Dummer Jack, Stokes Tim
Dept of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
Dept of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
Breathe (Sheff). 2020 Sep;16(3):200161. doi: 10.1183/20734735.0161-2020.
Continuity of care refers to the delivery of coherent, logical and timely care to an individual. It is threatened during the transition of care at hospital discharge, which can contribute to worse patient outcomes. In a traditional acute care model, the roles of hospital and community healthcare providers do not overlap and this can be a barrier to continuity of care at hospital discharge. Furthermore, the transition from inpatient to outpatient care is associated with a transition from acute to chronic disease management and, in a busy hospital, attention to this can be crowded out by the pressures of providing acute care. This model is suboptimal for the large proportion of patients admitted to hospital with acute-on-chronic respiratory disease. In a chronic care model, the healthcare system is designed to give adequate priority to care of chronic disease. Integrated care for the patient with respiratory disease fits the chronic care model and responds to the fragmentation of care in a traditional acute care model: providers integrate their respiratory services to provide continuous, holistic care tailored to individuals. This promotes greater continuity of care for individuals, and can improve patient outcomes both at hospital discharge and more widely.
To understand the concept of continuity of care and its effect at the transition between inpatient and outpatient care.To understand the difference between the acute and chronic models of healthcare.To understand the effect of integration of care on continuity of care for patients with respiratory disease and their health outcomes.
连续性护理是指为个体提供连贯、合理且及时的护理。在医院出院时的护理过渡期间，连续性护理会受到威胁，这可能导致患者预后更差。在传统的急性护理模式中，医院和社区医疗服务提供者的角色不重叠，这可能成为医院出院时连续性护理的障碍。此外，从住院护理向门诊护理的转变与从急性病管理向慢性病管理的转变相关，在繁忙的医院中，对此的关注可能会被提供急性护理的压力所挤出。对于很大一部分因慢性呼吸系统疾病急性发作而住院的患者来说，这种模式并非最优。在慢性病护理模式中，医疗系统旨在充分优先考虑慢性病护理。对呼吸系统疾病患者的综合护理符合慢性病护理模式，并应对传统急性护理模式中的护理碎片化问题：提供者整合他们的呼吸服务，以提供针对个体的持续、整体护理。这促进了个体护理的更大连续性，并可在医院出院时及更广泛范围内改善患者预后。
了解连续性护理的概念及其在住院和门诊护理过渡中的作用。了解急性和慢性医疗模式之间的差异。了解护理整合对呼吸系统疾病患者护理连续性及其健康结局的影响。
