Community caregivers and innovative financing: a qualitative analysis of Thailand's Ubolratana Hospital model using the consolidated framework for implementation research.

Thailand's healthcare system faces challenges in delivering effective community-based care for dependent patients in rural areas; while access has expanded over more than four decades, services remain fragmented and effective coverage from community to higher-level care is still lacking. The Ubolratana Hospital model in Khon Kaen Province represents an innovation, combining a full-time 24-hr community caregiver cadre integrated within a hospital-led local healthcare team with five adaptive diversified funding streams. This qualitative implementation research, guided by the Consolidated Framework for Implementation Research (CFIR), examined the determinants of adoption and sustainment of the model over its 6-year operation. The CFIR-informed interview guide was used as the key data collection and analytical framework across its five domains [innovation, outer setting, inner setting, individuals (roles and characteristics), and implementation process]. We conducted semi-structured interviews with key informants spanning hospital administrators, physicians, nurses, community caregivers, sub-district primary care unit personnel, local government officials, community leaders, and family members between March and May 2025. Data were analysed using framework analysis combining deductive CFIR coding with inductive sub-coding. Adoption was facilitated by a hospital-initiated caregiver role, sustained inner-setting leadership embodied in a long-tenured 'social engineer' hospital director and his successor team, a three-stage community-led caregiver selection process, and Buddhist-integrated spiritual care; sustainment relied on a coordinated multi-level care process and the continuity of care centre's reflective evaluation. Outer-setting barriers included fragmented public health financing, the 2022 decentralization of sub-district primary care units to provincial administrative organizations, and donor-funding uncertainty. Since 2020 the model has been progressively scaled under Ramathibodi Faculty of Medicine sponsorship to 22 districts across 15 provinces (53 villages, cumulative investment >10 million baht). The Ubolratana experience therefore offers a practical, rather than directly replicable, framework whose diffusion depends on cultivating local leadership, building trust, and adapting innovation components to local conditions.