Health Empowerment Theory -Based Transitional Care Model For Retired Cadres Of PLA From Hospital To Home

Objective To investigate the hospital-to-home transitional care needs and willingness of retired cadres of PLA.Through the establishment of health empowerment theory based transitional care model for retired cadres to enhance their self- management capacity and improve their physical and mental health level.Methods 1. Systematic literature reviews were performed in the databases Pubmed,Cochrane and Embase and four Chinese databases to find evidence-based effective interventions for elders' hospital-to-home transitional care model.2. The self-designed questionnaire was used to investigate the transitional care needs and willingness of 208 retired cadres of PLA from three hospitals. Logistic regression analysis was performed on the relevant factors influencing the care willingness of them.3. The semi-structured interviews were conducted with the caregivers and medical staffs of the retired cadres in the transitional period to explore the current situation and necessity of constructing the transitional care model.4.Delphi method was conducted on 21 nursing experts to form a health empowerment theory based transitional care model framework for retired cadres .5. A total of 60 retired cadres with coronary heart disease were divided into experimental group and control group. In the experimental group, the transitional care model was used,while the control group was treated with routine discharge care. The baseline level of the two groups was analyzed,and the physical and mental health status,the hospitalization rate and the satisfaction rate were observed after 1 month and 2 months after the intervention.Results 1. 19 articles met inclusion criteria and the literature shows: hospital-to-home transitional care should be implemented as individualized nursing care based on comprehensive assessment; transitional care nurses are required to have high quality; The strategy of empowerment can improve the long-term effect of patient self-care .2. 208 military retired cadres average age 84.16 ± 7.36, 62.5% of them suffering from more than 5 diseases, 39.90% of them admitted to hospital more than 3 times a year, 63.31%of their readmission due to the same disease, emergency admission accounted for 54.81 %.84.13% of the retired cadres are willing to accept hospital-to-home transitional care. The transitional care willingness of the retired cadres is related to the way of admission, the kinds of diseases and the frequency of admission per year.3. The caregivers' interviews include six themes: tired of daily care, bear the pressure of multiple roles, influenced by the patient's mood changes, lack of trust of patients, feeling helpless when responding to emergencies, hope to get professional guidance; The medical staffs' interviews include five themes: the retired cadres' transitional care is not paid enough attention, implementation is full of challenges, role expectation, self-management is expected, thinking of the implementation details.4.After collecting and analyzing the valid questionnaires of Delphi method, we established the health empowerment theory based transitional care model.5. The transitional care model effectively improved the self-efficacy and satisfaction of the retired cadres and improved the physical and mental health level.Conclusions The average age of the retired cadres was 84.16 years old, 62.5% of the retired cadres had more than 5 diseases, 39.90% of them were hospitalized >3 times, and 63.31% of the retired cadres were hospitalized for the same disease. According to the retired cadres' care willingness, the caregiver and the medical staffs' interview and the experts' suggestion , health empowerment theory -based transitional care model for retired cadres of PLA was established.lt shows that the model can effectively improve the self-efficacy and self-care ability of the retired cadres from hospital to home during the transitional period and improve their health outcomes.