In January 2017, the ”10-Year Long-Term Care plan 2.0” policy (Long-Term Care 2.0) promoted by the Government in Taiwan. In response to the long-term care needs arising from the increase in disability, dementia and frailty, Long-Term Care service system has been established in a community-based to alleviate the pressure on primary caregivers to return home and assist patients to return to the community as soon as possible.The purpose of this study was to investigate the effectiveness of the discharge preparation service plan linked to Long-Term Care service 2.0 for the elderly patient in post Orthopedic surgery.
Methods:
Analysis of hospitalized elderly patients (age >65 years) in 2017 who performed orthopedic surgery in our hospital, the number of cases for the discharge preparation service plan was 79, and only 3 people (3.78%) were included in the Long-Term Care 2.0.Through the focus group interview unit senior registered nurse, the reason for the low number of cases was found to be 1.No dedicated personnel, 2.The public does not understand Long-Term Care 2.0, 3.There is no long-term recipient standard work procedures, etc.; Intervention 1.Set up Long-Term Care 2.0 dedicated personnel, 2.Produce the long-term referral process of the Instructions handout and posters, and arrange schedule about the Long-Term Care 2.0 of group hospital health education, 3.Develop and announce about the long-term recipient standard work procedures, use the communication software to set up a group, and immediately reply to the questions of the nurses in the evaluation and application of Long-Term Care 2.0.
Results:
From January to July, 2018, the total number of discharge preparation services for hospitalized elderly patients who performed orthopedic surgery in our hospital was 82, of which 12 (14.63%) were used for the Long-Term Care 2.0, and the number of cases received before the improvement was improved by 4 times.
Conclusion:
After the intervention improvement strategy, it showed that the effect of discharge planning linked to Long-Term Care plan 2.0 for elderly orthopedic surgery patient, which were elevated to four times in half a year, although the patients and their families did not understand the Long-Term Care 2.0 plan and had a desired gap in the implementation process. Fortunately, the assistance and support of the Nurse Head, the nurse managers of the nursing department and colleagues have enabled the project to proceed smoothly, to implement the social welfare that the government actively promotes, and it is also possible to allow patients and their families to obtain more complete continuity care when they return to their homes.