冠心病患者基于出院评估单的医院-社区-家庭联动延续护理

目的 探讨冠心病患者基于出院评估单的医院-社区-家庭三方联动的延续护理实施效果。方法 根据住院时间将2019年1~5月心内科收治的78例冠心病患者设为对照组，给予常规出院评估、出院指导和随访；2019年6~10月心内科收治的80例冠心病患者设为观察组，在常规出院处置基础上，出院前评估患者出院准备度，根据出院评估单实施医院-社区-家庭三方联动的延续护理。比较两组出院准备度、家庭自我管理、复诊、基层医疗机构就诊、非计划就医和再入院情况。结果 观察组出院准备度得分、家庭自我管理得分显著高于对照组（均P＜0.01），患者基层医疗机构就诊、复诊情况高于对照组，而非计划就医和再入院情况低于对照组。结论 基于出院评估单的医院-社区-家庭三方联动延续护理的实施，可加强医院-社区-家庭三方的互联互通，完善冠心病患者的院外管理，改善患者预后，减少非计划就医和再入院，并提高患者的基层就诊率，促进分级诊疗。

Hospital-community-family linkage transitional care based on discharge evaluation sheet for patients with coronary heart disease

Objective To explore the application effect of hospital-community-family trinity linkage transitional care based on discharge evaluation sheet for patients with coronary heart disease. Methods According to hospitalization time, 78 patients with coronary heart disease admitting to the department of cardiology from January to May 2019 were taken as a control group, who were given routine discharge assessment, discharge guidance and follow-up; and another 80 patients admitting to the department from June to October 2019 were regarded as an experimental group, who additionally received discharge readiness assessment and hospital-community-family trinity linkage transitional care according to the discharge evaluation sheet. The discharge readiness, family self-management, follow-up visit, primary health care institution visit, unplanned visit and readmission were compared between the two groups. Results The score of discharge readiness and family self-management in the experimental group were significantly higher than those in the control group (P<0.01 for both). The primary health care institution visits and planned follow-up of the experimental group were more than those of the control group, and the unplanned emergency visit and readmission were less than those of the control group. Conclusion Implementation of the hospital-community-family trinity linkage transitional care based on discharge evaluation sheet, can strengthen the hospital-community-family connection and communication, effectively improve the management of patients with coronary heart disease at home and their prognosis, reduce unplanned emergency visit and readmission, enhance primary treatment rate, and promote the hierarchical diagnosis and treatment.