Ko Hsiu-Ching, Pai Yu-Chu, Chu Kuo-Min
Department of Nursing, Taipei Veterans General Hospital, No. 201 Shih-Pai Road Section 2, Taipei 11217, Taiwan, ROC.
Hu Li Za Zhi. 2005 Aug;52(4):40-50.
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.
仔细分析表明，科室的病例管理有改进的潜力，以降低患者再入院率。本项目的目的是利用病例管理尽早识别患者出院后的潜在护理问题和护理需求，制定护理计划，安排服务和转诊，并促进患者高效出院。该项目还通过电话随访提供持续护理。该项目分为准备、实施和评估阶段。我们的结果表明，我们不仅提高了护理质量和护患关系，而且显著增加了遵循出院计划的患者数量（从31例增加到74例，增加了138%）以及电话随访的患者数量（从31例增加到253例，增加了716%）。出院计划的满意度评分从2.8提高到4.4，再入院率从12.1%降至4.5%。因此，我们可以看出，出院计划和电话随访对于提高服务质量和患者满意度非常重要。
