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The Experience of Providing Older Adult Patients with Transitional Care from an Acute Care Hospital to Home in Cooperation with a Public Health Center

Journal of Korean Medical Science 2020년 35권 39호 p.348 ~ 348
신진영, 한설희, 최재경, 김윤숙, 이종민,
소속 상세정보
신진영 ( Shin Jin-Young ) - Konkuk University School of Medicine Konkuk University Medical Center Department of Family Medicine
한설희 ( Han Seol-Heui ) - Konkuk University School of Medicine Konkuk University Medical Center Department of Neurology
최재경 ( Choi Jae-Kyung ) - Konkuk University School of Medicine Konkuk University Medical Center Department of Family Medicine
김윤숙 ( Kim Yoon-Sook ) - Konkuk University Medical Center Department of Quality Improvement
이종민 ( Lee Jong-Min ) - Konkuk University School of Medicine Konkuk University Medical Center Department of Rehabilitation Medicine

Abstract


Background: This study aimed to describe the experience of providing older adult patients with transitional care from an acute care hospital to home in cooperation with a public health center, in order to present the barriers to that care and suggest better organizational methods.

Methods: This was a cross-sectional study to show the results of the Geriatric Screening for Care-10 (GSC-10) and outcomes of transitional care. Among 659 hospitalized patients aged 65 years or above who lived in an administrative district, forty-five subjects were enrolled between June 24, 2019 and January 23, 2020. Within 48 hours of admission, using the 10 areas of GSC-10, they were assessed for cognitive impairment, depression, polypharmacy (5 or more medications), functional mobility, dysphagia, malnutrition, pain, and incontinence, and were reassessed before discharge. The transitional care plan (containing the treatment summary, the results of the GSC-10 assessment, and the post-discharge plan) was forwarded to a representative of the public health center, who provided continued disease management and various health care services, such as chronic disease and frailty care, and physical rehabilitation.

Results: Of all the participants, 64.4% had more than 1 GSC-10 concern. The most prevalent concerns were functional immobility (35.6%) and polypharmacy (22.2%). About 15.6% of the participants were readmitted to a nursing home or hospital. A total of 38 participants received the transitional care intervention. They received an average of 2.7 administered interventions. However, the rate of rejection was high (30.1%) and patients were visited an average of 16.5 days after discharge.

Conclusion: Through our experience of providing transitional care from an acute care hospital to home in cooperation with a public health center, we expect that the transitional care suitable for the Korean medical situation could be established and successful.

키워드

Aged; Hospitalization; Patient Discharge; Transitional Care

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