Abstract：
The transitional care model for people who have suffered brain injuries is a relatively recent addition to the Thai healthcare system. The aim of this study was to explore experience of Thai Isan older stroke survivors and their family caregivers across different points of transition from hospital to home. Fifteen dyads of older stroke survivors and their family caregivers were recruited following the inclusion and exclusion criteria. Data were collected through participant observations and semi-structured interviews. Forty-seven participation observation field notes and twenty-four interview transcriptions were analyzed using the Four Phases of the Data Analysis Enabler and the Leininger-Templin-Thompson Ethnoscript Coding Enabler. Three themes emerged: I feel lost with managing care at home; it has been challenging for our family to maintain continuity of care; and it is a matter of who fits in and is convenient for family care responsibilities. The findings of this study have highlighted the dispersion of care among Thai-Isan people during the patient\'s transition to home. Therefore, a transitional care plan should be developed that specifies who is responsible for monitoring and supporting patients and families throughout this period.
摘要：
针对脑损伤患者的过渡性护理模式是泰国医疗保健系统中相对较新的补充。这项研究的目的是探索泰国伊桑老年中风幸存者及其家庭护理人员在从医院到家庭的不同过渡期的经验。根据纳入和排除标准，招募了15位年龄较大的中风幸存者及其家庭护理人员。通过参与者观察和半结构化访谈收集数据。使用数据分析启用程序的四个阶段和Leininger-Templin-ThompsonEthnoscript编码启用程序分析了47个参与观察现场笔记和24个访谈转录。出现了三个主题：我对在家中管理护理感到失落；对我们的家庭来说，保持护理的连续性一直是具有挑战性的；这是谁适合并方便家庭护理责任的问题。这项研究的结果强调了在患者过渡到家中期间，泰伊桑人的护理分散。因此,应制定过渡性护理计划,规定在这一期间由谁负责监测和支持患者和家属.
