Bruce W. Carter Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center and Research Service, Miami, Florida 33125, USA.
Gerontologist. 2010 Aug;50(4):451-8. doi: 10.1093/geront/gnq015. Epub 2010 Feb 25.
Community-based frail older adults, burdened with complex medical and social needs, are at great risk for preventable rapid rehospitalizations. Although federal and state regulations are in place to address the care transitions between the hospital and nursing home, no such guidelines exist for the much larger population of community-dwelling frail older adults. Few studies have looked at interventions to prevent rehospitalizations in this large segment of the older adult population. Similarly, standardized disease management approaches that lower hospitalization rates in an independent adult population may not suffice for guiding the care of frail persons. Care management interventions currently face unique challenges in their attempt to improve the transitional care of community-dwelling older adults. However, impending national imperatives aimed at reducing potentially avoidable hospitalizations will soon demand and reward care management strategies that identify frail persons early in the discharge process and promote the sharing of critical information among patients, caregivers, and health care professionals. Opportunities to improve the quality and efficiency of care-related communications must focus on the effective blending of training and technology for improving communications vital to successful care transitions.
社区中身体虚弱的老年人，由于存在复杂的医疗和社会需求，面临着可预防的快速再次住院的巨大风险。尽管联邦和州的法规已经到位，以解决医院和疗养院之间的护理过渡问题，但对于居住在社区中的数量庞大的体弱老年人来说，没有这样的指导方针。很少有研究关注干预措施，以防止这一大部分老年人群体再次住院。同样，在独立成年人中降低住院率的标准化疾病管理方法可能不足以指导体弱患者的护理。在努力改善居住在社区中的体弱老年人的过渡性护理方面，护理管理干预措施目前面临着独特的挑战。然而，即将出台的旨在减少潜在可避免住院的国家强制性措施，将很快要求并奖励那些能够在出院过程中及早识别体弱患者并促进患者、护理人员和医疗保健专业人员之间共享关键信息的护理管理策略。提高与护理相关的沟通质量和效率的机会必须侧重于培训和技术的有效融合，以改善对成功过渡护理至关重要的沟通。
