从熟练护理机构到家庭的复杂过渡：患者和护理人员的观点。
Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives.
机构信息
Indiana University Center for Aging Research, Indianapolis, IN, USA.
Regenstrief Institute, Inc., Indianapolis, IN, USA.
出版信息
J Gen Intern Med. 2021 May;36(5):1189-1196. doi: 10.1007/s11606-020-06332-w. Epub 2020 Nov 2.
BACKGROUND
Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship.
OBJECTIVE
To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home.
DESIGN
Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone.
PARTICIPANTS
A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers.
MAIN MEASURES
A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition.
KEY RESULTS
The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home.
CONCLUSIONS
Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.
背景
从医院过渡到熟练护理机构（SNF）再回到家中的患者群体具有多种合并症和功能障碍，他们经历了一系列复杂的转变，这使他们成为一个独特的患者群体。在护理过渡研究中，对于从医院出院到 SNF 然后再返回家中的患者的需求和结果研究不足。
目的
研究从医院过渡到 SNF 再回到家中的患者和照护者所面临的挑战和观点。
设计
在从 SNF 出院后 48 小时至 1 周内，对在家中的患者和照护者进行了便利样本的半结构式访谈。在基线访谈后的 1 至 2 周内，通过电话进行了随访访谈。
参与者
共有 39 名受访者，包括经历从医院到熟练护理机构再到家庭的一系列过渡的老年人及其非专业照护者。
主要措施
采用建构主义、扎根理论方法对访谈进行编码，确定主要主题和子主题，并开发一个理论模型来解释从 SNF 到家庭过渡的结果。
主要结果
患者的平均年龄为 76.6 岁，照护者的平均年龄为 64.8 岁。确定了四个主要主题：家的舒适、信息需求、SNF 后的护理以及独立性。患者表示离家时间延长，并渴望返回并留在家中。信息需求的满足程度不同，这会影响 SNF 后的护理，包括药物管理、预约以及治疗的进展和挫折。受访者认为在家中独立生活是过渡回家的最重要结果。
结论
从 SNF 出院后需要迅速提供在家中的支持，以防止不良后果。基于患者和照护者的独特情况和需求，在家中的支持需要高度个体化。
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