Page 55 - Policy-Communication-Report-Volume-67

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đöČęĂéĎĒúøĆÖþćêćöĒîüìćÜĒóì÷ŤĒñîĕì÷øŠüöÖĆïÿĀüĉßćßĊóÙøïǰ6 đéČĂîĒúšüÝąÝĞćĀîŠć÷ÝćÖøąïïǰIMC ĒêŠÝąéĎĒúêćöõćüąÿč×õćó
đöęęęęČęĂéĎĒúøĆÖþćêćöĒîüìćÜĒóì÷ŤĒñîĕì÷øŠüöÖĆïÿĀüĉßćßĊóÙøïǰ6 đéČĂîĒúšüÝąÝĞćĀîŠć÷ÝćÖøąïïǰIMC ĒêŠÝąéĎĒúêćöõćüąÿč×õćó
Discharge
LTC ĒúąðøąđöĉîÙüćöóĉÖćø
F/U ôŚŪîôĎ
No Multiple impairment
Disability/Handicap
with Multiple impairment
BI < 11
BI 11 – 19 or
BI = 20 and
êøüÝüĉîĉÝÞĆ÷éšü÷ÖćøĒóì÷ŤĒñîĕì÷øŠüöÖĆïĒóì÷ŤĒñîðŦÝÝčïĆîǰüćÜĒñîÖćøéĎĒúøĆÖþćêćöĒîüìćÜĒóì÷ŤĒñîĕì÷øŠüöÖĆïÿĀüĉßćßĊó
êøüÝüĉîĉÝÞĆ÷éšü÷ÖćøĒóì÷ŤĒñîĕì÷øŠüöÖĆïĒóì÷ŤĒñîðŦÝÝčïĆîǰüćÜĒñîÖćøéĎĒúøĆÖþćêćöĒîüìćÜĒóì÷ŤĒñîĕì÷øŠüöÖĆïÿĀüĉßćßĊó
ðøąđöĉîǰBI ìčÖǰ1 – 2 đéČĂîÝîÙøïǰ6 đéČĂî
ðøąđ ĉ öĉî BI ìčÖǰ1 – 2 đéČČČĂîÝîÙøïǰ6 đéČČČĂî
Community rehabilitation
OPD rehabilitation
IPD intensive rehabilitation
Out-reached or

ēé÷ñĎšðśü÷ĒúąâćêĉøŠüöêĆéÿĉîĔÝ
ÖćøéĎĒúøĆÖþćǰIMC êćöÙüćöóøšĂöĒúąïøĉïì×ĂÜóČĚîìĊęǰ
BI < 15 or BI œǰ15 with Multiple Impairment

ĒúąÙüćöïÖóøŠĂÜìćÜÖćøĒóì÷Ť
- ðøąÿćîǰøóß. đóČęĂĔĀšǰRehabilitation
BI œǰ15 & No Multiple Impairment
- ÝĞćĀîŠć÷ǰóøšĂöĔĀšǰHome program
ðøąđöĉîǰBarthel index ADL
Acute ĒúąÿõćüąìćÜÖćøĒóì÷ŤÙÜìĊę
IMC care process
ñĎšðśü÷ǰStroke øóý. Ēúąǰøóì. ìĊęóšîøą÷ąǰ

Ļ ÖćøđÿøĉöóúĆÜñĎšðśü÷ĒúąñĎšéĎĒúǰ(Empowerment)
ĻÖćøÿøšćÜÙüćöøĂïøĎšÿč×õćóéšćîÖćøĒóì÷ŤĒñîĕì÷ǰ(Literacy)
ĻÖćøéĎĒúêŠĂđîČęĂÜĔîßčößîǰ(Community care)
Discharge
Ħ. ÖćøéĎĒúêŠĂđîČęĂÜĒúąđÿøĉöóúĆÜǰ(Continuity of care)
Ļ ÖćøêĉéêćöĂćÖćøĀúĆÜÖćøøĆÖþćǰ(Follow up)
ĻÖćøüĉîĉÝÞĆ÷đóČęĂÿĉĚîÿčéÖćøøĆÖþćǰ(Finalized diagnosis)
Care Delivery
Ļ ÖćøðøąđöĉîđóČęĂüćÜĒñîÝĞćĀîŠć÷ǰ(Discharge planning)
ĥ. ÖćøÝĞćĀîŠć÷ǰ(Discharge)
Ļ ÖćøðøąđöĉîĒúąêĉéêćöÖćøøĆÖþćĒêŠúąüĆîǰ(Reassessment)
Empowerment
ĻÖćøøĆÖþćêćöĒîüìćÜðäĉïĆêĉđüßÖøøöĕì÷ǰ(TTM guideline)
Continuity of Care
Care Planning
Education &
Ļ ÖćøøĆÖþćêćööćêøåćîÖøöÖćøĒóì÷Ť/øćßüĉì÷ćúĆ÷ǰ(CPG)
Ĥ. ÖćøéĎĒúøĆÖþćǰ(Care delivery)
ĻÖćøüĉîĉÝÞĆ÷ÝĞćĒîÖÙüćöøčîĒøÜǰ(Diagnosis & Classification)
Assessment & Dx
Ļ ÖćøêøüÝøŠćÜÖć÷đóČęĂðøąđöĉîĂćÖćøǰ(Patient Assessment)
ĻÖćøàĆÖëćöðøąüĆêĉÖćøđÝĘïðśü÷ǰ(History taking)
ģ. ÖćøðøąđöĉîĒúąüĉîĉÝÞĆ÷ǰ(Assessment & Diagnosis)

ĻÖćøïĆîìċÖךĂöĎúÿŠüîïčÙÙúǰ(Personal data)
Access & Entry
Access & Entry
Ļ ÖćøúÜìąđïĊ÷î÷Čî÷ĆîêĆüêîđךćÿĎŠøąïïǰ(Identification)
ĻÖćøÙĆéÖøĂÜđïČĚĂÜêšîǰ(Screening)
Ģ. ÖćøøĆïđךćÿĎŠøąïïǰ(Access & Entry)
Patient Care Process TTM