Kjenaas M A
Hosp Community Psychiatry. 1980 Jun;31(6):401-3. doi: 10.1176/ps.31.6.401.
A pilot project for improving aftercare in a rural area places the responsibility of aftercare on the project staff rather than on the hospital staff or referral agency personnel. Three counselors cover 31 counties in the catchment area. They contact patients before discharge and again within one month after discharge. When the patient is receiving the desired aftercare, the counselor steps aside, but maintains contact with the referral agency and is available to help the patient when necessary. A study of 23 patients after the first year of the program showed that the average number of days each spent in the hospital during one year dropped from 159 to 49, and the average yearly cost of hospitalization per patient decreased from 8614 dollars to 3384 dollars. Two brief case examples show that the program also has enhanced the quality of life for many of the discharged patients.
一个旨在改善农村地区后续护理的试点项目将后续护理的责任交给了项目工作人员，而非医院工作人员或转诊机构人员。三名顾问负责服务范围内的31个县。他们在患者出院前进行联系，并在出院后一个月内再次联系。当患者得到所需的后续护理时，顾问便不再介入，但会与转诊机构保持联系，并在必要时为患者提供帮助。对该项目开展第一年之后的23名患者进行的一项研究表明，每人每年的住院天数从159天降至49天，每位患者每年的住院费用从8614美元降至3384美元。两个简短的案例表明，该项目还提高了许多出院患者的生活质量。
