Research progress of transitional care programs on patients with chronic diseases_West China Medical Journal

Authors：

CAO Xiaoyi ¹ , CHEN Lin ¹ , SHI Mei ¹ ,  JIANG Xiaolian ²

1. Hemodialysis Center, Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. School of Nursing, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

JIANG Xiaolian, Email: jiang_xiaolian@126.com

Keywords：

Chronic diseases; Transitional care; Literature review

DOI：

10.7507/1002-0179.201609264

Video：

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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.

Citation： CAO Xiaoyi, CHEN Lin, SHI Mei, JIANG Xiaolian. Research progress of transitional care programs on patients with chronic diseases. West China Medical Journal, 2018, 33(8): 1037-1041. doi: 10.7507/1002-0179.201609264 Copy

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.

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.

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