Publication date: May 29, 2025

Patients with post-COVID-19 continue to experience lingering physical and psychological symptoms, requiring coordinated and continuous care. Addressing these needs is essential, especially in resource-limited settings. The objectives of this paper are to study the issues and needs, as well as the nursing and continuous care systems for residents living with COVID-19, to design and develop a database system, develop continuous care guidelines, and evaluate the effectiveness of the database system for continuous monitoring and care for residents living with COVID-19 in Nakhon Pathom Province, Thailand. Participatory action research was used to engage stakeholders and guide the development process. A total of 375 patients and family members affected by post-COVID-19 symptoms reported that symptoms persisted for approximately 6 months, with common symptoms including persistent cough and easy fatigue. These patients experienced reduced access to health care services, relying mainly on symptomatic treatment at local facilities and using telehealth nursing systems. They expressed a need for continuous care support from 50 professional nurses and village health volunteers. As a result, health care guidelines for post-COVID recovery were developed, comprising 5 core components: (1) self-care through digital information retrieval, (2) care via telehealth nursing systems, (3) physical health care services postrecovery, (4) mental health services postrecovery, and (5) continuous care for referral in case of postrecovery incidents. These guidelines were used to design a database system for continuous monitoring and care, which was evaluated as highly effective (mean 4. 51, SD 0. 59). This research highlights the critical need for a proactive and comprehensive approach to managing post-COVID-19 care in Nakhon Pathom Province. By developing and implementing a database system for continuous monitoring and care, along with clear guidelines, the study effectively addresses the ongoing needs of individuals recovering from COVID-19. The integration of technology, along with continuous care provided by professional nurses and village health volunteers, has been shown to be highly effective in improving the quality of care. The findings suggest that adopting these strategies, along with implementing supportive policies on data management and communication systems focused on home visits, will significantly enhance health service management and better prepare the region for future public health challenges.

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