Ko Michelle Y, Darouian Navid
Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA.
Internal Medicine, University of California Los Angeles, Los Angeles, USA.
Cureus. 2024 Oct 16;16(10):e71629. doi: 10.7759/cureus.71629. eCollection 2024 Oct.
Significant gaps exist in the transition of care for patients from acute hospitalization to skilled nursing facilities. Amongst the several well-studied interventions that exist to improve the transition of care, few investigate the efficacy of using an interdisciplinary team (IDT) approach. Here, we report the case of a 78-year-old man with a complicated social situation who had a successful medical and social transition of care from the hospital to the skilled nursing facility (SNF) with an IDT meeting that entailed the collaboration of hospital and SNF physicians and social workers.
患者从急性住院过渡到专业护理机构的护理过程中存在显著差距。在现有的几种经过充分研究的改善护理过渡的干预措施中，很少有研究调查使用跨学科团队（IDT）方法的效果。在此，我们报告一例78岁男性患者的病例，该患者社会情况复杂，通过一次由医院和专业护理机构的医生及社会工作者共同参与的IDT会议，成功实现了从医院到专业护理机构的医疗和社会护理过渡。
