从医院到家庭的联系:确保慢性病患者的高质量过渡
Emily Simon1, Melissa Feeney1, Joan Mendenhall1
1Strive Health, Denver, CO, USA.
Journal of patient experience
|September 2, 2025
概括
过渡性护理管理 (TCM) 计划显著减少慢性病患者的再入院. 这种以患者为中心的方法提高了患者的坚持和导航能力,使再入院率降低了42%.
科学领域:
- 肝脏病学
- 医疗保健管理
- 提高质量
背景情况:
- 与普通人群相比,慢性病患者的再入院率更高.
- 联邦计划激励过渡期护理管理 (TCM) 以改善患者的结果并降低成本.
- 基于价值的护理模式旨在改善患者住院后的旅程.
研究的目的:
- 评估基于价值的护组织的TCM计划在减少慢性病患者再入院的有效性.
- 评估TCM对患者意识,药物坚持和护理导航的影响.
- 确定与TCM计划注册相关的再接收率的降低.
主要方法:
- 采用了一个质量改善案例研究设计.
- 在分析中包括适度至高风险的可接受再入院的CKD患者.
- 在TCM计划中注册的患者和拒绝的患者之间的再入院率的比较.
主要成果:
- 加入TCM计划导致医院再入院的数量在出院后的7,14和30天显著减少 (P < .01).
- 在TCM参与者中,再入院率在7天降低了42%,在14天降低了37%,在30天降低了25%.
- 这项TCM计划对患者参与和护理协调产生了积极影响.
结论:
- 以患者为中心的过渡性护理方法,如TCM,有效地减少了CKD患者的再入院.
- 实施TCM计划可以减少患者利用率并提高住院后护理质量.
- 医疗机构应采用TCM策略,以优化对高风险患者的护理.
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