TRANSITIONING TO THE COMMUNITY: BRIDGING GAPS IN PATIENT CARE

摘要

The problem of transitioning heart failure patients back to the community is assessed through a review of relevant literature and a set of qualitative studies. Based on the results, information flow and temporal models of patient management are developed. Gaps in existing discharge planning and post-discharge are noted, and opportunities for facilitating patient self-care management through education and telemonitoring are identified.