Development of digital technology innovations to enhance healthcare and social service systems through a social telecare platform

Abstract

This research aimed to: (1) develop a Platform Social Telecare (PST) for monitoring and providing care for vulnerable patients with non-communicable diseases (NCDs); (2) promote the use of health information systems for designing appropriate health services; and (3) develop policy and operational proposals for a home-visit follow-up system to enhance social care and quality of life among patients after hospital discharge.

A quasi-experimental research design was conducted with a sample of 3,477 NCD patients from eight hospitals. The findings indicated that the development of the Platform Social Telecare (PST) enabled systematic monitoring and classification of the severity of social problems among NCD patients. From a total of 13,419 identified social problems, the majority were of moderate severity (57.29%). The most common problems included financial difficulties, caregiving burden, and barriers to treatment access. The platform supported multidisciplinary health teams in planning targeted and comprehensive interventions across medical and social dimensions.

In addition, the PST contributed to strengthening hospital financial sustainability in line with the 2025 Health Service Fee Schedule Policy, which enhanced the role of medical social work services. Data from the Social Telecare Platform showed 11,738 service visits, generating a total value of 6,027,880 baht, with an average of 513 baht per visit. Most services were classified as core activities, including social problem assessment and counseling.

Regarding the promotion of health information utilization for service design, the PST supported standardized holistic assessment and social diagnosis, and effectively integrated health information systems with social services through API linkages between HOSxP and the A-MED Home Ward system. This integration reduced duplication of work and improved the quality of care, with a cumulative total of 12,445 API calls recorded.

The development of proposals for a home-visit follow-up system revealed that proactive services such as home visits accounted for a relatively low proportion of service delivery, despite their critical importance for vulnerable patients. This limitation was attributed to constraints in workforce capacity,geographic context, transportation, and digital competencies of service providers, which restricted the continuity of home visits and follow-up care.

Based on these findings, the study recommends positioning the Platform Social Telecare (PST) as the core infrastructure for post-discharge patient follow-up. This includes integrating HOSxP and A-MED data through secure APIs, systematically applying social and family assessment tools, monitoring social outcomes via dashboards, and ensuring robust personal data protection in compliance with the Personal Data Protection Act (PDPA) at both policy and operational levels. These measures are expected to enhance home-visit services, reduce health and social inequities, and promote the sustainable care of vulnerable patients in the future.