华西医学

华西医学

慢性病患者过渡期管理干预的研究进展

查看全文

慢性病患者出院后从医院过渡至家庭的过渡期健康管理面临严峻挑战,如缺乏充分的出院准备度、出院后用药错误增加、自我管理能力不足,无法参与健康照护决策等,这些均可导致出院患者的再入院率增加,危及患者安全。该文对国内外慢性病患者过渡期管理的定义、过渡期管理单成分干预策略、过渡期管理多成分干预策略进行了综述,以期为我国开展安全、有效的慢性病患者过渡期健康管理干预提供参考和借鉴。

Patients with chronic diseases usually face severe challenges during their transition from hospital to home, such as poor discharge preparation, the increased incidence of medical errors, insufficient self-care capability, and poor participation in healthcare decision, which can result in increased readmission and poor patient safety. This paper reviews the definition of transitional care, single-element transitional care intervention strategy, and multiple-element transitional care intervention strategy, in order to provide new insights into the development of effective and safe transitional care strategies in China.

关键词: 慢性病; 过渡期管理; 文献综述

Key words: Chronic diseases; Transitional care; Literature review

引用本文: 曹晓翼, 陈林, 石梅, 蒋晓莲. 慢性病患者过渡期管理干预的研究进展. 华西医学, 2018, 33(8): 1037-1041. doi: 10.7507/1002-0179.201609264 复制

登录后 ,请手动点击刷新查看全文内容。 没有账号,
1. Rosenthal JM, Miller DB. Providers have failed to work for continuity. Hospitals, 1979, 53(10): 79-83.
2. Verweij L, Jepma P, Buurman BM, et al. The cardiac care bridge program: design of a randomized trial of nurse-coordinated transitional care in older hospitalized cardiac patients at high risk of readmission and mortality. BMC Health Serv Res, 2018, 18(1): 508.
3. Grace SL, Krepostman S, Brooks D, et al. Referral to and discharge from cardiac rehabilitation: key informant views on continuity of care. J Eval Clin Pract, 2006, 12(2): 155-163.
4. Coleman EA, Boult C, American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc, 2003, 51(4): 556-557.
5. Assiri GA, Grant L, Aljadhey H, et al. Investigating the epidemiology of medication errors and error-related adverse drug events (ADEs) in primary care, ambulatory care and home settings: a systematic review protocol. BMJ Open, 2016, 6(8): e010675.
6. Kavanagh C. Medication governance: preventing errors and promoting patient safety. Br J Nurs, 2017, 26(3): 159-165.
7. Sluggett JK, Ilomäki J, Seaman KL. Medication management policy, practice and research in Australian residential aged care: current and future directions. Pharmacol Res, 2017, 116: 20-28.
8. Cao XY, Tian L, Chen L, et al. Effects of a hospital-community partnership transitional program in patients with coronary heart disease in Chengdu, China: a randomized controlled trial. Jpn J Nurs Sci, 2017, 14(4): 320-331.
9. Couppé C, Comins J, Beyer NH, et al. Health-related quality of life in patients with chronic rheumatic disease after a multidisciplinary rehabilitation regimen. Qual Life Res, 2017, 26(2): 381-391.
10. Johnson-Warrington V, Rees K, Gelder C, et al. Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomized controlled trial. Int J Chron Obstruct Pulmon Dis, 2016, 11: 1161-1169.
11. Toback M, Clark N. Strategies to improve self-management in heart failure patients. Contemp Nurse, 2017, 53(1): 105-120.
12. Rymer JA, Kaltenbach LA, Anstrom KJ, et al. Hospital evaluation of health literacy and associated outcomes in patients after acute myocardial infarction. Am Heart J, 2018, 198: 97-107.
13. Williams MV, Davis T, Parker RM, et al. The role of health literacy in patient-physician communication. Fam Med, 2002, 34(5): 383-389.
14. Ha Dinh TT, Bonner A, Clark RT, et al. The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review. JBI Database System Rev Implement Rep, 2016, 14(1): 210-247.
15. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med, 2009, 360(14): 1418-1428.
16. Garg T, Lee JY, Evans KH, et al. Development and evaluation of an electronic health record-based best-practice discharge checklist for hospital patients. Jt Comm J Qual Patient Saf, 2015, 41(3): 126-131.
17. Hirschman KB, Shaid E, McCauley K, et al. Continuity of care: the transitional care model. Online J Issues Nurs, 2015, 20(3): 1.
18. Mackavey C. Advanced practice nurse transitional care model promotes healing in wound care. Care Manag J, 2016, 17(3): 140-149.
19. Rosen BT, Halbert RJ, Hart K, et al. The enhanced care program: impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities. J Hosp Med, 2018, 13(4): 229-236.
20. Mitchell SE, Weigel GM, Laurens V, et al. Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study. BMC Health Serv Res, 2017, 17(1): 291.
21. Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med, 2013, 8(8): 421-427.
22. Marsteller JA, Hsu YJ, Wen M, et al. Effects of guided care on providers’ satisfaction with care: a three-year matched-pair cluster-randomized trial. Popul Health Manag, 2013, 16(5): 317-325.
23. 王少玲, 黄金月, 周家仪. 建立慢性阻塞性肺疾病延续护理的循证实践. 中华护理杂志, 2009, 44(5): 431-434.
24. 任玉英, 杨雪梅, 蒋晓莲, 等. 过渡期护理模式在冠心病病人出院过渡期中的应用效果. 护理研究, 2017, 31(9): 1068-1071.
25. 顾玉萍. 过渡期护理干预模式对出院慢性阻塞性肺疾病病人生活质量和疾病不确定感的影响. 全科护理, 2017, 15(23): 2891-2893.
26. 钟彩棠, 廖莲清, 张春梅, 等. 过渡期护理模式在出院后中度慢性阻塞性肺疾病病人肺功能改善中的应用. 护理管理杂志, 2015, 15(2): 117-119.