从过渡期护理的概念界定、团队成员与职责、干预内容及主要任务、干预程序及效果分析,对Coleman的以"教练"主导的老年人过渡期护理干预模式进行了详细介绍.在此基础上,分析了我国老年人过渡期护理发展的现状,提出开发适合我国老年慢性病患者的过渡期护理服务模式的相关对策建议,如组建多学科合作的过渡期护理服务团队为患者提供连续的医疗照护服务、鼓励患者与照顾者对疾病进行自我管理、建立考核和评价机制保证服务质量等.%This paper detailed the Coleman concept and practice of coach-led transitional care of elderlies,team members and their responsibilities,intervention aspects and main tasks,as well as the intervention program and its effect analysis.Then the authors analyzed the present transitional care development in China,and recommended on development of a likewise care model for senior chronic disease patients in the country,such as building multi-disciplinary transitional care teams to provide uninterrupted care and service,encourage patients and caregivers to embrace self-management of diseases,and build an appraisal mechanism to ensure quality of care.
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