Chonburi Mental Health Model Extends Care to Patients' Homes
Chonburi province's integrated mental health model combines hospital treatment with home-based follow-up involving families and communities to ensure patients receive continuous care and avoid relapse. The system uses village health volunte
"I've had constant auditory hallucinations and have been in treatment for over 14 years. I'm much better now and haven't been a burden to anyone." Those simple words come from a patient who began treatment at age 19, but behind them lies nearly half a lifetime spent with mental illness. The statement reflects an important truth: when people receive continuous treatment and care, they can recover and return to living with their families. Hospital treatment alone, however, is often not enough.
The "Chonburi Model" at Wat Yansangwaram Temple Hospital in Chonburi province connects inpatient care with home-based follow-up, drawing on cooperation from families, communities, and the national health insurance scheme—the "Gold Card"—to ensure patients receive continuous care and remain within the treatment system.
Dr. Sudanee Boonbeunjaisadhiep, hospital director, emphasizes that one person's mental health problem affects not only the patient but also family and community. The hospital does not focus solely on treating disease but cares for the entire family. When patients return to community life, the key is ensuring that the community does not stigmatize them and is ready to welcome them safely. "We cannot rely on public health staff alone," she explains. "But when communities participate, think together, monitor together, and evaluate results, we create genuine community care—people looking after one another and sharing in wellbeing."
The Chonburi Model establishes a system in which the main hospital, subdistrict health centres, village health volunteers, and families work together as one network. This spans from assessment, diagnosis, and treatment planning in the hospital through screening, referral, symptom monitoring, and home visits at the community level. This approach gives mental health patients—including those with Gold Card coverage—better access to mental health services without financial burden.
Nurmol Sunsaksawat, head of psychiatric nursing, explains that the heart of the Chonburi Model is continuity. When village health volunteers identify patients with severe symptoms—such as aggression or risk of self-harm—they alert the subdistrict health centre, which coordinates with the main hospital for assessment. Patients then enter a treatment pathway including psychiatric consultation, physical examination, blood tests, ECG, medication, and a psychiatrist-designed care plan. Once symptoms stabilize, they return to the subdistrict health centre and community for ongoing care.
The system also categorizes patients by risk level to determine follow-up frequency. Red-tier patients—those recently discharged after severe aggression—receive home visits at least monthly. Yellow-tier patients with improving symptoms are seen every 2–3 months. Green-tier patients who take medication consistently and manage well are monitored every 6 months.
Rattanya Chuaykhwamdi, a senior professional nurse at Baan Huai Yai Subdistrict Health Centre, adds that when the community receives a case from the hospital, the team visits homes together with the responsible village health volunteer, alongside network partners such as village heads, community leaders, and municipal officials to plan coordinated home visits. All of these services are free under the Gold Card, covering screening, referral, and follow-up home visits.
