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Related Concept Videos

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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Transitional Care Management from Emergency Services to Communities: An Action Research Study.

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Summary
This summary is machine-generated.

Transitional care for elderly patients discharged from emergency services is poor, with low continuity and high readmission rates. Improving hospital-to-community care coordination is urgently needed for better patient outcomes.

Keywords:
agedcaregiversemergenciesemergency nursingpatient dischargetransitional care

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Area of Science:

  • Nursing
  • Gerontology
  • Health Services Research

Background:

  • Nurses are developing hospital-to-community transition projects.
  • Effective transitional care is crucial for elderly patients post-emergency services discharge.

Purpose of the Study:

  • To analyze transitional care for elderly individuals (70+) discharged from emergency services back to the community.

Main Methods:

  • Action research involving nurses, elderly patients, and caregivers.
  • Data collection via interviews, medical records, observation, phone calls, and meetings.
  • Qualitative analysis (Bardin's) and statistical treatment (SPSS).

Main Results:

  • Only 31.4% experienced care continuity post-discharge.
  • 33.4% were readmitted to emergency services within 30 days.
  • Identified issues include poor referral data, inter-level communication barriers, lack of policies, and low patient health literacy.

Conclusions:

  • Urgent need to improve hospital-to-community care coordination for elderly patients.
  • Transitional care planning must address communication, policy, and patient understanding.
  • Enhanced support is vital for patients returning home after emergency care.