提升出院準備服務病人無縫銜接長照2.0之改善專案

The Improvement Project to Improve the Seamless Connection of Long-Term Care 2.0 for Patients in Preparation for Discharge

為滿足病人出院後續照顧需求，透過醫院出院準備與長期照顧管理中心連結相互銜接，配合政府及院方政策出院準備服務病人銜接長照2.0 轉介量無明顯成長，專案目的為提升出院準備服務病人無縫銜接長照2.0 轉介量，原因分析後確立改善方案1. 病房在職教育長照2.0 課程及製作長照溫馨提醒小卡2. 院內網站公告銜接長照相關訊息3. 張貼出院準備服務銜接長照2.0 海報、立牌4. 舉辦院內長照2.0 教育訓練課程及宣導活動5. 修改轉介照會流程6. 相關會議宣導長照政策及流程7. 病房放置長照2.0 宣導單8. 修正電腦照會介面等資訊系統9. 建立跨團隊聯繫溝通管道。改善後出服轉介長照2.0 量由113 人提升至242 人成長122%，期望病人返家後能及時獲得長照服務，降低再住院率及非必要的醫療成本。

Under the current government policies and hospital discharge preparation services. There has been no significant increase in the number of patients that transferred to long-term care 2.0 after discharging from hospital. The purpose of this project is to increase the number of referrals for seamless transition between hospital and long-term care 2.0 for patients receiving discharge preparation services. After analyzing the current situations, an improvement plan is established. 1. Providing on-the-job education related to long-term care 2.0 in the ward and making warm reminder cards. 2. Annoucing Information about the transition to long-term care on the hospital website. 3. Posters and Signs related to discharge preparation services, especially information about transition to long-term care 2.0. 4. Long-term care 2.0 training courses and advocacy activities in the hospital. 5. Improvement of the referral notification process. 6. Relevant meetings to promote long-term care policies and procedures. 7. Flyers about Long-term care 2.0 in the ward. 8. Optimizations and correctinons of computer system. 9. Establishing cross-team communication channels. After the improvements, the number of referrals for long-term care 2.0 has increased from 113 to 242, which is an increase of 122%. It is expected that patients can obtain long-term care services in time after returning home, and reduce the rate of readmissions and unnecessary medical costs.