| ObjectivesTo establish hospital and community integration transitional care model of discharged patients in respiratory department to suitable for our national conditions.To evaluate the results and explore the effects on the application of this transitional care model of discharged patients in respiratory department.MethodsUsing Omaha System as theory framework,we design the respiration care problems assessment form by expert consultation and pre-experimental on transitional care needs and exisiting nursing problems from 150 discharged patients in respiratory department.Checking out previous foreign and native studies,we established the respiration hospital and community integration transitional care program which contained 3 parts:?Tertiary hospital:estabilishing respiratory patients' electronic information files,care needs assessment before discharged,intervention scheme and investigation and instruction community nurses;?Mutual referral between hospital and community:establish health service communi-cation center,clinical nurses inform nurses in communities by telephone,send patients' electronic health information files and transitional care planning to communities that patients;?The nurses in the community provide continuing care to patients and feedback according to the transitional care planning designed by clinical nurses.Inpatients in department of respiratory medicine of a hospital in Nanjing from January to December in the year of 2016 were selected by convenient sampling.We selected 128 patients as samples who signed informed consent,and all of them were meet the inclusion criteria and exclusion criteria,and we used random number table to divided them into intervention group and control group,and each group had 64 samples and intervention for 6 months.Routine care were given to the patients in control group.Patients in the intervention group accepted routine care and the hospital and community integration transitional care.The Exercise of Self-care Agency Scale(ESCA),the Short Form-36 Health Survey(SF-36),health service utilization and questionnaires of nursing service satisfaction by self-made were used to evaluate the effects of self-management ability,quality of life,health service utilization and nursing satisfaction by telephone follow-up or interview within a week before discharge,1 month,3month,and 6 month after discharge.Results1.The results of expert consultation was showed that CVI of each item was 0.91?1.00,average CVI of all items was 0.962,Cronbach'? was 0.949,and Guttman was 0.919,and retest reliability was0.988.2.There were 80.7%discharged patients needed TC.79.3%of patients selected telephone follow-up as manner of TC;48.0%of patients hoped to accept TC biweekly,and selected clinical nurses(64.7%)and community nurses(52.0%)as the executors,more than half patients(51.3%)willing to pay for transitional care,and price charge within 10-150 yuan.The number of nursing problems of patients including respiratory(100%),health care guidance(80.7%),recognition(64.0%),physical activity(52.7%)and medicine abuse(51.3%).3.The self-management ability was compared between two groups showed there is no significant differences in total score and each dimension score(P>0.05)before discharge.In total score,there were significant differences in 3 month and in 6 month after discharged(P<0.05)except in 1 month after discharged(P>0.05);in each dimension score,there were significant differences in dimension of self-management concept,sense of self-responsibility,self-management skills in 1 month,3 month and 6 month after discharged(P<0.05),no significant differences in dimension of health knowledge level(P>0.05).4.The quality of life was compared between two groups showed there is no significant differences in total score and each dimension score(P>0.05)before discharge.In total score,there were significant differences in 1 month,3 month and 6 month after discharged(P<0.05);in each dimension score,there were significant differences in GH,PF,RP,BP,SF,RE,MH in 1 month after discharged(P<0.05),and there were significant differences in all items in 3 month and 6 month after discharged(P<0.05).5.Compared with the utilization of health service between intervention group and control group,there were no statistical difference between the two groups regarding community-visit times,emergency-visit times(P>0.05).But theoutpatients-visit times and.readmission times of intervention group were significantly better than that of control group(P<0.05).6.Compared with the nursing satisfaction between intervention group and control group,there were no statistical difference between the two groups before discharged(P>0.05).At 1,3,6 month,the patients' nursing satisfaction of intervention group were better than that of control group(P<0.05).ConclusionThe hospital and community integrated transitional care in respiratorary discharged patients we established proved to be better suited the respiratorary patients.It could effectively improve the health condition and self-care ability of respiratorary patients.Transitional care has some effect on improving the utilization of health service and nursing satisfaction. |
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