Curtin School of Allied Health, Curtin University, Perth, WA, Australia.
Department of Aged Care and Rehabilitation, Armadale Kelmscott Memorial Hospital, East Metropolitan Health Service, Armadale, WA, Australia.
Front Public Health. 2021 Jun 28;9:688640. doi: 10.3389/fpubh.2021.688640. eCollection 2021.
Continued evaluation of Transition Care Programs (TCP) is essential to improving older adults' outcomes and can guide which older adults may benefit from undertaking TCP. The aim of this study was to audit a transition care service to identify the association between the characteristics of older adults undertaking a facility-based TCP and (i) discharge destination and (ii) functional improvement. An audit ( = 169) of older adults aged 60 years and above who completed a facility-based TCP in Australia was conducted. Outcomes audited were performance of activities of daily living (ADL) measured using the Modified Barthel Index (MBI) and discharge destination. Data were analyzed using logistic regression and linear mixed modeling. Older adults [mean age 84.2 (±8.3) years] had a median TCP stay of 38 days. Fifty-four older adults (32.0%) were discharged home, 20 (11.8%) were readmitted to hospital and 93 (55%) were admitted to permanent residential aged care. Having no cognitive impairment [OR = 0.41 (95% CI 0.18-0.93)], being independent with ADL at admission [OR = 0.41 (95% CI 0.16-1.00)] and a pre-planned team goal of home discharge [OR = 24.98 (95% CI 5.47-114.15)] was significantly associated with discharge home. Cases discharged home showed greater improvement in functional ability [MBI 21.3 points (95% CI 17.0-25.6)] compared to cases discharged to other destinations [MBI 9.6 points (95% CI 6.5-12.7)]. Auditing a facility-based TCP identified that older adults who were independent in ADL and had good cognitive levels were more likely to be discharged home. Older adults with cognitive impairment also made clinically significant functional improvements.
持续评估过渡护理计划（TCP）对于改善老年人的预后至关重要，并可以指导哪些老年人可能受益于进行 TCP。本研究的目的是审查过渡护理服务，以确定接受基于设施的 TCP 的老年人的特征与（i）出院去向和（ii）功能改善之间的关联。对在澳大利亚完成基于设施的 TCP 的 60 岁及以上老年人（n = 169）进行了审计。审核的结果是使用改良巴氏量表（MBI）评估的日常生活活动能力（ADL）和出院去向。使用逻辑回归和线性混合模型进行数据分析。老年人（平均年龄 84.2（±8.3）岁）的 TCP 中位停留时间为 38 天。54 名老年人（32.0%）出院回家，20 名（11.8%）再次入院，93 名（55%）入住永久性养老院。无认知障碍[OR = 0.41（95% CI 0.18-0.93）]、入院时 ADL 自理[OR = 0.41（95% CI 0.16-1.00）]和预先计划的团队目标为家庭出院[OR = 24.98（95% CI 5.47-114.15）]与家庭出院显著相关。出院回家的病例在功能能力方面的改善更为明显[MBI 21.3 分（95% CI 17.0-25.6）]，而出院到其他目的地的病例则改善较少[MBI 9.6 分（95% CI 6.5-12.7）]。对基于设施的 TCP 进行审核发现，ADL 自理且认知水平良好的老年人更有可能出院回家。认知障碍的老年人也有显著的临床功能改善。
