Project K: Training for hospital-community safe transition

ABSTRACT Objective: To define the safe transition process from hospital to community of patients with chronic mental disorders and their families. Method: This was an action research study included in the constructivist paradigm. The participants in the study were nurses from a psychiatry service and from primary healthcare services. Results: After the identification of causes of continuity fragmentation, the following items emerged from the participants’ speeches: a) two criteria categories for safe transition (those associated with health status, dependence level, and self-care capacity of patients, and those associated with knowledge and competence level of informal caregivers); b) the design of an algorithm to facilitate clinical decision-making. Final considerations: In order to promote adherence to therapeutic treatment in the hospital-community transition, treatment plans must include patients and their families, and improve communication networks and support among care levels.摘要 研究目的：明确慢性精神障碍患者及其家属从医院向社区过渡的安全流程。 研究方法：本研究属于建构主义范式下的行动研究，研究参与者为精神科服务与基层医疗卫生服务的护理人员。 研究结果：在明确照护连续性断裂的成因后，从参与者的发言中提炼出以下要点：a）安全过渡的两项标准范畴：其一与患者的健康状况、依赖程度及自我护理能力相关，其二与非正式照护者的知识与能力水平相关；b）研发了一款用于辅助临床决策的算法。 最终结论：为提升医院-社区过渡阶段患者的治疗依从性，治疗计划需纳入患者及其家属，并完善不同照护层级间的沟通网络与支持体系。