过渡期护理与出院计划、连续性护理的关系研究进展_West China Medical Journal

Authors：

刘欢 ¹ ,  宁宁 ² , 田永明 ¹

1. ;
2. ;

Corresponding author：

宁宁, Email: gkningning@126.com

Keywords：

过渡期护理; 出院计划; 连续性护理

DOI：

10.7507/1002-0179.201609218

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由于我国目前的医疗资源严重不能满足民众需求，医疗机构尝试通过缩短平均住院日、提高医疗服务效率和质量来提高病床周转率，而随着住院时间的缩短，患者常常在康复的中期出院而非完全康复后才出院。为保证患者出院安全，降低出院后不良事件的发生率和再入院率，过渡期护理、出院计划、连续性护理等相关概念和模式应运而生并被应用到临床，但国内部分研究对三者的内涵意义混淆不清。该文通过对过渡期护理的概念、研究内容、模式，出院计划的概念、实施过程，以及连续性护理的概念、实施要素进行阐述和分析，明确指出连续性护理是一种广泛的护理理念，为了实现患者照护的连续性，不同研究者提出了出院计划、过渡期护理、个案管理等护理模式或护理方案，共同形成了促进患者连续性照护的协调性、连续性、跨机构的健康网络。

Citation： 刘欢, 宁宁, 田永明. 过渡期护理与出院计划、连续性护理的关系研究进展. West China Medical Journal, 2017, 32(12): 1984-1987. doi: 10.7507/1002-0179.201609218 Copy

1.	宋萍, 张际. 以缩短平均住院日为切入点提高医院资源利用效率. 中国医院管理, 2009, 29(5): 10-11.
2.	汤维娟, 孙菲, 王毅欣, 等. 跨机构的连续性照护模式的研究进展. 护理研究, 2001, 25(3A): 572-574.
3.	姚立群, 庞书勤, 郑丽维, 等. 连续性护理的概念内涵及测量工具的研究进展. 中华护理杂志, 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.	单伟颖, 李青, 郭金玉. 过渡期护理模式的研究进展. 中华护理杂志, 2010, 45(3): 284-286.
7.	徐淑华, 孙静, 王芳, 等. ICU重度颅脑损伤患者转普通病区过渡期护理模式的实践. 护理学报, 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.	吕元红, 周雀云, 麦瑞琼. 过渡期护理模式在低体重早产儿中的应用探讨. 护士进修杂志, 2014, 29(9): 799-801.
18.	卿利敏, 席明霞, 莫文娟, 等. 过渡期护理模式对慢性阻塞性肺疾病出院患者自护行为的干预效果. 中华护理杂志, 2011, 46(10): 965-967.
19.	张建新, 张志坚, 饶富兰, 等. 过渡期护理模式对脑梗死出院患者肢体功能康复进程的影响. 南昌大学学报: 医学版, 2013, 53(4): 73-75.
20.	赵俐红, 杨蓉, 涂双燕, 等. 脑卒中病人出院-回家过渡期管理模式初探. 护理研究, 2014, 28(2B): 608-609.
21.	王赞丽. 对脑卒中家庭照顾者实施过渡期护理干预的效果研究. 天津: 天津医科大学, 2012.
22.	席淑华, 赵继军, 赵建华, 等. 成功大学附属医院出院准备服务概况与启示. 中华护理杂志, 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.	赵岳. 探讨连续护理过程中出院计划模式的应用. 中国护理管理, 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.	卢珏. 出院计划对脑卒中患者主要照顾者需求满足的效果研究. 苏州: 苏州大学, 2013.
27.	陈琴, 姜小鹰. 出院计划模式的研究进展. 护理研究, 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.	Hellesø 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, 张际. 以缩短平均住院日为切入点提高医院资源利用效率. 中国医院管理, 2009, 29(5): 10-11.
2. 汤维娟, 孙菲, 王毅欣, 等. 跨机构的连续性照护模式的研究进展. 护理研究, 2001, 25(3A): 572-574.
3. 姚立群, 庞书勤, 郑丽维, 等. 连续性护理的概念内涵及测量工具的研究进展. 中华护理杂志, 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. 单伟颖, 李青, 郭金玉. 过渡期护理模式的研究进展. 中华护理杂志, 2010, 45(3): 284-286.
7. 徐淑华, 孙静, 王芳, 等. ICU重度颅脑损伤患者转普通病区过渡期护理模式的实践. 护理学报, 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. 吕元红, 周雀云, 麦瑞琼. 过渡期护理模式在低体重早产儿中的应用探讨. 护士进修杂志, 2014, 29(9): 799-801.
18. 卿利敏, 席明霞, 莫文娟, 等. 过渡期护理模式对慢性阻塞性肺疾病出院患者自护行为的干预效果. 中华护理杂志, 2011, 46(10): 965-967.
19. 张建新, 张志坚, 饶富兰, 等. 过渡期护理模式对脑梗死出院患者肢体功能康复进程的影响. 南昌大学学报: 医学版, 2013, 53(4): 73-75.
20. 赵俐红, 杨蓉, 涂双燕, 等. 脑卒中病人出院-回家过渡期管理模式初探. 护理研究, 2014, 28(2B): 608-609.
21. 王赞丽. 对脑卒中家庭照顾者实施过渡期护理干预的效果研究. 天津: 天津医科大学, 2012.
22. 席淑华, 赵继军, 赵建华, 等. 成功大学附属医院出院准备服务概况与启示. 中华护理杂志, 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. 赵岳. 探讨连续护理过程中出院计划模式的应用. 中国护理管理, 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. 卢珏. 出院计划对脑卒中患者主要照顾者需求满足的效果研究. 苏州: 苏州大学, 2013.
27. 陈琴, 姜小鹰. 出院计划模式的研究进展. 护理研究, 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. Hellesø 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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