

72 |

:

. .

(Money Saving)






. ...

| 73

72 |

:

. .

(Money Saving)






. ...

| 73







..

60
80 1 4



80

3


1 7




1


(...)

74 |

2
6
6 1 ..
1





.. () 90







53
23

/

| 75







..

60
80 1 4



80

3


1 7




1


(...)

74 |

2
6
6 1 ..
1





.. () 90







53
23

/

| 75


.
20














..




.. ()

76 |

.


3

3 1)
..
2) .
3) 3






10
500-1,000



| 77


.
20














..




.. ()

76 |

.


3

3 1)
..
2) .
3) 3






10
500-1,000



| 77

 40-50





-






--

..
.
. 40
5,000 200,000
.

78 |

55






| 79

 40-50





-






--

..
.
. 40
5,000 200,000
.

78 |

55






| 79

80 |

| 81

80 |

| 81

 .. 2503-25731

.. 2503 .. 2543
.. 2543 ..
2573 1.1 ..

2503 60 1.5
5.4
60 7 7.6 ..

2552 11.5



.. 2543 .. 2573 15
.. 2568 14.9

1 ( 1,000)
60 .. 2503-2573
17,763
14,995
25.2
12,272
21.2
9,812
7,681
9.4
7.4
5.4 4.9 6.3
5,867
4,014
2,912
1,506 1,680
2503

2513 2523

2533 2543

60
1

.. 2552:
(..): 2553.

82 |

17.5

14.2

2553

2563

..
2573

60

2 .. 2552 .. 2573
17.8 25 ( 1 4)



1.1
.. 2503
.. 2552 J

60 1,000

60 1,000

: .. 2503-2543 .. 2503-2543
2543-2573 2543-2573
(

)
| 83

 .. 2503-25731

.. 2503 .. 2543
.. 2543 ..
2573 1.1 ..

2503 60 1.5
5.4
60 7 7.6 ..

2552 11.5



.. 2543 .. 2573 15
.. 2568 14.9

1 ( 1,000)
60 .. 2503-2573
17,763
14,995
25.2
12,272
21.2
9,812
7,681
9.4
7.4
5.4 4.9 6.3
5,867
4,014
2,912
1,506 1,680
2503

2513 2523

2533 2543

60
1

.. 2552:
(..): 2553.

82 |

17.5

14.2

2553

2563

..
2573

60

2 .. 2552 .. 2573
17.8 25 ( 1 4)



1.1
.. 2503
.. 2552 J

60 1,000

60 1,000

: .. 2503-2543 .. 2503-2543
2543-2573 2543-2573
(

)
| 83






60
7 11
65.4 ( 2553)

7 30

25 2573 (
) 1 10
20 1 4

2





1 7 ( 13.5)

(2551-2552) 1 5
1 3
20

4 :
(..): 2554.

84 |

30 23
7
1-2 ( 54.9)



3 5
( 62.8)
500

2552
5.6 ( 7 )

18.5
1 5 6
( 14.4

21.9)
3

| 85






60
7 11
65.4 ( 2553)

7 30

25 2573 (
) 1 10
20 1 4

2





1 7 ( 13.5)

(2551-2552) 1 5
1 3
20

4 :
(..): 2554.

84 |

30 23
7
1-2 ( 54.9)



3 5
( 62.8)
500

2552
5.6 ( 7 )

18.5
1 5 6
( 14.4

21.9)
3

| 85


1
2





: :


:

(Integrated care)

o


o /
o / //
o


-

-

- Home care, day
care, chronic care, terminal care

(Co-ordination)

:
(.): 2552

86 |

| 87


1
2





: :


:

(Integrated care)

o


o /
o / //
o


-

-

- Home care, day
care, chronic care, terminal care

(Co-ordination)

:
(.): 2552

86 |

| 87

o Social

welfare

o Care Provider



o Case manager



o Advocate and empowerment




.
o Law enforcement



o Resource support

88 |

()
o




o



o

/

| 89

o Social

welfare

o Care Provider



o Case manager



o Advocate and empowerment




.
o Law enforcement



o Resource support

88 |

()
o




o



o

/

| 89




:

/
- //
//

- /

- /

-

-

-

-

-
/
-

-
-
- /

- ///
- / /
-
90 |

3 4

1. 3
/


2.



3. : ..

3.1)

3.2)


3.3)

:

: 2553.

| 91




:

/
- //
//

- /

- /

-

-

-

-

-
/
-

-
-
- /

- ///
- / /
-
90 |

3 4

1. 3
/


2.



3. : ..

3.1)

3.2)


3.3)

:

: 2553.

| 91

 2 3

/

(///././
//././)

()

(.-..) (./
././
)

(.//
//
/)
()

: : .. , .
: 2553

/
( 2550) R2R
( 2551 - 2554)


1. 4
1. 2.
92 |

3.
4.

.

.


2.
(
)

. ()

.
.


3.

4
3.1.

| 93

 2 3

/

(///././
//././)

()

(.-..) (./
././
)

(.//
//
/)
()

: : .. , .
: 2553

/
( 2550) R2R
( 2551 - 2554)


1. 4
1. 2.
92 |

3.
4.

.

.


2.
(
)

. ()

.
.


3.

4
3.1.

| 93

3.2.
. (
)


.

3.3.

(. )




3.4.

94 |