无论年龄大小：纳入老年医学原则以改善对有复杂需求患者的护理过渡。
Regardless of age: Incorporating principles from geriatric medicine to improve care transitions for patients with complex needs.
作者信息
Arbaje Alicia I, Kansagara Devan L, Salanitro Amanda H, Englander Honora L, Kripalani Sunil, Jencks Stephen F, Lindquist Lee A
机构信息
Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Mason F. Lord Building, Center Tower, 5200 Eastern Avenue, 7th Floor, Baltimore, MD, 21224, USA,
出版信息
J Gen Intern Med. 2014 Jun;29(6):932-9. doi: 10.1007/s11606-013-2729-1.
With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make transitions more complex, (2) engaging care "receivers" and tailoring home care to meet patient needs, (3) building "recovery plans" into transitional care, (4) predicting and avoiding preventable readmissions, and (5) adopting a palliative approach, when appropriate, that optimizes patient and family goals of care. The article concludes with a discussion of practical aspects of designing, implementing, and evaluating care transitions programs for those with complex care needs, as well as implications for public policy.
老年医学专注于采用整体方法进行患者护理、照顾者支持和医疗服务体系重新设计，增进了我们对过渡期间最佳护理的理解。本文通过讨论以下要素，提供了一个将老年医学原则纳入护理过渡活动的框架：（1）确定使过渡更加复杂的因素；（2）让护理“接受者”参与进来并定制家庭护理以满足患者需求；（3）将“康复计划”纳入过渡护理；（4）预测并避免可预防的再入院情况；（5）在适当的时候采用姑息治疗方法，以优化患者和家庭的护理目标。文章最后讨论了为有复杂护理需求的人群设计、实施和评估护理过渡项目的实际问题，以及对公共政策的影响。
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