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This was a qualitative research. Tool was in-depth interview. Twelve participants were purposively selected from four groups, including Tha Chang Community Hospital, Community Health Center, as well as community health volunteers and the patients’ family members. Data were analyzed by using content analysis. Then the results were triangulated between sectors.
Criteria of effectiveness of Tha Chang referral program were patients’ clinical outcome, reduction of readmission, frequency of communication errors (transmission of medical data and patient’s information), and time delay of care after discharge. Key success factor was the Smart Discharge strategy using Bed Side Conference process. Key persons significantly influencing the Tha Chang Seamless referral program were the family care givers, accompanied by coaching, supporting and empowering from the Buddy Dream Team. The seamless referral system can be built upon staff, information, drug, transportation, referral form, know-how technics, and care.
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