Hosp Case Manag. 2017 Jan;25(1):11-2.
Wake Forest Baptist Medical Center’s transitional stroke clinic, developed to provide standardized care for stroke patients discharged to home, resulted in a 48% lower risk of 30-day readmissions among patients who made just one visit to the clinic. The clinic is run by nurse practitioners who see patients within 14 days of discharge and assess them for medical, cognitive, and psychosocial needs, conduct medication reconciliation, and screen for caregiver burnout. Patients attend the clinic in addition to going to their regular follow-up visits with the neurology clinic, their primary care providers, and therapy sessions. The model also includes follow-up phone calls by an RN within two days of discharge to ensure patients have filled their prescriptions and know how to take their medication, if any equipment has arrived, and to continue the education started in the hospital.
维克森林浸信会医疗中心的过渡性中风诊所旨在为出院回家的中风患者提供标准化护理。结果显示，仅去过该诊所一次的患者30天内再次入院的风险降低了48%。该诊所由执业护士运营，他们在患者出院后14天内为其看病，评估患者的医疗、认知和心理社会需求，进行药物重整，并筛查护理人员的倦怠情况。患者除了要去神经科诊所、初级保健医生处进行定期随访以及接受治疗外，还要前往该诊所就诊。该模式还包括在出院后两天内由注册护士进行随访电话，以确保患者已取到处方药物并知道如何服药，是否有任何设备已送达，并继续在医院开始的教育。
