Construction And Effect Of Hospital-based Transitional Care In Cardiovascular Disease

Objectives:Combined with Chinese current health care system,we established hospital-based transitional care model of cardiovascular disease.Then we designeda randomized controlled trial to evaluate it from multilevels.The transitional care model we established provided some reference value for other institutions to provide transitional care.Methods:During the construction of the transitional care model of cardiovascular disease,we based on the literature analysis and expert consultation,combined with the actual situation of the Chinese current medical system,then we determined the final version of the transitional care model by the research team.In the evaluation of the transitional care model,we used a randomized controlled trial design.Adopting the convenience sampling method,we selected 152 patients with cardiovascular disease from August 2015 to January 2016 at a three grade A hospital in Jinan,Shandong Province.Patients were randomly divided into intervention group(76 cases)and control group(76 cases).Intervention group implement a 6-month intervention of transitional care,control group implement routine nursing intervention.In stage T1(baseline)and stage T2(6 months after discharge),we collected the patient’s general information,health outcomes,health service utilization,medication adherence(Morisky Medication Adherence Scale,MMAS-8)and quality of life(China questionnaire of quality of life in patients with cardiovascular diseases,CQQC)and other data.SPSS 20.0 software were used for statistical analysis of data,descriptive analysis,independent sample t-test,chi-square,paired sample t test,rank and inspection,ANOVA of repeated measures were used to evaluate the effects of transitional care.Results:(1)The number of follow-up was to intervention group 69 cases,control group 69 cases,the lost general data of the two groups with no statistically difference(P>0.05).General data of two groups with no statistical difference(P>0.05).(2)The transitional care intervention can not reduce the patient’s disease recurrence and unscheduled readmission rate {χ2=1.526,P>1.526;χ2=2.551,P>0.05);It can reduce the patient’s visit to the emergency rate(χ2=4.376,P<0.05),improve the outpatient visits of the patients(Z=3.813,P<0.001),and improve the patients’medication adherence(t=2.637,P<0.05).(3)The quality of life compared between groups found that the scoles of quality of life and its six dimensions betweentwo groups have no significant difference(P>0.05)at T1.In addition to the work condition,other dimensions and quality of life scores were improved(P<0.05)in intervention group at T2;For control group,patient’s conditions,medical conditions,social psychological status and quality of life scores were higher at T2(P<0.05),and other dimension scores were no statistically significant difference(P>0.05).ANOVA of repeated measures shows that the time and group in the physical,condition,general life,social psychological condition exist interaction(P<0.05),it prompted transitional care can significantly improve quality of life in cardiovascular disease patients 6 months after discharge.Conclusions:(1)The topic builta hospital-based transitional care mode of cardiovascular disease,it meets the requirements of chronic disease management,it is a new attempt to implement quality care at tertiary hospitals.And ithas certain scientificity and repeatability.So as to provide a theoretical basis for other hospitals to carry out transitional care,then it provided some reference value for other institutions and community nursing staff to provide transitional care.(2)Transitional care intervention can reduce the emergency proportion of patients,improve patient outpatient visits,improve the patient’s treatment compliance and quality of life,but there is no statistical significance for the clinical outcomes of change.