過渡期護理與出院計劃、連續性護理的關系研究進展_West China Medical Journal

Authors：

劉歡 ¹ ,  寧寧 ² , 田永明 ¹

1. ;
2. ;

Corresponding?author：

寧寧, Email: gkningning@126.com

Keywords：

過渡期護理; 出院計劃; 連續性護理

DOI：

10.7507/1002-0179.201609218

Video：

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由于我國目前的醫療資源嚴重不能滿足民眾需求，醫療機構嘗試通過縮短平均住院日、提高醫療服務效率和質量來提高病床周轉率，而隨著住院時間的縮短，患者常常在康復的中期出院而非完全康復后才出院。為保證患者出院安全，降低出院后不良事件的發生率和再入院率，過渡期護理、出院計劃、連續性護理等相關概念和模式應運而生并被應用到臨床，但國內部分研究對三者的內涵意義混淆不清。該文通過對過渡期護理的概念、研究內容、模式，出院計劃的概念、實施過程，以及連續性護理的概念、實施要素進行闡述和分析，明確指出連續性護理是一種廣泛的護理理念，為了實現患者照護的連續性，不同研究者提出了出院計劃、過渡期護理、個案管理等護理模式或護理方案，共同形成了促進患者連續性照護的協調性、連續性、跨機構的健康網絡。

Citation： 劉歡, 寧寧, 田永明. 過渡期護理與出院計劃、連續性護理的關系研究進展. West China Medical Journal, 2017, 32(12): 1984-1987. doi: 10.7507/1002-0179.201609218 Copy

1.	宋萍, 張際. 以縮短平均住院日為切入點提高醫院資源利用效率. 中國醫院管理, 2009, 29(5): 10-11.
2.	湯維娟, 孫菲, 王毅欣, 等. 跨機構的連續性照護模式的研究進展. 護理研究, 2001, 25(3A): 572-574.
3.	姚立群, 龐書勤, 鄭麗維, 等. 連續性護理的概念內涵及測量工具的研究進展. 中華護理雜志, 2013, 48(11): 1026-1029.
4.	Naylor M, Keating SA. Transitional care. Am J Nurs, 2008, 108(9 Suppl): 58-63.
5.	Coleman EA, Boult C, American Geriatrics Society Health Care Systems. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc, 2003, 51(4): 556-557.
6.	單偉穎, 李青, 郭金玉. 過渡期護理模式的研究進展. 中華護理雜志, 2010, 45(3): 284-286.
7.	徐淑華, 孫靜, 王芳, 等. ICU重度顱腦損傷患者轉普通病區過渡期護理模式的實踐. 護理學報, 2013, 20(11A): 42-44.
8.	Van Walleghem N, Macdonald CA, Dean HJ. Evaluation of a systems navigator model for transition from pediatric to adult care for young adults with type 1 diabetes. Diabetes Care, 2008, 31(8): 1529-1530.
9.	Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med, 1994, 120(12): 999-1006.
10.	Naylor MD, Bowles KH, Mccauley KM, et al. High-value transitional care: translation of research into practice. J Eval Clin Pract, 2013, 19(5): 727-733.
11.	Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc, 2004, 52(11): 1817-1825.
12.	Parry C, Coleman EA, Smith JD, et al. The care transitions intervention: a patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q, 2003, 22(3): 1-17.
13.	Boston University Medical Center. Project RED (Re-Engineered discharge). (2014-08-15)[2017-12-07]. http://www.bu.edu/ fammed/projectred.
14.	Watkins L, Hall C, Kring D. Hospital to home: a transition program for frail older adults. Prof Case Manag, 2012, 17(3): 117-123; quiz 124-5.
15.	Dedhia P, Kravet S, Bulger J, et al. A quality improvement intervention to facilitate the transition of older adults from three hospitals back to their homes. J Am Geriatr Soc, 2009, 57(9): 1540-1546.
16.	Society of Hospital Medicine. Overview project BOOST implementation toolkit. (2016-09-18)[2017-12-07]. http://www. hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm.
17.	呂元紅, 周雀云, 麥瑞瓊. 過渡期護理模式在低體重早產兒中的應用探討. 護士進修雜志, 2014, 29(9): 799-801.
18.	卿利敏, 席明霞, 莫文娟, 等. 過渡期護理模式對慢性阻塞性肺疾病出院患者自護行為的干預效果. 中華護理雜志, 2011, 46(10): 965-967.
19.	張建新, 張志堅, 饒富蘭, 等. 過渡期護理模式對腦梗死出院患者肢體功能康復進程的影響. 南昌大學學報: 醫學版, 2013, 53(4): 73-75.
20.	趙俐紅, 楊蓉, 涂雙燕, 等. 腦卒中病人出院-回家過渡期管理模式初探. 護理研究, 2014, 28(2B): 608-609.
21.	王贊麗. 對腦卒中家庭照顧者實施過渡期護理干預的效果研究. 天津: 天津醫科大學, 2012.
22.	席淑華, 趙繼軍, 趙建華, 等. 成功大學附屬醫院出院準備服務概況與啟示. 中華護理雜志, 2007, 42(4): 341-342.
23.	Holland DE, Harris MR. Discharge planning, transitional care, coordination of care, and continuity of care: clarifying concepts and terms from the hospital perspective. Home Health Care Serv Q, 2007, 26(4): 3-19.
24.	趙岳. 探討連續護理過程中出院計劃模式的應用. 中國護理管理, 2007, 7(7): 78-80.
25.	Huang TT, Liang SH. A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling. J Clin Nurs, 2005, 14(10): 1193-1201.
26.	盧玨. 出院計劃對腦卒中患者主要照顧者需求滿足的效果研究. 蘇州: 蘇州大學, 2013.
27.	陳琴, 姜小鷹. 出院計劃模式的研究進展. 護理研究, 2011, 25(13): 1137-1140.
28.	Hospital referral of patients for continuity of nursing care. Am J Nurs, 1947, 47(11): 761-764.
29.	Anderson MA, Helms LB. Communication between continuing care organizations. Res Nurs Health, 1995, 18(1): 49-57.
30.	Gulliford M, Naithani S, Morgan M. What is ‘continuity of care’?. J Health Serv Res Policy, 2006, 11(4): 248-250.
31.	Biem HJ, Hadjistavropoulos H, Morgan D, et al. Breaks in continuity of care and the rural senior transferred for medical care under regionalisation. Int J Integr Care, 2003, 3(5): e03.
32.	van Servellen G, Fongwa M, Mockus D’errico E. Continuity of care and quality care outcomes for people experiencing chronic conditions: a literature review. Nurs Health Sci, 2006, 8(3): 185-195.
33.	Haggerty JL, Reid RJ, Freeman GK, et al. Continuity of care: a multidisciplinary review. Br Med J, 2003, 327(7425): 1219-1221.
34.	Helles? R, Lorensen M. Inter-organizational continuity of care and the electronic patient record: a concept development. Int J Nurs Stud, 2005, 42(7): 807-822.
35.	Simon GE, Ludman E, Unützer J, et al. Design and implementation of a randomized trial evaluating systematic care for bipolar disorder. Bipolar Disord, 2002, 4(4): 226-236.
36.	Clark A, Nadash P. The effectiveness of a nurse-led transitional care model for patients with congestive heart failure. Home Healthc Nurse, 2004, 22(3): 160-162.

1. 宋萍, 張際. 以縮短平均住院日為切入點提高醫院資源利用效率. 中國醫院管理, 2009, 29(5): 10-11.
2. 湯維娟, 孫菲, 王毅欣, 等. 跨機構的連續性照護模式的研究進展. 護理研究, 2001, 25(3A): 572-574.
3. 姚立群, 龐書勤, 鄭麗維, 等. 連續性護理的概念內涵及測量工具的研究進展. 中華護理雜志, 2013, 48(11): 1026-1029.
4. Naylor M, Keating SA. Transitional care. Am J Nurs, 2008, 108(9 Suppl): 58-63.
5. Coleman EA, Boult C, American Geriatrics Society Health Care Systems. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc, 2003, 51(4): 556-557.
6. 單偉穎, 李青, 郭金玉. 過渡期護理模式的研究進展. 中華護理雜志, 2010, 45(3): 284-286.
7. 徐淑華, 孫靜, 王芳, 等. ICU重度顱腦損傷患者轉普通病區過渡期護理模式的實踐. 護理學報, 2013, 20(11A): 42-44.
8. Van Walleghem N, Macdonald CA, Dean HJ. Evaluation of a systems navigator model for transition from pediatric to adult care for young adults with type 1 diabetes. Diabetes Care, 2008, 31(8): 1529-1530.
9. Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med, 1994, 120(12): 999-1006.
10. Naylor MD, Bowles KH, Mccauley KM, et al. High-value transitional care: translation of research into practice. J Eval Clin Pract, 2013, 19(5): 727-733.
11. Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc, 2004, 52(11): 1817-1825.
12. Parry C, Coleman EA, Smith JD, et al. The care transitions intervention: a patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q, 2003, 22(3): 1-17.
13. Boston University Medical Center. Project RED (Re-Engineered discharge). (2014-08-15)[2017-12-07]. http://www.bu.edu/ fammed/projectred.
14. Watkins L, Hall C, Kring D. Hospital to home: a transition program for frail older adults. Prof Case Manag, 2012, 17(3): 117-123; quiz 124-5.
15. Dedhia P, Kravet S, Bulger J, et al. A quality improvement intervention to facilitate the transition of older adults from three hospitals back to their homes. J Am Geriatr Soc, 2009, 57(9): 1540-1546.
16. Society of Hospital Medicine. Overview project BOOST implementation toolkit. (2016-09-18)[2017-12-07]. http://www. hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm.
17. 呂元紅, 周雀云, 麥瑞瓊. 過渡期護理模式在低體重早產兒中的應用探討. 護士進修雜志, 2014, 29(9): 799-801.
18. 卿利敏, 席明霞, 莫文娟, 等. 過渡期護理模式對慢性阻塞性肺疾病出院患者自護行為的干預效果. 中華護理雜志, 2011, 46(10): 965-967.
19. 張建新, 張志堅, 饒富蘭, 等. 過渡期護理模式對腦梗死出院患者肢體功能康復進程的影響. 南昌大學學報: 醫學版, 2013, 53(4): 73-75.
20. 趙俐紅, 楊蓉, 涂雙燕, 等. 腦卒中病人出院-回家過渡期管理模式初探. 護理研究, 2014, 28(2B): 608-609.
21. 王贊麗. 對腦卒中家庭照顧者實施過渡期護理干預的效果研究. 天津: 天津醫科大學, 2012.
22. 席淑華, 趙繼軍, 趙建華, 等. 成功大學附屬醫院出院準備服務概況與啟示. 中華護理雜志, 2007, 42(4): 341-342.
23. Holland DE, Harris MR. Discharge planning, transitional care, coordination of care, and continuity of care: clarifying concepts and terms from the hospital perspective. Home Health Care Serv Q, 2007, 26(4): 3-19.
24. 趙岳. 探討連續護理過程中出院計劃模式的應用. 中國護理管理, 2007, 7(7): 78-80.
25. Huang TT, Liang SH. A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling. J Clin Nurs, 2005, 14(10): 1193-1201.
26. 盧玨. 出院計劃對腦卒中患者主要照顧者需求滿足的效果研究. 蘇州: 蘇州大學, 2013.
27. 陳琴, 姜小鷹. 出院計劃模式的研究進展. 護理研究, 2011, 25(13): 1137-1140.
28. Hospital referral of patients for continuity of nursing care. Am J Nurs, 1947, 47(11): 761-764.
29. Anderson MA, Helms LB. Communication between continuing care organizations. Res Nurs Health, 1995, 18(1): 49-57.
30. Gulliford M, Naithani S, Morgan M. What is ‘continuity of care’?. J Health Serv Res Policy, 2006, 11(4): 248-250.
31. Biem HJ, Hadjistavropoulos H, Morgan D, et al. Breaks in continuity of care and the rural senior transferred for medical care under regionalisation. Int J Integr Care, 2003, 3(5): e03.
32. van Servellen G, Fongwa M, Mockus D’errico E. Continuity of care and quality care outcomes for people experiencing chronic conditions: a literature review. Nurs Health Sci, 2006, 8(3): 185-195.
33. Haggerty JL, Reid RJ, Freeman GK, et al. Continuity of care: a multidisciplinary review. Br Med J, 2003, 327(7425): 1219-1221.
34. Helles? R, Lorensen M. Inter-organizational continuity of care and the electronic patient record: a concept development. Int J Nurs Stud, 2005, 42(7): 807-822.
35. Simon GE, Ludman E, Unützer J, et al. Design and implementation of a randomized trial evaluating systematic care for bipolar disorder. Bipolar Disord, 2002, 4(4): 226-236.
36. Clark A, Nadash P. The effectiveness of a nurse-led transitional care model for patients with congestive heart failure. Home Healthc Nurse, 2004, 22(3): 160-162.

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