综合性医院老年失能出院患者延续性护理服务模式研究

The study of continuing care for disabled elderly patients after discharging from comprehensive hospital

目的:调查延续性护理服务模式对综合性医院老年失能出院患者的影响。方法:对出院患者实施预出院评估,筛选出老年失能且带管和(或)伤口未完全愈合的患者,出院后通过责任护士电话回访、居家护理成员上门访视、搭建居家护理宣传平台等实施延续护理干预1年。结果:老年失能患者14天再入院率降低,干预1年后并发症降低。结论:综合性医院实施延续性护理服务模式可减少护理并发症的发生,降低老年失能患者的再入院率。

Objective： To explore the impact of continuing care for discharged disabled elderly patients. Method： Firstly, conduct preliminary assessment on discharged patients, and select elderly disabled patients with catheter and （or） patients with open wounds. Secondly, conduct telephonic assessment after 1 to 2 weeks of discharge, and home visit to provide patient education on catheter care and wound care, and build continuing care platform. Result： Compared with before, the readmission and complication rate reduced. Conclusion： The implementation of continuing nursing service mode in general hospitals can decrease the readmission rate of the elderly patients with disability.