出院準備與轉銜照護之整合實務

Integration Practice of Discharge Preparation and Transfer Care

何麗娟(Li-Chuan Ho) ； 詹惠雅(Hui-Ya Chan) ； 王怡人(I-Ren Wang) ； 詹其峰(Chyi-Feng Jan) ； 余忠仁(Chong-Jen Yu) ； 曾家琳(Chia-Lin Tseng)

《領導護理》 21卷2期 (2020/06) Pp. 10-20

https://doi.org/10.29494/LN.202006_21(2).0002

摘要

因老化社會病人的急性醫療、慢性病與長期照護的分級醫療需求，住院病人出院準備往往需要結合病人的醫療服務轉診以及各種醫療資源的轉介，以提供複雜多重慢性病及末期病人及其家庭無縫隙的整合照護（Integrated care）。過去護理人員會電話追蹤高風險出院病人，目前許多醫院已發展專責的出院轉銜團隊。護理人員為整合照護團隊重要的一員，可以在協助病人順利轉銜至另一個醫療照護團隊上扮演著重要的協調者與個管師角色。本文提供某醫學中心分級醫療暨轉銜照護管理中心轉銜個管護理師的經驗，以三個住院病人出院準備服務的案例，提供護理臨床實務之參考。

關鍵字

整合醫療 ； 轉銜照護 ； 住院病人 ； 分級醫療

並列摘要

Due to the requirement of the graded system for aging society in terms of acute medical care, chronic diseases and long term care for patients. The integrated care team usually needs to provide seamless transitional care for palliative and multi-morbid patients when preparing inpatient discharge. At present dedicated discharge transfer team has already been developed in many hospitals; while phone tracking of high-risk discharged patients of nursing staff has been established in the past. Furthermore, nurse as an important member of the integrated care team can also play an important role as coordinator and case manager when assists patients in smoothing transfer process in between medical care teams. This article provides the experience of the transitional care nurse from a graded medical center, by sharing three different types of referral cases in the medical center, and hence provided the clinical guidance for transitional care in the future.

並列關鍵字

integrated care ； transitional care ； inpatient ； referral medicine

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