Development of the Discharge Planning System for Nursing Home

2023 Fiscal Year Final Research Report

• Project/Area Number: 20K11136
• Research Category: Grant-in-Aid for Scientific Research (C)
• Allocation Type: Multi-year Fund
• Section: 一般
• Review Section: Basic Section 58080:Gerontological nursing and community health nursing-related
• Research Institution: Sophia University (2023); Kyorin University (2020-2022)
• Principal Investigator: SAKAI SHIMA 上智大学, 総合人間科学部, 教授 (40439831)
• Co-Investigator(Kenkyū-buntansha): 高井 ゆかり 群馬県立県民健康科学大学, 看護学部, 教授 (00404921) ; 長江 弘子 亀田医療大学, 看護学部, 教授 (10265770) ; 石橋 みゆき 千葉大学, 大学院看護学研究科, 准教授 (40375853) ; 熊野 奈津美 杏林大学, 保健学部, 講師 (10510042) ; 大西 知子 杏林大学, 保健学部, 助教 (90845091) ; 西川 裕理 杏林大学, 保健学部, 学内講師 (00912388) ; 岩崎 孝子 杏林大学, 保健学部, 教授 (50826401)
• Project Period (FY): 2020-04-01 – 2024-03-31
• Keywords: 入退院支援 / 介護保険施設 / 連携

Outline of Final Research Achievements

We investigated what kind of cooperation is practiced by hospital and facility in charge of coordination in the admission and discharge support process for residents of long-term care insurance facilities. We found that (1) there is a system in which facility physicians and nurses and other staff can closely consult with each other on medical decisions, (2) there is continuous and repeated ACP involvement, not only at the time of admission, in hearing patients' intentions regarding medical care and care, (3) the hospital side shares with the facility the outlook for the length of hospitalization and the direction of treatment, and (4) when a patient is admitted to the hospital in an emergency, the medical staff from the facility being present at the time of emergency hospitalization and acting as a bridge between the patient's family and the hospital are factors that facilitate smooth admission and discharge support between the hospital and the long-term care insurance facility.

Free Research Field

入退院支援

Academic Significance and Societal Importance of the Research Achievements

医療・介護を必要とする高齢者が、住み慣れた地域で自分らしい暮らしを続けることができるよう、地域における医療・介護の関係機関の連携体制構築が求められている。病院と介護保険施設間の円滑な連携に向けた知見は、地域包括ケアシステムにおける医療と介護の連携強化、本人の心身の状況に合わせた繰り返しのアドバンスケアプランニングを推進することにつながり、高齢者本人の意向や必要な支援情報をシームレスにつなぎ、住み慣れた地域で最期までその人らしく生きるを支え、施設看取りの推進に寄与すると考える。