Lecturer, School of Nursing, Deakin University, Burwood, Vic., AustraliaSenior Research Fellow, School of Nursing, Deakin University, Burwood, Vic., AustraliaResearch Fellow, School of Nursing, Deakin University, Burwood, Vic., Australia.
Int J Older People Nurs. 2013 Dec;8(4):253-69. doi: 10.1111/j.1748-3743.2012.00314.x. Epub 2012 Feb 7.
To synthesise research-reporting literature about multi-professional communication between health and social care professionals within transitional care for older people, with particular attention on outcomes, enabling contextual factors and constraints.
Older adults experience high rates of morbidity and health care usage, and frequently transit between health services, and community and social care providers. These transition episodes place elders at increased risk of adverse incidents due to poor communication of information. Integrated multi-professional models of care built on enhanced communication have been widely promoted as a strategy to improve transitional care for older people. However, a range of findings exist in the literature to guide service providers and researchers.
Comprehensive literature search and review strategies were employed to identify, describe and synthesise relevant studies. Ten databases were searched in addition to Google Scholar.
Specified discharge worker roles, multi-professional care coordination teams, and information technology systems promote better service satisfaction and subjective quality of life for older people when compared with standard hospital discharge. Improved multi-professional communication reduces rates of re-admission and length of stay indicating greater cost effectiveness and efficiency for the health and social care systems. Systems of care emphasizing information exchange, education and negotiation between stakeholders facilitate communication in transitional care contexts for older adults. Conversely, lack of dialogue and lack of understanding of others' roles are barriers to communication in transitional care.
Enhanced multi-professional communication, transitional pathways, and role clarity are required to improve the quality, sustainability and responsiveness of aged care into the future. Recommendations for further research include: (i) Investigation of pathways promoting person-centred care planning including the older person, their family and relevant practitioners; (ii) Development of interventions aimed at improving multi-professional communication and transitional aged care with marginalised and socially disadvantaged elders on indicators of equity and access; (iii) Investigation of changing roles for practitioners in multi-professional teams with a focus on community-based teams including nurses specialising in aged care and general practice.
综合关于健康和社会保健专业人员在老年人过渡护理中多专业沟通的研究报告文献，特别关注结果、促进因素和限制因素。
老年人发病率和医疗保健使用率高，经常在卫生服务、社区和社会保健提供者之间转移。这些过渡事件使老年人由于信息沟通不畅而面临更高的不良事件风险。基于增强沟通的多专业综合护理模式已被广泛推广为改善老年人过渡护理的策略。然而，文献中存在一系列发现，为服务提供者和研究人员提供了指导。
采用全面的文献检索和综述策略，以确定、描述和综合相关研究。除了 Google Scholar 之外，还搜索了 10 个数据库。
与标准医院出院相比，指定的出院工作人员角色、多专业护理协调团队和信息技术系统可提高老年人对服务的满意度和主观生活质量。改善多专业沟通可降低再入院率和住院时间，表明对卫生和社会保健系统的成本效益和效率更高。强调利益相关者之间信息交换、教育和协商的护理系统有助于老年人过渡护理中的沟通。相反，缺乏对话和对他人角色的不理解是过渡护理中沟通的障碍。
需要增强多专业沟通、过渡途径和角色明确性，以提高未来老年护理的质量、可持续性和响应能力。进一步研究的建议包括：（i）调查促进以患者为中心的护理计划的途径，包括患者、他们的家人和相关从业者；（ii）制定旨在改善多专业沟通和过渡性老年护理的干预措施，针对弱势群体和社会劣势老年人在公平和获取方面的指标；（iii）调查多专业团队中从业者角色的变化，重点是包括专门从事老年护理和普通科的护士的社区团队。
