School of Healthcare, Baines Wing, University of Leeds, Leeds, LS2 9JT, UK. Electronic address: Jane.O'
Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK.
Appl Ergon. 2020 May;85:103060. doi: 10.1016/j.apergo.2020.103060. Epub 2020 Jan 22.
The period following discharge can present risks for older adults. Most research has focused on hospital discharge with less attention paid to on-going care needs. Despite evidence that patients undertake 'invisible work' to improve care safety, their reported willingness to be involved in care, and the consensus that successful transitions interventions include patient involvement, in reality, this is variable. Further, little research has viewed transitional care as a 'system', with gaps, interdependencies and variability across settings, nor the role of patients and families in supporting the system resilience.
We drew data from two studies: i) exploring the perspective of older adults across transitional care, and ii) exploring how health services experience transitional care. We employed the FRAM to develop a model of transitional care, with a system boundary spanning an older patient's admission to hospital, through to thirty days post-discharge.
Modelling transitional care from multiple perspectives was challenging. 27 functions were identified with interdependencies between hospital-based functions and patient-led functions once home, the success of which may impact on transitions 'outcomes' (e.g. safety events, readmissions). The model supported development of a theory of change, to guide future intervention development.
Supporting certain patient-facing upstream hospital functions (e.g. encouraging mobility, supporting a better understanding of medication and condition), may lead to improved outcomes for patients following hospital discharge.
出院后的阶段可能会给老年人带来风险。大多数研究都集中在医院出院上，而对持续的护理需求关注较少。尽管有证据表明患者为改善护理安全而进行“无形工作”，他们报告的参与护理的意愿，以及成功的过渡干预措施包括患者参与的共识，但实际上，这种情况是多种多样的。此外，很少有研究将过渡护理视为一个“系统”，存在着各个设置之间的差距、相互依存性和可变性，也没有研究患者和家庭在支持系统弹性方面的作用。
1）使用功能共振分析方法（FRAM）从多个角度对过渡护理进行建模；2）使用该模型开发一个变化理论，以支持干预措施的发展。
我们从两项研究中提取数据：i）探索过渡护理的老年人的多个角度，ii）探索卫生服务机构的过渡护理体验。我们采用 FRAM 来开发过渡护理模型，其系统边界跨越了老年患者从入院到出院后三十天的过程。
从多个角度对过渡护理进行建模具有挑战性。确定了 27 个功能，其中包括医院内功能和患者主导的功能之间的相互依存关系，这些功能的成功可能会影响过渡“结果”（例如安全事件、再入院）。该模型支持了变化理论的发展，以指导未来的干预措施的发展。
支持某些面向患者的上游医院功能（例如鼓励活动能力、支持更好地理解药物和病情），可能会改善患者出院后的结果。
