Department of Preventive Medicine, Kangwon National University Hospital, Chuncheon, Republic of Korea.
Team of Public Medical Policy Development, Gangwon State Research Institute for People's Health, Chuncheon, Republic of Korea.
BMC Health Serv Res. 2024 Feb 23;24(1):240. doi: 10.1186/s12913-024-10720-x.
Transitional care is an integrated service to ensure coordination and continuity of patients' healthcare. Many models are being developed and implemented for this care. This study aims to identify the facilitators and obstacles of project performance through the experiences of the coordinator in charge of the Community Linkage Program for Discharge Patients (CLDP), a representative transitional care program in Korea.
Forty-one coordinators (nurses and social workers) from 21 hospitals were interviewed using a semi-structured questionnaire, and thematic analysis was performed.
Three themes were found as factors that facilitate or hinder CLDP: Formation and maintenance of cooperative relationships; Communication and information sharing system for patient care; and interaction among program, regional, and individual capabilities. These themes were similar regardless of the size of the hospitals.
A well-implemented transitional care model requires a program to prevent duplication and form a cooperative relationship, common computing platform to share patient information between institutions, and institutional assistance to set long-term directions focused on patient needs and support coordinators' capabilities.
过渡护理是一种综合服务,旨在确保患者医疗保健的协调和连续性。为此,正在开发和实施许多模式。本研究旨在通过负责社区出院患者链接计划(CLDP)的协调员的经验,确定该项目性能的促进因素和障碍,该计划是韩国代表性的过渡护理计划。
采用半结构化问卷对 21 家医院的 41 名协调员(护士和社会工作者)进行访谈,并进行主题分析。
发现了三个促进或阻碍 CLDP 的主题:合作关系的形成和维持;患者护理的沟通和信息共享系统;以及计划、区域和个人能力之间的相互作用。无论医院规模大小,这些主题都相似。
一个实施良好的过渡护理模式需要一个防止重复和形成合作关系的计划,一个共享机构间患者信息的通用计算平台,以及一个关注患者需求和支持协调员能力的长期方向的机构援助。