Development of Transitional Care Program for Bedridden Elderly Patients from Hospital to Home Care

Abstract

Background : A systematic and effective of transitional care from hospital to home is a key issue in the transitional care of hospitalized elderly patients and caregivers to ensuring in the transition from hospital to home care safely.

Objective : The study for developed the transitional care program of bedridden elderly patients during transition from hospital to home care.

Methods : To Action research in 2 Phases. Phase I: situational analysis regarding continuing the transitional care for bedridden elderly patients from hospital to home care by means of review of the patient medical records and group interviewing with 2 focus groups includes 1) patients relatives and caregivers and 2) Nurses and multidisciplinary. Data was collected using personal data record forms and structural interview data. Analyzed using descriptive statistics and content analysis during July 2016 – January 2017.

Results : Development of transitional care program for bedridden elderly patients from hospital to home care showed that 52 representative sample found that Continuing care needs. The representative sample of 7 caregiver’s relatives need to know and learn to care for bedridden elderly patients and ensure for the transitional period from hospital to home safely and need a consultant to resolve problems occurring during patient care. 29 nurses and multidisciplinary samples need a standard and evidently operating guideline for bedridden elderly patients care in the transitional period by participation of multidisciplinary and have the effective and completely communication. Phase II: was the development of transitional care program for bedridden elderly patients; the program was developed using data synthesize in phase I with literature reviewed. To improve, collecting comments and suggestions from relevant groups including adjusted bedridden elderly patients to the group that have risk for re-hospitalization and complicated home care, hospital policies are written to better plan transitional care and have professional nurse is the coordinator of all care level. According to The Naylor’s approach, the transitional care must have a discharge planning that start from the first admitted to hospital or within 48 hours after the first admitted to hospital. Have process of discharge plan and referral system with a discharge plan coordinator by written forms or documents to communication with caregivers to be effective continuing care.

Keywords : bedridde n elder ly patien ts, transitional care