Guassora Ann Dorrit, Jarlbaek Lene, Thorsen Thorkil
The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, 5, Øster Farimagsgade, Postbox 2099, , 1014, Copenhagen K, Denmark.
PAVI, Knowledge Center for Rehabilitation and Palliative Care, National Institute of Public Health, University of Southern Denmark, 5A, Øster Farimagsgade 5A, 2nd floor, 1353, Copenhagen, Denmark.
BMC Health Serv Res. 2015 May 16;15:202. doi: 10.1186/s12913-015-0856-6.
Many patients consider the interface between secondary and primary care difficult, and in particular, the transition of care between these different parts of the healthcare system presents problems. This interface has long been recognized as a critical point for quality of care. The purpose of our study is to formulate solutions to problems identified by cancer patients and healthcare professionals during the transition from hospital back to general practice on completion of primary treatment for cancer.
A qualitative study based on focus groups at a seminar for professionals in both primary and secondary healthcare. Participants discussed solutions to problems which had previously been identified in patient interviews and in focus groups with general practitioners (GPs), hospital doctors, and nursing staff. The data were analyzed using framework analysis.
Solutions, endorsed by all groups at the seminar to improve transition back to general practice after primary treatment for cancer, were: 1) To add nurses' discharge letters addressing psychosocial matters to medical discharge letters; 2) To send medical discharge letters earlier from some hospital departments to GPs; 3) To provide plans and future affiliations for patients when they leave a department, and 4) To arrange a return visit to general practice dedicated to discussion of the patients' cancer disease and the treatment experience.
The transition of care of cancer patients appears too complex to be coordinated by administrative standards alone. We recommend that healthcare professionals are more engaged and present in the coordination of care across organizational boundaries.
许多患者认为二级医疗与初级医疗之间的衔接存在困难，尤其是医疗保健系统中这两个不同部分之间的护理过渡存在问题。长期以来，这种衔接一直被视为医疗质量的关键点。我们研究的目的是针对癌症患者和医疗保健专业人员在癌症初级治疗结束后从医院转回全科医疗过程中发现的问题制定解决方案。
在一次面向初级和二级医疗保健专业人员的研讨会上，基于焦点小组开展了一项定性研究。参与者讨论了此前在患者访谈以及与全科医生（GP）、医院医生和护理人员的焦点小组中所发现问题的解决方案。使用框架分析法对数据进行了分析。
研讨会上所有小组认可的、用于改善癌症初级治疗后转回全科医疗情况 的解决方案如下：1）在医疗出院小结中增加涉及心理社会问题的护士出院小结；2）一些医院科室更早地将医疗出院小结发送给全科医生；3）在患者离开科室时为其提供计划和未来安排，以及4）安排一次专门用于讨论患者癌症病情和治疗经历的全科医疗回访。
癌症患者的护理过渡似乎过于复杂，无法仅通过行政标准来协调。我们建议医疗保健专业人员更多地参与并介入跨组织边界的护理协调工作。
