Narsavage G L, Naylor M D
MSN Programs, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio 44106-4904, USA.
J Gerontol Nurs. 2000 May;26(5):14-20. doi: 10.3928/0098-9134-20000501-08.
Referrals for home care services initiated prior to hospital discharge may prevent or delay readmission or nursing home placement, especially for elderly individuals with multiple, chronic health problems. While multiple factors could justify the need for home follow-up after hospital discharge, little is known about those patient factors associated with clinicians' decisions to refer older adults with cardiac or pulmonary disorders. Increased understanding of factors that contribute to initiating a home care referral could enhance clinicians' decision-making and thus improve post-discharge outcomes for these patient groups. This study examined patient factors associated with and predictive of the decision to refer for home follow-up, using a sample of older adults hospitalized with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Study findings suggest a model that includes patients diagnosed with both COPD and CHF, who are not married, need home health aides, and have a longer than average length of hospital stay may be helpful in predicting the need for home care referrals.
在出院前启动家庭护理服务转诊，可能会预防或延迟再次入院或入住疗养院，特别是对于患有多种慢性健康问题的老年人。虽然有多种因素可以解释出院后进行家庭随访的必要性，但对于那些与临床医生决定转诊患有心脏或肺部疾病的老年人相关的患者因素，我们知之甚少。对促成启动家庭护理转诊的因素有更多了解，可能会增强临床医生的决策能力，从而改善这些患者群体的出院后结局。本研究以患有慢性阻塞性肺疾病（COPD）或充血性心力衰竭（CHF）的住院老年患者为样本，研究了与转诊进行家庭随访的决策相关且可预测该决策的患者因素。研究结果表明，一个包括被诊断患有COPD和CHF、未婚、需要家庭健康助理且住院时间长于平均水平的患者的模型，可能有助于预测家庭护理转诊的需求。
