Desafios da equipe interprofissionalna transição do cuidado hospitalar parao domicílio de pacientes oncológicos / Challenges of the interprofessional team in the transition from hospital care to home care for cancer patients

Os pacientes oncológicos necessitam de uma assistência integral, sobretudo no que se refere à transição do cuidado em saúde entre os diferentes locais e níveis de cuidado. Este estudo tem como objetivo investigar se existem protocolos assistenciais utilizados pela equipe interprofissional sobre a transição do cuidado oncológico hospitalar para o domicílio e identificar as estratégias utilizadas no planejamento e orientações da alta hospitalar. Trata-se de um estudo descritivo de abordagem qualitativa, realizado através de Grupo Focal, com profissionais da equipe interprofissional que atuam diretamente com o cuidado oncológico, em hospital filantrópico, localizado no interior do Estado do Rio Grande do Sul. Construíram-se categorias que elencaram as principais características: Desafios na transição do cuidado para a rede de atenção primária e domiciliar e Sugestões para a mudança nas intervenções do cuidado integrado em oncologia. Constatou-se que a equipe interprofissional apresenta dificuldades na compreensão sobre a transição do cuidado e a necessidade de uma maior quantitativo de colaboradores para a qualificação da assistência.(AU)

Cancer patients need comprehensive care, especially with regard to the transition of health care between different locations and levels of care. This study aims to investigate whether there are care protocols used by the interprofessional team on the transition from hospital to home oncology care and to identify the strategies used in hospital discharge planning and guidance. This is a descriptive study with a qualitative approach, carried out through focus groups with professionals from the interprofessional team who work directly with cancer care in a philanthropic hospital located in the interior of the state of Rio Grande do Sul. Categories were constructed which listed the main characteristics: Challenges in the transition of care to the primary and home care network and Suggestions for change in integrated oncology care interventions. It was found that the interprofessional team has difficulties in understanding the transition of care and the need for a greater number of collaborators to improve care.(AU)

Los pacientes oncológicos requieren una atención integral, especialmente en lo que se refiere a la transición de la asistencia sanitaria entre diferentes lugares y niveles asistenciales. Este estudio pretende investigar si existen protocolos asistenciales utilizados por el equipo interprofesional en la transición de la atención oncológica hospitalaria a la domiciliaria e identificar las estrategias utilizadas en la planificación y guías de alta hospitalaria. Se trata de un estudio descriptivo con abordaje cualitativo, realizado a través de grupos focales con profesionales del equipo interprofesional que trabajan directamente con la atención oncológica en un hospital filantrópico localizado en el interior del estado de Rio Grande do Sul. Se construyeron categorías que enumeraron las principales características: Desafíos en la transición de la atención a la red de atención primaria y domiciliaria y Sugerencias de cambio en las intervenciones de atención oncológica integrada. Se encontró que el equipo interprofesional tiene dificultades en la comprensión de la transición de la atención y la necesidad de un mayor número de colaboradores para mejorar la atención.(AU)

Current status and influencing factors of discharge planning of ward nurses in cardiovascular / 中国实用护理杂志

Objective:To explore the current status of discharge planning of ward nurses in cardiovascular department and analyzed influencing factors, and to provide reference for intervention strategies to build the discharge planning ability of the responsible nurses in cardiovascular department.Methods:This study was a cross-sectional survey. Convenience sampling method was adopted to select 267 ward nurses of cardiovascular department from 5 first-class hospitals in Dalian City from July to August 2022 as the research objects. The questionnaire survey was conducted by general data questionnaire, Job-Esteem Scale for Nurses in Hospital and Discharge Planning of Ward Nurses. Multiple linear regression analysis and Pearson correlation analysis were used for data analysis.Results:The total score of discharge planning of ward nurses in cardiovascular department was (103.86 ± 16.20) points; the total score of nurses' professional respect was (98.92 ± 13.67) points, and the total score of discharge planning of ward nurses in cardiovascular department was positively correlated with the total score of job-esteem and scores of all dimensions ( r values were 0.382-0.551, all P<0.01). Multiple linear regression analysis showed that age, professional title, certificate of cardiovascular nurses and job-esteem of nurses were influencing factors of discharge planning of ward nurses in cardiovascular department ( t values were 2.57-8.27, all P<0.05), accounting for 47.3% of the total variation. Conclusions:The discharge planning of ward nurses in cardiovascular department was above the medium level, and age, professional title, whether they were cardiovascular nurses and job-esteem were the influencing factors. From the perspective of improving nurses' job-esteem, nursing managers can focus on young nurses and nurses with low professional titles, attach importance to the training of specialized ward nurses in cardiovascular department, and take certain countermeasures to improve the discharge planning of ward nurses in cardiovascular department.

Validation of a checklist for responsible hospital discharge in a neonatal intensive care unit / Validación de una lista de verifiación para el alta hospitalaria responsable en una unidad de cuidados intensivos neonatales / Validação de um checklist para alta hospitalar responsável em unidade de terapia intensiva neonatal

ABSTRACT Objective: to create and validate a checklist for responsible hospital discharge processes in a neonatal intensive care unit. Method: a methodological study conducted from March to June 2022, in four phases: 1) Selection of topics relevant to the health of newborns discharged from the intensive care unit; 2) Elaboration of the first version of the checklist; 3) Content validation with expert judges by applying the Content Validity Index (CVI), accepting values > 0.8 per item; and 4) Correction and reformulation of the final version. The assessment instrument was structured by means of a Likert-type scale. The validation process was performed in electronic and printed means by approaching the evaluators within the neonatal unit, totaling 16 participants. Descriptive statistics was used for data analysis. Results: the checklist was validated with an overall Content Validity Index of 0.87. Analyzing the items individually, the following Content Validity Index values were found: 0.92 in the objectives, 0.89 for language, 0.84 for the content, 0.79 for relevance, 0.90 for layout, 0.94 for motivation and 0.88 for culture. Conclusion: the checklist presented favorable Content Validity Index values in the vast majority of the evaluation criteria, with the exception of relevance. However, it is noted that it can be implemented and tends to contribute to a responsible discharge process.

RESUMEN Objetivo: elaborar y validar una lista de verificación para el proceso de alta hospitalaria responsable en una unidad de cuidados intensivos neonatales. Método: estudio metodológico realizado de marzo a junio de 2022 en cuatro etapas: 1) Selección de temas relevantes a la salud de neonatos que reciben el alta de una unidad de cuidados intensivos; 2) Elaboración de la primera versión de la lista de verificación; 3) Validación del contenido con jueces especialistas aplicando el Índice de Validez de Contenido (IVC), aceptándose valores > 0,8 por ítem; y 4) Corrección y reformulación de la versión final. El instrumento para la evaluación se estructuró por medio de una escala tipo Likert. La validación se realizó por medios electrónico e impreso acercándose a los jueces dentro de la unidad neonatal, totalizando 16 participantes. Para el análisis de los datos se utilizó estadística descriptiva. Resultados: la lista de verificación se validó con un Índice de Validez de Contenido general de 0,87. Cuando se analizaron los ítems individualmente se encontraron los siguientes valores de IVC: 0,92 en los objetivos; 0,89 para el lenguaje; 0,84 para el contenido; 0,79 para la relevancia; 0,90 para el diseño; 0,94 para la motivación; y 0,88 para la cultura. Conclusión: la lista de verificación obtuvo un Índice de Validez de Contenido favorable en la amplia mayoría de los criterios de evaluación, con la única excepción del aspecto de la relevancia. Sin embargo, se destaca que puede ser implementado y tiende a contribuir a un proceso de alta hospitalaria responsable.

RESUMO Objetivo: construir e validar um checklist para o processo de alta hospitalar responsável em uma unidade de terapia intensiva neonatal. Método: estudo metodológico realizado no período de março a junho de 2022 em quatro etapas: 1) seleção de temas relevantes à saúde do neonato egresso da unidade de terapia intensiva; 2) construção da primeira versão do checklist; 3) validação de conteúdo com juízes especialistas mediante à aplicação do Índice de Validade de Conteúdo, aceitando-se o valor de > 0,8 por item; 4) correção e reformulação da versão final. O instrumento para avaliação foi estruturado por meio de uma escala, tipo Likert. A validação foi realizada por meio eletrônico e impresso com abordagem pelos juízes dentro da unidade neonatal, totalizando 16 participantes. Para análise dos dados utilizou-se a estatística descritiva. Resultados: o checklist foi validado com IVC geral de 0,87. Analisando-se os itens individualmente foi encontrado o Índice de Validade de Conteúdo de 0,92 nos objetivos, 0,89 para linguagem, 0,84 para o conteúdo, 0,79 para a relevância, 0,90 para o layout, 0,94 para a motivação e 0,88 para a cultura. Conclusão: o checklist apresentou Índice de Validade de Conteúdo favorável na grande maioria dos critérios de avaliação, com exceção apenas da relevância. Entretanto, destaca-se que o mesmo pode ser implementado e tende a contribuir para um processo de alta responsável.

Development of Discharge Planning Instruments Based on Patient Family-Centered Care in the COVID-19 Inpatient Room, Universitas Airlangga Hospital, Surabaya

@#Introduction: The current era of the COVID-19 pandemic requires innovation in the provision of discharge planning by involving family members through the media safely and effectively. This study aimed to develop a discharge planning instrument based on patient family-centered care. Method: Research design Research and Development. The sampling technique used purposive sampling with a total sample of 110 medical record documents, 23 focus group discussion participants, and 2 experts (expert consultation). Data were collected through observation sheets, focus group discussions, and expert consultations. Data analysis using descriptive analysis, and validity test using I-CVI. Results: Development of a patient family centered care-based discharge planning instrument at the beginning of the patient’s admission (admission), namely sorting and adding assessment items to the level of knowledge of the disease, information and education needs, values, and beliefs, cultural background as well as physical and psychological. During treatment, namely arranging and sorting discharge planning items, providing information and education according to the assessment results using a media approach and the method according to the COVID-19 pandemic protocol. Towards home that is adding items; readiness or environmental conditions (environment), referral plans (Outpatient referral), and continued treatment while at home (Medication). Conclusion: The developed instrument tested is valid. As a result of this development, the new instrument can be tested and applied, and researched in the next stage on the outcomes of patient family-centered care.

Effects of nurse-led discharge planning on discharge readiness and ostomy psychological adaptation in patients with enterostomy / 中国实用护理杂志

Objective:To investigate the intervention effects of nurse-led discharge planning on discharge readiness and ostomy psychological adaptation in patients with enterostomy.Methods:A total of 70 patients with enterostomy admitted from January 2019 to October 2020 in Jiangsu Province Hospital of Chinese Medicine were enrolled in the present study. They were assigned to experimental group and control group according to the admission time, there were 35 cases in each group. There was one case lost in the control group in the end. The control group received the routine care, while the experimental group implemented nurse-led discharge planning. The Chinese version of Readiness for Hospital Discharge Scale (RHDS) and Ostomy Adjustment Inventory (OAI) were adopted as indicators, the intervention effects was compared between the two groups.Results:On discharge, disease knowledge, coping ability, personal status and expected support dimension scores and total scores in RHDS were (58.06 ± 12.54) , (23.57 ± 3.73), (24.29 ± 3.48) , (30.40 ± 5.25), (136.31 ± 14.32) points in the experimental group, which were significantly higher than those in the control group (49.57 ± 13.28), (18.63 ± 4.97), (22.37 ± 4.28), (26.11 ± 5.66), (101.68 ± 13.04) points, and the differences were statistically significant ( t values were 2.05-4.91, all P<0.05) . On discharge and 1 month after discharge, the persistent worry, acceptance, positive attitude towards life dimension scores and total scores in OAI were (21.34 ± 2.72) , (13.29 ± 2.36), (15.26 ± 3.24), (49.89 ± 5.70) points and (22.03 ± 3.45), (12.49 ± 3.10), (15.09 ± 3.06), (49.60 ± 5.55) points in the experimental group, which were significantly higher than those in the control group (19.35 ± 2.98) , (11.56 ± 2.79), (13.26 ± 3.15), (44.18 ± 5.63) points and (19.91 ± 3.34), (10.76 ± 2.80), (12.24 ± 3.25), (42.91 ± 4.76) points, the differences were statistically significant ( t values were 2.42-5.36, all P<0.05). Conclusions:Nurse-led discharge planning can promote discharge readiness and ostomy psychological adaptation in patients with enterostomy.

The Needs of Orthopaedic Patients in Discharge Planning

@#Introduction: Patients' transition from hospital to home could be challenging for patients and caregivers. This is of utmost importance for patients requiring special or long-term care such as post-orthopaedic surgery. Effective discharge planning is required to ensure that patients are prepared to and get continuous care after returning home to prevent complications. Patients' need assessment is essential to develop effective discharge planning to meet the patient's needs. Materials and methods: This mixed-method study aimed to determine the patient's needs to develop a discharge planning for total knee replacement surgery. The needs for 96 total knee replacement patients were assessed using the Needs Evaluation Questionnaire (NEQ). The in-depth interview primary focus was to explore the lived experience of the post-total knee replacement patients receiving care in the hospital. Results: A total of 96 participants (100%) completed the NEQ questionnaire. Most of the needs concerned by the participants were expressed by at least 70% of them except the financial need (59.4%). The semi-structured interview found two elements which were a support group and patients’ needs in terms of emotional, physical and spiritual preparation in developing effective discharge planning. Conclusion: This study clarified that the patient needs assessment in the patient care plan.

Patient and caregiver preparedness for discharge from the internal medicine wards of the University of the Philippines – Philippine General Hospital

BACKGROUND@#Preparedness before discharge correlates with good clinical outcomes.@*OBJECTIVE@#The study described the perception, attitudes, and perceived preparedness of patients and caregivers for discharge from the Internal Medicine wards of the University of the Philippines-Philippine General Hospital (UP-PGH).@*METHODS@#A cross-sectional survey among 142 patients about to be discharged from the Internal Medicine wards of the Philippine General Hospital and/or their caregivers from May to June 2017 was done using a validated Filipino version of B-PREPARED, an 11-item self-administered questionnaire that measures patient preparedness for home. The questionnaire has three domains: self-care information, equipment/services, and confidence. The highest possible B-PREPARED score is 22 with higher scores indicating better discharge preparedness. Mean B-PREPARED scores were calculated. Post-hoc linear regression analysis between the scores and characteristics was performed.@*RESULTS@#The Filipino translation of the B-PREPARED questionnaire had good internal consistency (Cronbach’s alpha 0.8). One hundred forty-two patients and caregivers participated. The mean B-PREPARED score was 14.57 ± 4.34, with a median of 15. The lowest scores were for information on available community services (1.20 ± 0.76), arranged equipment (0.83 ± 0.88), information on side effects of medications (1.19 ± 0.85), and additional information sought (0.61 ± 0.92). There was no significant correlation between preparedness and age, employment status, educational attainment, diagnosis, length of hospitalization, the number of admissions one year prior, or whether the respondent was a patient or caregiver.@*CONCLUSION@#The Filipino translation of the B-PREPARED questionnaire had good internal consistency. Although most participants reported being confident and prepared for discharge, most felt they did not receive sufficient information on side effects and available community services, and assistance in arranging for the necessary equipment for home care.

Planificación del alta / Discharge planning

El alta hospitalaria constituye una transición clave en salud, cuya importancia frecuentemente queda invisibilizada ante el apremio por hospitalizaciones más abreviadas y procesos que por años se han desarrollado de determinada forma. Un alta planificada y/o ejecutada de manera inadecuada puede significar reingresos y repercutir negativamente a nivel del usuario, sus familias y sistemas de atención. Múltiples intervenciones, con distinto nivel de evidencia buscan optimizar el proceso, enfocándose en los equipos, dispositivos y/o usuarios involucrados. Dado que no existe una única estrategia efectiva, el presente artículo recorre aspectos que la literatura ha identificado como relevantes al momento de trabajar por altas planificadas.

Hospital discharge is a key transition health process, whose relevance is often overshadowed by the urgency of shortened hospitalizations and health institutions routines that have been settled for many years. An unplanned and inappropriate discharge can lead to readmissions and negative implications for patients, caregivers and hospitals. Therefore, multiple interventions exist, with different levels of evidence that seek to improve the discharge process by focusing on health teams, institutions and patients. Given there is no single effective strategy, this article covers aspects that several authors have identified as relevant when working on discharge planning.

Prediction of Chronic Disease-Related Inpatient Prolonged Length of Stay Using Machine Learning Algorithms / 대한의료정보학회지

Practical Abilities of Discharge Planning Nurses in Supporting Discharge of Terminal Cancer Patients

The aim of this study was to investigate the practical abilities of discharge planning nurses to support discharge of terminal cancer patients. A survey was mailed to 477 discharge planning nurses (DPNs) who were employed at 120 designated regional cancer centers in Japan. Responses from 198 (valid response rate 41.5%) DPNs were subjected to analysis. The median number of years of DPN experience of the subjects was 2.5 years, and 90.2% of them had more than 10 years of nursing experience. Among the discharge planning abilities, “To Coordinate Post-discharge Care Balance” was significantly higher in the group with more nursing experience and in the group with longer DPN experience; “To Estimate Post-discharge Care Balance” and “To Prepare for Transition from the Hospital to a Care Facility” was significantly higher in the group with longer DPN experience and in the group with more experience working in home and community care. But “To make an agreement with the patient and their families” was not significantly different for experienced DPNs. It was suggested that in order to improve the quality of discharge planning, it is necessary to create a system that allows staffing based on individual experience and sharing of knowledge and experience of veteran DPNs.

The Effects of Joint Case Conferences with Visiting Nurses on Discharge Planning Ability of Ward Nurses / 日本プライマリ・ケア連合学会誌

Objective: To improve the discharge planning ability of ward nurses, we carried out case conferences for discharged patients involving both ward nurses and visiting nurses, and assessed their effects.Methods: We compared the discharge planning ability of ward nurses with and without experience in home visits before discharge. The study involved 74 nurses from eight wards in three hospitals. We analyzed changes in the discharge planning ability of the 62 nurses without home visit experience after the case conferences.Results: Ward nurses with experience in home visits before discharge had significantly higher discharge planning ability than those without such experience. After a case conference, the discharge planning ability significantly changed for nurses without experience in home visits. Their attitude toward home care changed, and they recognized its importance, associating it with the words "poor-rich", "dirty-clean", and "confined-free". They also scored higher on the Discharge Planning Process Evaluation Measurement (DCP-PEM) for "understands the importance of educating the patient's family", and "devises a plan taking health care needs into account", and on the Discharge Planning Process Scale for hospital ward nurses for "makes contact with a care manager as early as possible".Conclusions: Involving ward nurses in home visits before discharge and case conferences with visiting nurses were effective educational methods to improve their discharge planning ability in the affective and psychomotor domain.

Care transition strategies in Latin American countries: an integrative review / Estrategias de transición de cuidados en los países latinoamericanos: una revisión integrativa / Estratégias de transição de cuidados nos países latino-americanos: uma revisão integrativa

Abstract OBJECTIVE To identify and analyze available literature on care transition strategies in Latin American countries. METHODS Integrative literature review that included studies indexed in PubMed, LILACS, Web of Science Core Collection, CINAHL, SCOPUS databases, and the Scientific Electronic Library Online (SciELO), published in Portuguese, Spanish or English, between 2010 and 2017. RESULTS Eleven articles were selected and the strategies were grouped into components of care transition: discharge planning, advanced care planning, patient education and promotion of self-management, medication safety, complete communication of information, and outpatient follow-up. These strategies were carried out by multidisciplinary team members, in which nurses play a leading role in promoting safe care transitions. CONCLUSIONS Care transition activities are generally initiated very close to patient discharge, this differs from recommendations of care transition programs and models, which suggest implementing care transition strategies from the time of admission until discharge.

Resumen OBJETIVO Identificar la literatura disponible sobre estrategias de transición del cuidado entre niveles de atención a la salud en países de América Latina. MÉTODOS Revisión integradora que incluyó estudios indexados en las bases de datos PubMed, LILACS, Web of Science Core Collection, CINAHL, Scopus y Scientific Electronic Library Online (SciELO), publicados en portugués, español o inglés, entre 2010 y 2017. RESULTADOS Se seleccionaron once artículos y las estrategias fueron agrupadas en componentes de la transición del cuidado: planificación de alta, planificación anticipada de cuidados, educación del paciente y promoción de la autogestión, seguridad de la medicación, comunicación completa de las informaciones y acompañamiento ambulatorial. Estas estrategias fueron realizadas por miembros del equipo multidisciplinario, en los que las enfermeras desempeñan un papel de liderazgo en la promoción de transiciones de cuidados seguras. CONCLUSIÓN Las actividades de transición del cuidado generalmente se inician muy cerca del alta del paciente, esto difiere de las recomendaciones de programas y modelos de transición de cuidados, que sugieren la implementación de estrategias de transición del cuidado desde el momento de la admisión hasta la alta.

Resumo OBJETIVO Identificar a literatura disponível sobre estratégias de transição do cuidado entre níveis de atenção à saúde em países da América Latina. MÉTODOS Revisão integrativa da literatura que incluiu estudos indexados nas bases de dados PubMed, LILACS, Web of Science Core Collection, CINAHL, SCOPUS e Scientific Electronic Library Online (SciELO), publicados em português, espanhol ou inglês, entre 2010 e 2017. RESULTADOS Onze artigos foram selecionados e as estratégias foram agrupadas em componentes da transição do cuidado: planejamento de alta, planejamento antecipado de cuidados, educação do paciente e promoção do autogerenciamento, segurança da medicação, comunicação completa das informações e acompanhamento ambulatorial. Essas estratégias foram realizadas por membros da equipe multidisciplinar, nas quais enfermeiros desempenham um papel de liderança na promoção de transições de cuidados seguras. CONCLUSÕES As atividades de transição do cuidado geralmente são iniciadas muito próximas da alta do paciente, isso difere das recomendações de programas e modelos de transição de cuidados, que sugerem a implementação de estratégias transição de cuidado desde o momento da admissão até a alta.

Effect of discharge planning on blood glucose management of diabetes patients / 现代临床护理

Objective To explore the effects of discharge planning on blood glucose management of diabetes patients. Methods About 181 patients with type 2 diabetes as the research object between April 2014 and July 2014 treated at our hospital were divided into a experimental group and control group according to random number table.When discharged,the experimental gronp used discharge planning,the control gronp used traditional menthod. Results 3 months after discharge patients self management efficiency of the total score is the experimental gronp were higher than that of control group patients with statistical difference (P<0.01); the hypoglycaemia incidence is lower than that of the control group, where the difference was statistically significant (P<0.01);the FBG,2 h PBG effect, time effect and interaction effect of patients between the group difference was statistically significant (all P< 0.05). Conclusion Discharge planning service model can improve blood glucose management level of diabetes patients to a certain extent, reduce hypogly caemia incidence and improve self management efficiency.

Alta hospitalar de clientes com lesão neurológica incapacitante: impreteríveis encaminhamentos para reabilitação / Hospital discharge of patients with disabling neurological injury: necessary referrals to rehabilitation

Resumo Trata-se de pesquisa de abordagem qualitativa realizada no segundo semestre de 2014, mediante entrevistas com 12 médicos e 13 enfermeiros gestores atuantes em Hospital de grande porte, referência na área de urgência e emergência para a Zona da Mata Mineira. Buscou identificar os critérios utilizados por médicos e enfermeiros para o preparo da alta de pessoas com lesão neurológica incapacitante e indicação para acesso a programa de reabilitação física. Para o tratamento dos dados, utilizou-se a técnica de Análise de Conteúdo, modalidade temática. Os resultados mostram que os gestores hospitalares ainda encontram dificuldades para proceder ao encaminhamento adequado dessas pessoas para serviços especializados de reabilitação, o que compromete a autonomia e independência para o autocuidado. Conclui-se que os gestores além de envolver cuidadores e familiares no preparo da alta de pessoas com lesão neurológica que resulta em incapacidades para o autocuidado, deveriam avaliar as condições de acessibilidade em seus domicílios e fazer encaminhamentos adequados para serviços de reabilitação disponíveis na comunidade, a despeito da pouca divulgação acerca dos fluxos da Rede de Cuidados da Pessoa com Deficiência.

Abstract The present qualitative study was conducted in the second semester of 2014 via interviews with 12 doctors and 13 nurses working as managers at a large hospital that serves as a reference center for urgent and emergent care in the Zona da Mata region of Minas Gerais State, Brazil. The study sought to identify the criteria that doctors and nurses use to discharge individuals with disabling neurological injury with instructions related to accessing physical rehabilitation programs. Thematic content analysis was used to examine data. The results show that the participating hospital managers still have difficulties providing adequate referrals to specialized rehabilitation services and that their patients’ autonomy and independence for self-care are impaired as a result. We concluded that in addition to involving relatives and other caregivers in the discharge of patients with a neurological injury that impairs their self-care abilities, managers should assess the accessibility of the patient’s home and make adequate referrals to rehabilitation services in the community in light of the poor dispersal of information about what is available within the Care for People with Disability Network.

Engaging the Family, The Family Conference

Family engagement should be part of a holistic management of any patient. This is especially so in patients who have an acute change in their health condition or function that stresses their social setup. Conducting a family conference is one of the many ways to engage patients and their caregivers and address their bio-psycho-social needs. It is a focused and purposeful approach that engages every member of the health care team and family members in facilitating a common understanding and decision-making with the aim of improving patient care and outcome. A family conference is resource intensive, and should be planned well to maximise the goals that it was set out to achieve. This article was written as a primer to help family physicians understand the indications, preparations needed, and steps to take in conducting a family conference. To facilitate a family conference confidently is a skill and an art that requires practice and constant refinement.

Discharge Planning from the Hospital to the Primary Care Clinic

Discharge planning is an integral component of transitional care. Patients need to have their care needs assessed early in the admission to put in place a robust care plan that can meet the medical, functional, and social needs of the patient. The care plan must then be clearly communicated to the next care provider as well as the patient and his caregiver to avoid gaps during transition across different settings and providers. For patients with complex care needs in the community, an intensive form of primary care far beyond what is offered in traditional primary care is needed. This can be achieved by being connected to the health system and resources, additional efforts in providing the care coordination to navigate the health system, and optimising clinical and social care around the patient’s needs.

International Progress and Understanding of Discharge Planning / 中国康复理论与实践

With the social development and the transformation of medical model, providing patients with continuous services and seam-less transfer between different medical institutions, namely continuity care, is inevitable. Discharge planning take patients as the center and patient's needs as the guidance. Patients and their families should actively take part in the plan. Through multi-disciplinary and multi-institu-tional cooperation, patients can continue to enjoy health services after discharge. Discharge planning is the basis of continuous medical ser-vice. This article summrized the background and situation of discharge planning in the United States, Canada, Brazil, the United Kingdom, Ireland, Australia, Japan, India, South Africa, and Hong Kong, Taiwan and mainland in China. When heavy medical burden, aging, im-balence between supply and demand occurred, discharge planning could be helpful to make rational use of medical resources, save medical costs, guarantee the quality of medical service continuity, avoid the occurrence of adverse events after discharge and improve the patients' function and quality of life. This article reviewed group members, time, institutions and process of discharge planning in order to provide ev-idence-based basis for the development of discharge planning in China.

Discharge Planning in China / 中国康复理论与实践

Discharge planning is the basis of continuous medical service. It could shorten the length of hospital stay, improve bed occu-pancy, reduce readmission rate, save medical costs, and improve the quality of life. It's considered to be important and supplemented by rele-vant policies and regulations to promote development in the United States, the United Kingdom, Canada, Australia and other developed countries. In China, even though Hong Kong and Taiwan have issued discharge planning policies, the mainland is still at the stage of explora-tion. Discharge planning in Chinese mainland has problems like restricted objectives, imperfect content, un-optimized process, unestablished professionals and organizations and so on. Standardized discharge planning guide still needs further research. As the health service system including hospitals, public health institutions and primary health institutions coverd urban and rural gradually, and the new pattern of grad-ing diagnosis and treatment established, it's necessary to analyze the necessity, importance, obstacles and measures of discharge planning in China.

Evaluation of the Effect of Discharge Planning Model in Patients with Intracoronary Stent Implantation / 中国医科大学学报

Objective To evaluate the effect of discharge planning service mode in patients with intracoronary stent implantation. Methods Total?ly 106 patients with intracoronary stent implantation were divided into intervention group and control group,the intervention group received discharge planning services. The control group received routine nursing and follow?up of Department of Cardiology. The intervention lasted 6 months. Compari?son of two groups of patients in hospitalization days,cost of hospitalization and cardiovascular events and the rate of readmission and Compliance be?havior and clinical indicators and quality of life. Results The incidence rate of cardiovascular events and readmission rate in discharge planning group is lower than the routine nursing group(P<0.05);Discharge planning group of smoking cessation rates,weekly rehabilitation exercise times and coronary heart disease in two level prevention drug use rate is superior to that of routine group(P<0.05). Discharge planning group,left ventric?ular ejection fraction,success rate of blood lipids and the quality of life is better than the routine group(P<0.05). Conclusion Discharge plan?ning intervention can reduce the incidence of cardiovascular events and readmission rate,improve ventricular function and the compliance behavior and the quality of life in patients with coronary stent implantation.

Explicating discharge planning preferences among a select group of Filipino nurses: a conjoint analysis

Discharge planning is integral in the delivery of effective patient care in clinical settings. Hence, an organized and coordinated system is necessary in facilitating the discharge process and in ensuring a seamless transition of patients from one level of care to another. The purpose of this study is to identify the preferences of nurses on discharge planning, and to analyze the significant differences of nurses' discharge planning preferences and their demographic information. A two-part researcher-made instrument was utilized in the conduct of the study including the robotfoto and plan cards. Preliminarily, the plan cards having nine attributes with two levels each were validated by experts and was pilot-tested to a select group of respondents from the target population. A conjoint analysis survey of 230 nurses in a teaching-and-training hospital was conducted from May and June 2013. Capitalizing on the power of conjoint analysis, preferences of nurses have been unveiled. The most important attribute is the structure (importance value= 19.25%) in which nurses utilize in facilitating the discharge plan. Nurses prefer to employ formal structure (part worth value= 0.442) as it encompasses patient and family involvement following an organized protocol and has detailed documentation. Conversely, comprehensive patient assessment has been the least preferred attribute (importance value= 3.71%) in which the head-to-toe assessment had its part worth value of 0.86. As a whole, an analysis and understanding of nurses' preferences serve as an impetus for them to actively engage in  the discharge planning process by developing effective structures that will benefit patients.