퇴원 후 연계 임상진료지침

Clinical Practice Guideline for Care Transition

Background: After successful care transition, it is crucial to improve health care, health promotion, and quality of life of the elderly. In addition, successful care transition reduces readmission rate of the elderly, improves health recovery, and prevents functional decline after discharge. However, Republic of Korea does not have a care transition system for continuous management after discharge. We developed a clinical practice guideline to ensure that healthcare providers in hospitals can safely and successfully perform care transitions. Methods: The clinical practice guideline for care transition was first developed by the Konkuk University Medical Center, using a 23-step adaptation method. Evidence levels and recommendation ratings were established in accordance with SIGN 2011 (The Scottish Intercollegiate Guidelines Network). Results: The final four recommendations were derived from expert advice: assessing during admission and before discharge; establishing care transition planning through an interprofessional team; educating the patient, his or her family, and the healthcare provider; and establishing organization-wide systems for communicating client information during care transitions. Conclusion: The use of this guideline by healthcare providers helps elderly patients maintain continuity of care when moving from one place to another.