The Application And Effects Of Transitional Care Programme On Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

ObjectiveThis study aimed to develop transitional care model and test its effectiveness within a sample of patients receiving continuous ambulatory peritoneal dialysis (CAPD) in Yunnan. This study provides empirical findings on the transitional care model and supplies new evidence for researchers and clinical nurses. To provide reference basis for establish long-term health care service model in Yunnan province.MethodsFrom February 2013 to September 2014,70 CAPD patients from nephrology department of the second affiliated hospital were randomly divided into two groups such as the study group (n=37) and the control group (n=33). The patients of study group were cared by the transitional care model during hospitalization and follow-up after 12 weeks of discharge while the control group were cared by the conventional care model. Transitional care model including comprehensive pre-discharge assessment, peritoneal dialysis practice exam and individual education programme during hospitalization, with the first time telephone follow-up in 48 hours and a weekly telephone follow-up service for 6 weeks after discharge. In addition, The implementation of family follow-up during the period of 6 weeks after discharge. Subjective evaluation index including quality of life and self-management ability with CAPD patients. Patients were investigated with the KDQOLTM (Kidney Disease Quality of Life)questionnaire in the day before discharge, then at week 6 and week 12 after discharge, respectively. Patients were investigated with the self-management ability questionnaire in week 12.Objective evaluation index including incidence of peritonitis and readmission rate with CAPD patients. The collected data were analvzed by the statistical software SPSS 18.0 and the statistical methods included statistical description, t-test, chi-square test. The histogram were used by the software Excel2007.ResultsFor quality of life, in study group, the scores increase amplitude during the prior to discharge to 6weeks after discharge higher than during the period of 6 weeks to 12 weeks. In control group, the scores increase amplitude during the prior to discharge to 6 weeks after discharge lower than during the period of 6 weeks to 12 weeks. The mean score of quality of life compared with study group and control group at the day before discharge, there were no statistically significant differences between two group (P>0.05). At week 6, the study group had higher mean scores for quality of life than control group, there were statistically significant differences between two group (P<0.05), however, there were statistically significant differences on physical health and symptom/problem in five dimensions at week 6(P<0.05). At week 12, the study group had significantly higher mean scores for quality of life than control group, there were statistically significant differences between two group (P<0.05), nevertheless, there were no statistically significant differences on burden of kidney disease in five dimensions at week 12 (P>0.05). With regard to self-management ability, study group had higher scores than control group on dialysis behavior and adherence, there were statistically significant differences between two group (P< 0.05). Although study group had slightly higher scores than control group on dialysis knowledge and attitude, but there were no statistically significant differences between two group (P>0.05). For incidence of peritonitis, study group was lower than control group, however, no statistically significant differences between two group (P>0.05). In terms of readmission rate, there were no statistically significant differences at week 6 (P>0.05), whereas there were statistically significant differences at week 12 (P <0.05)ConclusionThe study results showed that the transitional care model improved CAPD patients’quality of life and self-management ability. The outcomes also revealed that this care model play a positive role in reducing the incidence of peritonitis and readmission rate of the patients after discharge. The findings demonstrated that the transitional care model has been effective in improvement of health outcomes and economic results. It is a kind of emerging health care service pattern that could to maximize the health care benefits.