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

1. 摘要本研究的目的是调查92名体弱老人出院后继续照护的实际情况，包括他们的家庭照护者和护士。问题在以下几个方面被发现：1】了解老年人和家庭状况；【○!2】放电计划；【○!3】召开出院会议；【○!4】教学为出院；【○!5】向出院后护理人员提供信息；【〇！】6】出院后支持。出院后继续护理方案的制定和评估我们根据初步研究的结果制定了解决继续护理问题的总体方案，并在29家医院的79名体弱老年人中进行了实际应用。通过对项目记录的分析以及主管护士和出院后护理人员填写的问卷调查，验证了该方案在解决上述问题方面是有效的。医院持续护理体系的建立1)医院护理管理人员完成问卷调查，明确医院持续护理体系配置的主题。2)对持续护理制度不同的四家医院的护理管理人员进行了访谈，并对集中型和分散型进行了调查。护士继续护理教育在“A”医院开展，后来发展成为该项目的核心要素。召开了A市卫生、医疗和福利人员座谈会，讨论建立持续照护制度的问题；相互理解加深，并与定期的团队合作活动联系在一起。

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.