Hospital to Home

Abstract

The results of this study demonstrate the importance of extending social support and health education into the home after discharge from the hospital. Access to immediate in-home care services such as transportation, housekeeping, laundry, and light meal preparation allows patients not to experience gaps in care that could result in a readmission. The assigned navigator reinforces medical management and connects participants to appropriate community resources in order to remain safe at home.

Community services' involvement in the discharge of older adults from hospital into the community

“…Poor description of usual care hindered the ability to identify the difference(s) between the intervention group and the usual care group and what potentially could be contributing to the difference(s) in outcome. Another methodological concern was that while the studies justified a need for improved discharge planning, all but three studies [30–32] did not justify why that particular intervention, over ‘usual care’, had been designed and researched. These methodological concerns impact on the applicability of the findings to inform further research and clinical practice.…”

“…Various interventions were discussed in these studies, including; nurses liaising with community services to arrange follow-up care [28,31,33]; specialised hospital teams coordinating older adults care across the interface [34]; hospital pharmacists organising care with community pharmacists [35]; community services assessing older adults in-hospital and arranging supporting following discharge from hospital [30,36] and hospital staff undertaking home visits after discharge while coordinating care with community service providers [32,37]. These interventions were generally compared to usual care, which, as previously noted, was generally poorly defined.…”

“…Two of the studies in this review described a model of community service involvement whereby hospital staff crossed the hospital–community interface into the community, where they implemented certain aspects of the discharge plans [32,37] (Figure 4). During this implementation phase, hospital staff liaised with community services to deliver other aspects of the discharge plans (Table 7).…”

Saugesnio Ir Veiksmingesnio Pacientų Tarpstacionarinio Transportavimo Principai

“…Tačiau didžiąją transportuojamų pacientų dalį sudaro nekritinės būklės ligoniai, reikalaujantys tretinio TT, kuris, pasak mokslinių tyrimų, reikšmingai didėja [18][19][20]. Pavyzdžiui, 2007Pavyzdžiui, -2008 metais Australijos vyriausybė išleido apie 2 bilijonus Australijos dolerių tretiniam pacientų TT vykdymui, o metinis šių paslaugų augimas siekė 8.5 proc.…”

Testing the chronic care model for depression in homebound older adults.

“…Better communication among health care and community organizations could optimize care and improve transitions between care organizations. Transitional care from a hospital or rehab facility to home care can be optimized with a program that initiates home health care quickly, connects the patient with needed services, conducts a thorough assessment, uses telephone and inhome follow-ups, and looks for 11 risk factors for hospital readmission (Watkins, Hall, & Kring, 2012). In-home visits and the use of a care manager are important factors of transitional care to prevent hospitalizations (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011).…”