Effectiveness of a discharge-planning pilot program for orthopedic patients in Taiwan

The purpose of this pilot project was to establish a discharge-planning model and evaluate its effectiveness. Orthopedic patients who scored 7 or above on a high-risk screening form were recruited for the project. Case managers served as discharge planners, and handled the following procedures: screening of patients, drawing up of the discharge plan, providing pre-discharge instructions, coordinating resources and services, and telephone follow-up. Results showed that discharge planning improved both the completion rate of pre-discharge instructions and patient satisfaction with discharge planning. It is suggested that, in future research, experimental studies could be used to examine the effectiveness of discharge planning. The study showed the importance of dedicated case managers for improving the effectiveness of discharge planning.     

出院电话随访对慢性心力衰竭患者再入院率的影响

目的探讨出院电话随访对慢性心力衰竭(chronic heart failure,CHF)患者再入院率的影响。方法将161例患者随机分为观察组81例和对照组80例,两组患者出院时均给予常规出院指导,观察组在患者出院后进行电话随访6个月,给予个性化护理干预。比较两组患者出院后6个月再入院率情况。结果观察组患者再入院率30.9%,对照组为42.5%,两组比较,P0.05,差异具有统计学意义。结论出院后依据CHF患者复发诱发因素制订个性化护理干预措施,通过电话随访,可降低患者病情复发,从而降低再入院率。     

Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes

Interventions focused on ensuring safe transitions for patients from hospital to home can assist in providing continuity of care, preventing readmissions, and reducing duplication of services. Patients undergoing a Transcatheter Aortic Valve Implantation (TAVI) procedure are often frail, elderly, and have multiple co-morbidities. A pilot initiative evaluating transitional care strategies through telephone follow up was implemented in a tertiary centre with the aim to identify gaps and intervene, preventing re-admission and improving patient outcomes. TAVI patients or caregivers were contacted at 3 days and 30 days post discharge by an Advanced Practice Nurse (APN). Telephone follow up centered on best practices for transitional care. Outcomes revealed fluid balance monitoring, medication management, and feelings of anxiety and depression post TAVI were the most frequent areas requiring intervention. Findings from this initiative reinforce the need to establish consistent processes that support elderly patient populations during potentially vulnerable points in the care trajectory.     

Nursing case management: application to neuroscience nursing.

The changing health care environment has challenged nurses to develop creative care delivery systems that provide for quality, comprehensive, cost-effective care in a time of restricted reimbursement and diminishing human and material resources. Nursing case management has been identified as one such approach to health care delivery that has resulted in quality, patient-centered care and improved resource utilization. The case management plan, critical path and discharge planning sheet are primary tools in this care delivery model. Because of the diverse case types and variety of patient care settings, neuroscience nursing is an ideal arena for implementing a nursing case management model of care.     

Health-related quality of life and health service use following total hip replacement surgery

AIMS OF THE STUDY: The study investigated health-related quality of life in relation to demographic and clinical factors, and health service use and satisfaction by older total hip replacement (THR) patients following discharge from one Australian Hospital. RATIONALE: Understanding health-related quality of life and patterns of service use during recovery informs caregiving and patient and family education needs for discharge planning and case management. BACKGROUND: Post-discharge, older THR patients have a high rate of health services use. Few valid measures of outcomes link nursing discharge or case management to patient-identified health status or service needs. RESEARCH METHODS: Ward nurses conducted telephone interviews to study self-perceived health-related quality of life using Medical Outcomes Study Short-Form (SF-36) and responses to an accompanying questionnaire on demographics, service use and satisfaction at 1, 2, 4, 8, and 12 weeks postdischarge. SF-36 scores were compared with Australian population norms according to age and gender to determine the relative extent of postdischarge recovery. RESULTS: Psychosocial recovery preceded physical recovery, which steadily improved. Physical component summary scores reached population norms and mental component summary scores exceeded norms by week 1. No differences in quality of life were found by age, but women took longer to recover physically. Those who lived alone did not have lower scores than those with residential support. General practitioners were seen most often; nursing visits were frequent only in weeks 1 and 2, specialist visits occurred at weeks 8 and 12. Allied health, hospital and pathology services were used less often. Most patients were satisfied or very satisfied with all services used. DISCUSSION/CONCLUSIONS: An almost immediate impact on quality of life was evident, probably indicating successful pain alleviation. Service use indicated adequate discharge planning and successful recovery. Having ward nurses as researchers was instrumental to continuity of communication between patients, families and service providers, which suggests increased potential for continuity of care.     

个案管理对慢性阻塞性肺疾病患者生活质量的影响

目的探讨个案管理对慢性阻塞性肺疾病患者生活质量的影响。方法将符合纳入标准的103例慢性阻塞性肺疾病患者分为观察组（51例）和对照组（52例）,自患者入院至出院后3个月内,对照组接受常规护理和随访,观察组在此基础上实施个案管理,首先培训个案管理护士,设计个案管理记录表,与患者一起制订呼吸功能锻炼、康复运动计划,患者出院后通过电话和门诊相结合的方式进行随访实施个案管理。结果干预后两组患者生活质量均提高,其中出院后1个月、3个月观察组患者生活质量高于对照组,差异具有统计学意义（P〈0．01）。结论个案管理能够提高慢性阻塞性肺疾病患者的生活质量。     

Continuity of care and monitoring pain after discharge: patient perspective

Title.  Continuity of care and monitoring pain after discharge: patient perspective.
Aim.  This paper is a report of a study conducted to evaluate, from the patients' perspective, a Liaison and Continuity of Care Programme coordinating care provision between a hospital and primary care centres.
Background.  Promoting continuity of care between hospitals and primary care improves quality of care, patient satisfaction and decreases further hospitalizations. However, inadequate pain management is common after discharge.
Method.  A sample of patients from the Liaison and Continuity of Care Programme were included in a longitudinal study in 2007. We conducted standardized telephone interviews at 24 hours, 7 days, 1 and 3 months after discharge. Outcome measures included readmission, time between hospital discharge and readmission, information level at discharge, patient satisfaction, queries about care and information related to perceived state of health and pain.
Results.  Eighty-three adult patients (average age 69·3, 50·6% males) who needed continued care at discharge were followed. Ten participants died during follow-up, and seven required readmission. A total of 49·4% of patients stated that they had understood the information given at discharge very well or perfectly. At 24 hours after discharge, 30% already had doubts about their state of health and the management of their condition. In relation to perceived health, only 25·3% stated that this was good or very good. Prevalence of pain 24-hours after discharge was 58·3% in surgical patients and 17·1% in other patients.
Conclusion.  The preparation and education of patients and family members should be improved before discharge, and appropriate written information must be given, especially if a patient has pain or requires complex care.     

Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs: a literature review

A model of emergency department (ED) case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction. The individual and combined roles of the dyad team of social worker and nurse case manager are discussed. A literature review includes how a case management dyad team of social worker and nurse case manager in the ED can decrease utilization of the ED for nonemergent visits, promote the use of community resources, and improve discharge planning to avoid excessive costs. The importance of the dyad team working with the interdisciplinary team in the ED, the primary care physician (PCP), and other community health care providers in order to provide a holistic approach to care is addressed. A discussion about the improvement of both patient and staff satisfaction demonstrates the results of case management strategies that support and advocate for patients to receive quality, cost-effective care across the health care continuum, while decreasing the use of the ED for nonemergent care.     

Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs: a literature review

A model of emergency department (ED) case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction.3 The individual and combined roles of the dyad team of social worker and nurse case manager are discussed. A literature review includes how a case management dyad team of social worker and nurse case manager in the ED can decrease utilization of the ED for nonemergent visits, promote the use of community resources, and improve discharge planning to avoid excessive costs. The importance of the dyad team working with the interdisciplinary team in the ED, the primary care physician (PCP), and other community health care providers in order to provide a holistic approach to care is addressed. A discussion about the improvement of both patient and staff satisfaction demonstrates the results of case management strategies that support and advocate for patients to receive quality, cost-effective care across the health care continuum, while decreasing the use of the ED for nonemergent care.     

Consumer-orientated outcomes in discharge planning: a pilot study

? The desired outcome of health care provision can only be known by evaluating care from the perspective of the consumer. ? An exploratory study was undertaken to develop and evaluate a research instrument (a semistructured telephone interview guide) as a measure of patient outcomes in discharge planning. ? A sample of 29 patients was recruited from three medical wards of a large tertiary referral teaching hospital in Sydney, Australia. ? Participants were contacted at home after discharge from hospital and interviewed by telephone. Their perceptions of hospital discharge and continuing care needs were investigated. ? Preliminary analysis of the data obtained in the pilot study demonstrated that there were deficiencies in hospital discharge procedures which impacted on continuing care and that patients can contribute useful information for evaluating and improving discharge planning.     

The impact of follow-up telephone calls to patients after hospitalization

We studied whether pharmacists involved in discharge planning can improve patient satisfaction and outcomes by providing telephone follow-up after hospital discharge. We conducted a randomized trial at the General Medical Service of an academic teaching hospital. We enrolled General Medical Service patients who received pharmacy-facilitated discharge from the hospital to home. The intervention consisted of a follow-up phone call by a pharmacist 2 days after discharge. During the phone call, pharmacists asked patients about their medications, including whether they obtained and understood how to take them. Two weeks after discharge, we mailed all patients a questionnaire to assess satisfaction with hospitalization and reviewed hospital records. Of the 1,958 patients discharged from the General Medical Service from August 1, 1998 to March 31, 1999, 221 patients consented to participate. We randomized 110 to the intervention group (phone call) and 111 to the control group (no phone call). Patients returned 145 (66%) surveys. More patients in the phone call than the no phone call group were satisfied with discharge medication instructions (86% vs. 61%, P = 0.007). The phone call allowed pharmacists to identify and resolve medication-related problems for 15 patients (19%). Twelve patients (15%) contacted by telephone reported new medical problems requiring referral to their inpatient team. Fewer patients from the phone call group returned to the emergency department within 30 days (10% phone call vs. 24% no phone call, P = 0.005). A follow-up phone call by a pharmacist involved in the hospital care of patients was associated with increased patient satisfaction, resolution of medication-related problems, and fewer return visits to the emergency department.     

Use of store and forward technology for vascular nursing teleconsultation service

Accurate assessment is critical in planning appropriate therapeutic management of a patient with a vascular wound. However, several factors may inhibit wound assessment by trained professionals or subspecialists. Multiple co-morbidities and lack of transportation and finances contribute to problems with access to specialty clinics for both rural and urban patients with vascular disease. To assess the application of telemedicine in meeting the needs of rural patients with vascular disease, the vascular nurse clinician of a regional medical network was incorporated into a telemedicine research project that used a still-image transmission system known as the Picasso telephone, which allows a diagnostic quality image to be transmitted over a regular telephone line. Telephone consultation between sender and receiver occurs simultaneously at the time of image transmission. Because images can be collected and stored for future reference, this technology is commonly called “store and forward” technology. The application of advanced technology in a rural health care environment has the potential to reduce costs for both patient and managed care insurance plans, allow for expert consultation from distant centers, and promote collegiality and learning among professionals.     

Next day telephone follow up of the elderly: a needs assessment and critical incident monitoring tool for the accident and emergency department

BACKGROUND: Patients over the age of 75 years comprise an increasing proportion of accident and emergency (A&E) department attendances. Within this group there is a high incidence of comorbidity, which mandates effective discharge coordination from the A&E department. OBJECTIVES: The aims of this study were to assess the needs of these patients the day after discharge, target patients for appropriate interventions and identify critical incidents. SETTING: The study was undertaken in a district general hospital A&E department that has 62000 new patient attendances per year. INCLUSION CRITERIA: Patients aged 75 years or over who were discharged from the A&E department. EXCLUSION CRITERIA: Nursing home patients. Patients without a telephone. STUDY DESIGN: Pre-discharge information was collected from the medical notes. A community liaison nurse (CLN) then contacted patients by telephone. A semistructured questionnaire was used to assess patients. Patients were risk stratified and appropriate interventions made. Interventions initiated by the CLN were scored from 1 to 6 based on the level of input required. RESULTS: 551 patients or their carers were contacted by telephone. Existing home support was felt to be insufficient in 44 (8%) cases and in need of immediate intervention in a further 45 (8%) cases. Sixty five (11%) Category 1 patients required no intervention, 223 (42%) Category 2 patients required advice only, 107 (19%) Category 3 patients were referred to their GP, 127 (23%) Category 4 patients required a domicillary visit by a GP or a nurse, 26 (5%) Category 5 patients were at risk requiring urgent home assessment and three Category 6 patients had to re-attend A&E. Advice was given by the CLN on a broad range of issues and a wide range of health care services was accessed. Five hundred and fifty nine referrals were made by the CLN after telephone assessment. CONCLUSIONS: Telephone follow up of patients over 75 attending our A&E department identified a number of areas where care could be improved before and after discharge. This low cost, high quality intervention has the potential for decreasing inappropriate return visits to the department by a vulnerable group of patients as well as improving overall quality of care.     

Discharge planning: communication, education and patient participation

For the most part, discharge from hospital is routine and uneventful. However, for a percentage of people, discharge from acute care requires careful planning to ensure continuity of care. This is particularly the case with older patients who have complex medical needs. This literature review reveals that the essential elements for discharge planning are: communication, coordination, education, patient participation and collaboration between medical personnel. Outcomes measures of successful discharge planning include patient satisfaction and quality of life. Smooth and efficient coordination of this process reduces stress and anxiety for the patient, family, nurse, doctor, hospital and community services.     

深化基础护理服务的实践与体会

目的 进一步深化基础护理服务内涵,提升护理服务品质.方法 在参观学习、开展工作调研的基础上,合理配置人力资源,强化护理人员技能培训;改革护士分工模式;简化护理文书记录;建立及完善护理绩效考评等管理制度.结果 病人对护理工作的满意度由94.05%上升至98.76%,基础护理质量提高(P<0.01).结论 深化基础护理服务...     

少数民族地区肠造口患者院外延续护理的方法与效果

目的探讨少数民族地区肠造口患者院外延续护理的管理模式。方法对符合纳入标准的150例患者通过造口门诊进行门诊随访、电话随访、入户随访、健康教育等方法进行院外延续护理,并比较院外延续护理开展前和开展6个月后的患者造口知识、态度、生活质量、并发症的发生率。结果肠造口患者的造口知识、态度、生活质量均提高(P<0.01),造口并发症发生率下降(P<0.01)。结论对边疆地区肠造口患者实施院外延续护理,有利于患者早日康复,重返社会。     

Integrating case management and palliative care

Most seriously ill Americans live at home under the care of their primary physician and with the support of family caregivers. To reduce costs while simultaneously improving the quality of patient care, insurers have increasingly turned to the concept of case management. While case management is targeted to individuals with life-threatening illnesses, palliative care assessment and interventions are typically not included in the management protocols. An academic/care management/health plan partnership between Mount Sinai School of Medicine, Franklin Health, a care management organization, and South Carolina Blue Cross Blue Shield, was formed in 1998 to test the utility of integration of case management with formal palliative care assessment, feedback and recommendations to treating physicians, and ongoing support for implementation of a palliative care plan. The goal of the project was to ensure identification and optimal care of seriously ill patients' complex needs, while facilitating doctor-patient continuity, improving patient/family/physician communication, providing assistance with decision-making, ensuring quality care at home, and promoting efficient use of health care resources. Care management nurses were randomly assigned to a control (usual care) group or to the intervention (palliative care) group. Intervention nurses were trained in formal palliative care assessment and interventions, supported by treatment protocols and communication strategies with treating physicians. Measurements included symptom burden, prescribing practices, advance care planning status, satisfaction, and health care utilization. These results are pending completion of study run-out and analysis. Preliminary programmatic results indicate that combining palliative care with the case management approach is a logical, feasible, and effective strategy to improve the care of seriously ill patients living in the community. Franklin Health has offered the program to their entire client base because they feel that the integration of palliative care into their case management program improved the standard of patient care. Blue Cross Blue Shield of South Carolina has also chosen to sustain this enhanced model of care management for seriously ill patients.     

Reducing re-admission for asthma: impact of a nurse-led service

High rates of re-admission of children with acute asthma led to the establishment of a nurse-led service in one hospital in England. Improved approaches to care, discharge planning and subsequent management were introduced based on the BTS/SIGN guideline for asthma management. These approaches included a reducing regime for salbutamol inhaler treatment, consistent assessment of need for regular preventer treatment and of 'step up' asthma control measures at home. Review of inhaler technique is particularly important to ensure that the appropriate drug delivery device is used depending on the age of the child. Telephone follow-up is used to re-enforce information provided prior to discharge. Subsequent follow up in the nurse-led clinic provides an opportunity to review the child's home management and effectiveness of any treatment changes. Audit data indicate a reduction in re-admission rates for children with asthma from 22 per cent to around six per cent.     

多学科团队延续性护理模式在心房颤动患者中的应用研究

目的 探索护士主导的多学科团队延续性护理模式在心房颤动患者中的应用效果。 方法 2017年10月—2018年10月,选取北京市某三级甲等医院心脏中心住院治疗的心房颤动患者为研究对象,按病区分为试验组和对照组。试验组在常规护理与健康教育的基础上给予护士主导的多学科团队延续性护理,对照组接受心内科常规护理与健康教育。比较两组入组时及出院后6个月时的服药依从性和生活质量,比较出院后1个月、3个月、6个月因心血管事件再入院情况,采用Cox比例风险模型比较两组因心血管事件再入院情况。 结果 共纳入148例心房颤动患者,试验组80例,对照组68例,两组一般资料的比较,差异无统计学意义（P>0.05）。试验组出院后6个月时中文版服药依从性量表得分、中文版生活质量简表总分及其生理职能、躯体疼痛和精神健康维度得分均高于对照组,差异具有统计学意义（P<0.05）。虽然两组出院后因心血管事件再入院率的比较,差异无统计学意义（P>0.05）,但Cox比例风险模型显示,试验组的再入院风险相对较低（HR=0.633,95%CI=0.322~1.245）。 结论 护士主导的多学科团队延续性护理可以提高患者的服药依从性,提升其生活质量,改善患者健康结局。     

基于时机理论的家庭护理对慢性心力衰竭患者自我管理的效果研究*

目的: 探讨以时机理论为框架的家庭护理对慢性心力衰竭患者自我管理的影响。方法: 选择2018年1月至12月入住心内科首次心力衰竭发作的患者23例为观察组。在常规护理与随访的基础上给予以时机理论为基础的家庭护理;对照组为2017年1月至12月心内科住院的首次心力衰竭发作的25例患者。接受心内科常规护理与随访;比较两组出院6个月时的自我管理、生活质量及再入院率。结果: 出院6个月时,观察组的自我管理优于对照组。生活质量得分、再入院率低于对照组,差异有统计学意义（P<0.05）。结论: 基于时机理论的家庭护理能有效提高CHF患者的自我管理能力,改善其生活质量,降低再入院率。