Department of Public Health Services, Kangwon National University Hospital, Chuncheon, Korea.
Department of Health Policy and Management, Kangwon National University School of Medicine, Chuncheon, Korea.
J Korean Med Sci. 2020 Nov 2;35(42):e352. doi: 10.3346/jkms.2020.35.e352.
Community-based health management policies are needed considering societal aging. We aimed to develop a transitional care model (TCM) program for patients with pneumonia, asthma, and chronic obstructive pulmonary disease. First, we conducted in-depth interviews with patients who were hospitalized, released, and readmitted for those three conditions to identify issues with the current hospitalization/discharge system and post-discharge processes. Next, we developed a new TCM program suited to the realities of the current medical environment. Interviews revealed problems including inadequate awareness of disease and health management; insufficient information exchange between patients, caregivers, and primary medical institutions; and absence/low usage of community-based care services. The investigation applying the new TCM program to patients and following up on readmission rates and life satisfaction after discharge is ongoing. Reviewing these results and conducting further studies in the future will allow improvements to the model.
考虑到社会老龄化，需要制定基于社区的健康管理政策。我们旨在为患有肺炎、哮喘和慢性阻塞性肺疾病的患者开发一种过渡护理模式（TCM）计划。首先，我们对因这三种疾病住院、出院和再次入院的患者进行了深入访谈，以确定当前住院/出院系统和出院后流程存在的问题。接下来，我们根据当前医疗环境的实际情况开发了一种新的 TCM 计划。访谈揭示了一些问题，包括对疾病和健康管理的认识不足；患者、护理人员和基层医疗机构之间的信息交流不足；以及社区护理服务的缺失/使用率低。目前正在将新的 TCM 计划应用于患者，并对再次入院率和出院后的生活满意度进行随访。回顾这些结果并在未来进行进一步研究，将有助于改进该模式。
