Department of Physical Therapy, Indiana University, Indianapolis, IN.
Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA.
Arch Phys Med Rehabil. 2019 Jun;100(6):1162-1175. doi: 10.1016/j.apmr.2018.10.017. Epub 2018 Nov 19.
Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group's Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs. Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.
基于对证据的回顾，美国康复医学会卒中组运动干预工作组的成员提出了以下 5 项建议，以帮助改善患者及其护理人员的护理交接：（1）改善沟通流程；（2）使用交接专家；（3）实施以患者为中心的出院清单；（4）使用标准化的结果测量指标；（5）与社区健康计划建立伙伴关系。由于医疗保健政策的变化，有动力在卒中康复期间改善交接。尽管交接管理计划通常包括多学科团队、药物管理、护理人员教育和随访护理管理，但在卒中后康复期间实施交接管理协议缺乏全面和标准化的方法。本文使用交接模型（TOC）来构思如何在出院时实现全面的以患者为中心的交接，以最大限度地提高患者的功能和健康。具体来说，本文回顾了当前的指南，并提供了一些常见方法（早期支持性出院、计划出院前家访、出院清单）的证据总结，以管理交接，然后描述了有效的交接障碍。以患者为中心和标准化的交接管理可以改善卒中幸存者的社区融入、日常生活活动表现和生活质量，同时还可以降低从医院到家庭到社区的过渡期间的再入院率。
