以慢性病患者为中心的延续性护理模式的实施与效果

Implementation and effects of transitional care centered by patients with chronic diseases

目的探索以慢病患者为中心的延续性护理服务模式及其效果。方法成立了"慢病延续性护理管理小组",组建了社区健康教育学校、护理社康部、出院随访组、医院-社区专科护理协作小组4个平台,全方位为出院慢病患者提供规划化、延续性护理服务。实施前后对患者满意度、对疾病知识知信行及护理人员满意度进行比较。结果实施前后,患者的对疾病的认知、信念、相关行为明显改善,差异具有统计学意义(P<0.01);患者对护理工作的满意度明显提高,差异具有统计学意义(P<0.01);护士对护理工作的满意度明显提高,差异具有统计学意义(P<0.01)。结论以延续性护理管理小组为主导的团队化、分工协作性的护理服务模式具有可行性、有效性,为慢病患者提供更专业的延续性护理服务。

Objective To analyze the effects of transitional care in patients with chronic diseases. Methods The transitional care team was established to provide continuous nursing for discharged patients with chronic diseases,and the members of team bad different tasks including community health education school,community health care depart- ment,follow-up team,and hospital-community collaboration group. The effectiveness was evaluated by questionnaire from patients and nurses. Results Transitional care enhanced the cognition,attitude and behaviorofpatients（P〈0.01） and improved patients＇ satisfaction（P〈0.01） and job satisfaction of nurses （P〈0.01）. Conclusion Transitional care is feasible and effective to provide continuous nursing for patients with chronic diseases.