出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Potentially preventable hospitalizations (PPH) are hospitalizations that could be avoided with ambulatory care. Post hospital syndrome(PHS) is described as a transient period of generalized susceptibility, after hospital discharge, to disease and risk for adverse events, including hospital readmission and death. International efforts focus on hospital-to-home transitions and chronic disease management. Journeys to acute admissions may further inform PPH and PHS. Monash Watch (MW) aims to reduce preventable hospitalizations within current funding, in a cohort with predicted ³ 3 admissions/year within Health Links Chronic Care (HLCC) program in Victoria, Australia. MW applies a telehealth approach with ongoing monitoring of self-reported health journeys. Theory/Methods : PPH and PHS represent a complex interplay of biological, psychosocial, and environmental influences in the context of local service processes. A range of theories exist – from chronic disease flare-ups, poor care transitions to hospitalization-induced allostatic overload. These phenomena reflect diverse, but challenging opportunities for anticipatory care approaches. Aims : To describe patterns of self-reported concerns and health 10 days before and 10 days after discharge from an acute admissions in MW cohort. Methods : Telecare guides conduct regular patient outbound phone calls using Patient Journey Record System (PaJR), an online informatics program. PaJR alerts are intended to act as a self-reported barometer of health perceptions with more alerts per call indicating greater risk of deterioration, PPH and PHS Participants : 103 patients who had an acute admission (total 232 patients) in HLCC cohort monitored for >40 days - in MW intervention group. Measures : Self-reported health care status in 764 PaJR phone call records. Acute (non-surgical) admissions from Victorian Admitted Episode database. Analysis : Descriptive Timeseries using homogeneity metrics using XLSTAT. Results : All self-reported problems (Total Alerts) shifted to a higher level 3 days before an acute admission and stayed at a high level for 10 days post admission. Reported acute disease and illness symptoms (Red Alerts) increased 1 day prior to admission and remained higher level for the 10 days post admission. Patients reported more medication/drug/alcohol changes before than after acute admissions. Self-rated health and feeling depressed worsened around 5 days post discharge. igh levels of medication or drug or alcohol use changes preceded admission, and caregiver/support concerns were at a high level across the board. Discussion : These findings suggest a ‘prehospital phase’ of poor health and problems that persisted on discharge and seemed worse 5 days after discharge (PHS). The contribution of hospitalization should be re-examined in unstable journeys Conclusions (comprising key findings) : Many of those who have acute medical admissions demonstrate deteriorations before admission and do not ‘recover’ post admission and may deteriorate further. Lessons learned : A ‘pre-hospital’ phase may prefigure PPH and PHS. Greater attention to self-reported patient journeys in each location may enable anticipatory care. Limitations: A small sample in one geographic location with descriptive data does not have external generalizability. Provider or system integration features are not described. Suggestions for future research : Anticipatory care using telehealth monitoring for PPH and PHS in different settings and cohorts.
关键词：preventable hospitalizations ; post hospital syndrome ; telehealth ; care transitions
