Significance and Feasibility of Discharge Planning for Elderly People Receiving Integrated Medical and Nursing Care after Hospital Discharge：a Study from a Medical Social Worker's Perspective

doi:10.12114/j.issn.1007-9572.2018.34.009

Abstract

Abstract: The promotion of integrated medical and nursing care is a positive initiative for addressing the health needs of the ageing population，as well as for achieving the goals of "Healthy China" and boosting the development of China's elderly care industry.Discharge planning is made by health professionals based on assessing the patient's needs，which aims to ensure the patient achieve good health and quality of life by receiving integrated and continued care from the institution to which he is admitted after discharge from hospital.It enhances the coordination of services after discharge from hospital，bridges the gap between hospital and the place to which the patient is discharged，guaranteeing the patient access to continued care for improving rehabilitation.The delivery of integrated medical and nursing care is favorable for the implementation of discharge planning，which makes the access to continued care after hospital discharge possible.Medical social workers involved in the formulation and implementation of discharge planning plays a vital role in assessing the overall health needs of older people，increasing the professional inter-institutional communication and cooperation and improving the rehabilitation after discharge from hospital.It is urgent to develop a discharge planning by professionals involving medical social workers based on the national conditions and national implementation status of integrated medical and nursing care.We discussed the importance of discharge planning whose formulation and implementation involve medical social workers，and analyzed its feasibility，hoping to offer an important reference for assessing the general health needs of the elderly，strengthening the communication and cooperation between multidisciplinary professionals，and following up geriatric rehabilitation after hospital discharge.

Key words: Combination of medical care and pension, Discharge planning, Medical social work

摘要： 在“健康中国”和健康养老服务的大背景下，应积极应对人口老龄化，推进医养结合。出院计划是利用专业人员帮助患者及照护者在转换医疗照护机构时，能达到完整且持续性的照顾，以求得到最佳的健康状况及生活质量。医养结合为推行出院计划提供了客观条件，为老年人出院后得到连续性照护服务提供了可能。同时，出院计划能够将老年人住院期间的康复状况与出院后的照护联结起来，整合资源，为老年人继续康复提供保障。医务社会工作介入出院计划，对评估老年人整体需求、增强专业沟通合作、跟进出院后的康复状况有重要作用。结合我国医养结合现状，发展医务社会工作参与的，适合国情的出院计划是亟待开展的工作。本研究旨在探讨由医务社会工作介入的出院计划在医养结合中的重要性，并分析其可行性，为评估老年人整体需求、增强专业沟通合作、跟进出院后的康复状况提供重要参考。

关键词: 医养结合, 出院计划, 医务社会工作

WANG Suming,WANG Zhizhong,QI Jian. Significance and Feasibility of Discharge Planning for Elderly People Receiving Integrated Medical and Nursing Care after Hospital Discharge：a Study from a Medical Social Worker's Perspective[J]. Chinese General Practice, 2018, 21(34): 4206-4211. DOI: 10.12114/j.issn.1007-9572.2018.34.009.
王素明,王志中,齐建. 基于医务社会工作视角的出院计划在医养结合中的重要性及可行性研究[J]. 中国全科医学, 2018, 21(34): 4206-4211. DOI: 10.12114/j.issn.1007-9572.2018.34.009.

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