Chapin Rosemary Kennedy, Chandran Devyani, Sergeant Julie F, Koenig Terry L
a Office of Aging and Long Term Care, School of Social Welfare , University of Kansas , Lawrence , Kansas , USA.
Soc Work Health Care. 2014;53(4):311-29. doi: 10.1080/00981389.2014.884037.
Discharges from the hospital to community-based settings are more difficult for older adults when there is lack of communication, resource sharing, and viable partnerships among service providers in these settings. The researchers captured the perspectives of three different groups of participants from hospitals, independent living centers, and Area Agencies on Aging, which has rarely been done in studies on discharge planning. Findings include identification of barriers in the assessment and referral process (e.g., timing of discharge, inattention to client goals, lack of communication and partnerships between hospital discharge planners and community providers), and strategies for overcoming these barriers. Implications are discussed including potential for Medicaid and Medicare cost reductions due to fewer re-hospitalizations.
当这些环境中的服务提供者之间缺乏沟通、资源共享和可行的伙伴关系时，老年人从医院出院并转至社区环境会更加困难。研究人员收集了来自医院、独立生活中心和地区老龄问题机构的三组不同参与者的观点，这在出院计划研究中很少见。研究结果包括确定评估和转诊过程中的障碍（例如，出院时间、对客户目标的忽视、医院出院计划人员与社区提供者之间缺乏沟通和伙伴关系）以及克服这些障碍的策略。文中还讨论了相关影响，包括因再住院次数减少而降低医疗补助和医疗保险成本的可能性。
