Verified Research on Continuity of Care after Hospital Discharge among Frail Elderly

1.本研究旨在探讨92位出院老人、其家属照顾者及护理人员的持续照顾现况。在以下方面发现了问题：[○！1]了解老人和家庭的情况; [○！2]出院规划; [○！3]召开出院会议;【○！4]出院教学; [○！5]向出院后护理提供者提供信息;以及[○！6]放电后的支持。2.出院后继续照护方案的开发与评估我们根据初步研究的结果，开发了一个解决继续照护问题的整体方案，并在29家医院的79名体弱老人中进行了实际应用。通过对项目记录的分析以及对主管护士和出院后护理人员的问卷调查，验证了该项目能有效解决上述问题.医院持续照护系统的建立1）各医院护理管理人员完成问卷调查，厘清医院持续照护系统配置的主题。2）访谈四家持续照护系统不同的医院的护理管理人员，3）在A医院开展护士继续护理教育，后来发展成为那里的程序的核心元素。为了建立持续护理制度，“A”市的卫生、医疗和福利工作人员举行了一次研讨会;加深了相互理解，并将其与定期合作小组活动联系起来。

1. Study of Care Received among Frail Elderly and Their Families after Discharge from HospitalThe purpose of this study was to investigate the actual conditions of continuing care among 92 elderly who were discharged from hospital, their family caregivers and their nurses. Problems were found in the areas: 【○!1】understanding about conditions of elderly and family; 【○!2】discharge planning; 【○!3】holding discharge conference; 【○!4】teaching for discharge; 【○!5】information to post-discharge care providers; and 【○!6】support after discharge.2. Development and Evaluation of a Program for Continuing Care after Hospital DischargeWe developed an overall program for solving the problems of continuing care based on the results of the initial study, which was put to practical use among 79 frail elderly at 29 hospitals. The program was verified to be effective in the solution of the above-mentioned problems from analysis of program records and questionnaires completed by charge nurses and post-discharge care providers.3. Establishment of a Continuing Care System in Hospital1) Nursing administrators at the hospitals completed questionnaires and the subject of the continuing care system configuration in a hospital was clarified.2) Interviews were conducted with the nursing administrators of four hospitals where continuing care systems differ, and a concentrated type and a distributed type were examined.3) Nurse education about continuing care was carried out in "A" hospital, and later developed into a core element of the program there.4. A symposium by the health, medical and welfare staffs of "A" city was held for the purpose of establishment of a continuing care system ; mutual understanding was deepened, and it was tied to periodic cooperative team activity.