3Naylor M, Brooten D, Jones R, et al. Comprehensive dis charge planning for the hospitalized elderly. A randomized clinical trial[J].Ann Intern Med, 1994,120(12) : 999-1006.
4Naylor M, Brooten D, Campbell R,et al. Comprehensive discharge planning and home follow up of hospitalized elders: a randomized clinical trial[J]. JAMA, 1999,281 (7):613 -620.
5Naylor M, Brooten D, Campbell R, et al. Transitional care of older adults hospitalized with heart failure:a ran- domized controlled trial[J]. J Am Geriatr Soe, 2004,52 (5) :675-684.
6Coleman E A, Boult C E. American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs[J]. J Am Geriatr Soc,2003,51(4) :556- 557.
7Wong F K, Mok M P, Chan T, et al. Nurse follow-up of patients with diabetes: randomized controlled trial [J]. J Adv Nuts,2005,50(4) :391-402.
8Chen Z T, Lin C, Dai Y T. The problems of family caregiving among discharged patients in first month[J]. Nurs Res,1999,7(5):423 434.
9Saultz J W, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review[J]. Ann Fam Med,2004,2(5) :445-451.
10Shepperd S, Doll H, Angus R M,et al. Avoiding hospital admission through provision of hospital care at home: a systematic review and meta analysis of individual patient data[J].CMAJ, 2009,180(2) :175-182.
