Status investigation of transitional care of chronic diseases developed by secondary and tertiary hospitals cooperated with communities in China

Abstract

Objective To investigate the status of transitional care of chronic diseases developed by secondary and tertiary hospitals cooperated with communities in China. Methods Self-designed questionnaires were used to investigate the status of transitional care of chronic diseases developed by 109 secondary and tertiary hospitals of 30 provinces in China. Results About 94.5% thought that it is vital to carry out transitional care of chronic diseases; 88.1% considered that it is necessary to realize the linkage and interaction of transitional care of chronic diseases between hospitals and communities; whereas only 51.4% expressed their intention to participate in this project. 88 hospitals (80.7%) said the status of transitional care of chronic diseases was not well; 61 hospitals thought that the content of transitional care was not standardized; 68.9% considered that their leaders do not care about and support transitional care; 85 hospitals (78.0%) said that there is no enough human resources to carry out transitional care. Transitional care was carried out well in following four aspects in secondary and tertiary hospitals, namely, health education before discharge (82.6%) , discharge planning (80.7%) , specialist out-patient of chronic diseases (72.5%) , and regular follow-up after discharge (72.5%) . 106 hospitals (94.5%) had a cooperation with continuities in transitional care of chronic diseases. As for the content, transitional care was carried out well in three aspects: 76 hospitals (69.7%) set up two-way referral center, 62 hospitals (56.9%) provided professional guidance, technical assistance and accept community people to study, besides, 59 hospitals (54.1%) cooperated with communities to help patients make an appointment of outpatient and examine. Forms mainly included research project (82.6%) and health lecture (77.1%) , etc. Conclusions Transitional care of chronic diseases has been carried out in most secondary and tertiary hospitals in our country, in spite of the general condition, there are still some block factors, transitional care programs should be improved and managed further to provide and strengthen the linkage of hospitals and communities, so as to forming a standard system reference for effectively construct a three-dimension linkage (Hospital-Community-Family) mode of transitional care. Key words: Chronic diseases; Hospital; Community health center; Transitional care; Status investigation