[Promoting the efficacy of discharge planning through the case management model]

Careful analysis has shown that case management in unit, has the potential to be improved in to reduce patient re-admission rates. The purposes of this project were to use case management to identify as early as possible the potential care problems and care needs of patients after discharge, to establish care programs, to arrange services and transfers, and facilitate efficient patient discharges. The project also provided sustainable care via telephone visiting. The project was divided into preparation, performance and evaluation phases. Our results showed that we not only improved the quality of nursing care, and the nursing-patient relationship, but that we also dramatically increased the number of patients following discharge planning (from 31 to 74, an increase of 138%), and telephone visiting (from 31 to 253, an increase of 716%). The rate of satisfactions with discharge planning increased from 2.8 to 4.4, and the re-admission rate decreased from 12.1% to 4.5%. Thus, we can see that discharge planning and telephone visiting are very important to improvements in service quality and the satisfaction of patients.