Construction of specialized transitional care process and effect evaluation

Objective To build the specialized transitional care process and evaluate its effect . Methods Firstly,the specialized transitional care organization structure was constructed , to make clear the responsibility of the member;to develop the specialized transitional care process .The transitional care content , medical costs including expense and time cost , patients’ satisfaction, and nurses’ satisfaction were investigated through self-made questionnaire .Results The main transitional care programs provided by the professional team were ordered from high to low： catheter care （ including PICC maintenance , stomach tube, catheter, etc., 27.3%）, wound care （including colostomy care, 25.5%）, pressure ulcers care（21.8%）, peritoneal dialysis care （ 16.4%）, function exercise guidance （ including surgery, hemiplegia after stroke, diabetic foot, postpartum breast massage guidance , etc., 9.0%）.There were statistically significant differences about medical expense [（195.73 ±114.77） vs （95.11 ±25.68）] and time cost [（195.73 ±12.00）h vs （3.95 ± 1.68）h] before and after the operation of specialized transitional care process （t=69.71,80.93,respectively;P〈0.05）.Conclusions Building the specialized transitional care process is helpful to reduce the medical expense and time cost ,and to improve patients ’ satisfaction to nursing service .In the future it is necessary to optimize transitional care process based on the hospital-community-family ternary linkage . Key words: Transitional care; Process; Effect evaluation