Research progress on quality improvement strategy for transitional care of patients with chronic diseases

This paper summarized the common transitional care models from hospital to home,including the care transitions intervention model( CTA),transitional care model( TCM),Brtter outcomes for older adults through safe transitions( BOOST),re-engineered discharge( RED),guided care( GC) and Geriatric Resources for Assessment and Care of Elders( GRACE). Paper also analyzed the root causes of ineffective transitional care of patients with chronic diseases and strategies of quality improvement,including training and quality certification of transitional care professional staff,defining the responsibilities of transmitter and receptor,developing corresponding communication system,quality control of transitional care,enhancing the communication and cooperation of nursenurse and nurse-patient,and encouraging patients to participate care plan and adopting reverse demonstration to test the effects of health education,so as to provide guidance for the practice of transitional care in our country.