Masters Stacey, Halbert Julie, Crotty Maria, Cheney Fiona
Department of Rehabilitation and Aged Care, Flinders University, Repatriation General Hospital, Daw Park, South Australia, Australia.
Australas J Ageing. 2008 Jun;27(2):97-102. doi: 10.1111/j.1741-6612.2008.00285.x.
Transition Care is a new program in Australia, jointly funded by the Commonwealth and State/Territory Governments. Implementation is undertaken by state health departments, in some cases through aged care organisations, against a set of key requirements. This paper examines reports from providers to reveal enablers and barriers to compliance with the requirements and to highlight emerging patterns of practice. The first 23 self-reports were content analysed. Person-centred and goal-orientated care was evidenced. General practitioner, pharmacist and geriatrician involvement in care planning and review was low. While service agreements between Transition Care services, referring hospitals and community providers improved the efficiency of information transfer and discharge arrangements, these were rare, hindering entry and discharge from the program. Transition Care offers older people a flexible model of care. While the flexibility of the model is a strength, service providers are struggling to achieve integration with existing services.
过渡护理是澳大利亚的一个新项目，由联邦政府和州/领地政府共同资助。实施工作由州卫生部门负责，在某些情况下通过老年护理机构进行，以符合一系列关键要求。本文研究了提供者的报告，以揭示符合要求的促进因素和障碍，并突出新出现的实践模式。对前23份自我报告进行了内容分析。以患者为中心和目标导向的护理得到了证明。全科医生、药剂师和老年病医生参与护理计划和审查的程度较低。虽然过渡护理服务、转诊医院和社区提供者之间的服务协议提高了信息传递和出院安排的效率，但这些协议很少见，阻碍了该项目的入院和出院。过渡护理为老年人提供了一种灵活的护理模式。虽然该模式的灵活性是一个优势，但服务提供者在努力实现与现有服务的整合方面面临困难。
