Vesterlund Martha, Granger Bradi, Thompson Terry J, Coggin Chuck, Oermann Marilyn H
Medical Associates of Central Virginia, Appomattox (Ms Vesterlund); Duke University School of Nursing, Durham, North Carolina (Drs Granger and Oermann); Medical Director Hospitalist Service, Centra Southside Community Hospital, Farmville, Virginia (Dr Thompson); and Medical Associates of Central Virginia, Lynchburg (Dr Coggin).
Qual Manag Health Care. 2015 Apr-Jun;24(2):91-5. doi: 10.1097/QMH.0000000000000055.
The purpose of this project was to decrease heart failure (HF) readmissions in a rural community by redesigning the inpatient education model.
An integrated plan of care (ICP) was developed using 6 interventions, tailored to the needs of patients in this community. The interventions in this quality improvement project included (1) upgraded HF education for patients and families using teach-back methodology, (2) a discharge HF packet with survival skills, (3) nutrition education, (4) case management, (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge, and (6) a follow-up phone call to each patient within 48 hours postdischarge.
Readmission rates decreased 36.9% with implementation of the ICP. Patients without the discharge teaching/packet were almost 7 times more likely to be readmitted.
The IPC was effective in decreasing HF readmissions.
These findings suggest that organizations should focus on developing their discharge teaching methods and ICP to meet the needs of their community. Projects such as these can be used for many chronic disease processes, not only HF.
本项目的目的是通过重新设计住院教育模式来降低农村社区的心力衰竭（HF）再入院率。
制定了一项综合护理计划（ICP），采用了6种干预措施，这些措施是根据该社区患者的需求量身定制的。这个质量改进项目中的干预措施包括：（1）使用反馈教学法为患者及其家属提供升级后的心力衰竭教育；（2）一份包含生存技能的出院心力衰竭资料包；（3）营养教育；（4）病例管理；（5）为患者安排在出院后5至7天与他们的初级保健提供者进行复诊，并在出院后2周与他们的心脏病专家进行复诊；（6）在出院后48小时内对每位患者进行随访电话。
实施ICP后，再入院率下降了36.9%。没有接受出院指导/资料包的患者再入院的可能性几乎高出7倍。
综合护理计划在降低心力衰竭再入院率方面是有效的。
这些发现表明，各组织应专注于开发其出院指导方法和综合护理计划，以满足其社区的需求。此类项目不仅可用于心力衰竭，还可用于许多慢性疾病过程。
