Development of a new transitional support model to prevent rehospitalization (PHR-TC): current status and effectiveness study

2023 Fiscal Year Final Research Report

• Project/Area Number: 20K23188
• Research Category: Grant-in-Aid for Research Activity Start-up
• Allocation Type: Multi-year Fund
• Review Section: 0908:Society medicine, nursing, and related fields
• Research Institution: The University of Tokyo
• Principal Investigator: Yuka Sumikawa 東京大学, 大学院医学系研究科(医学部), 助教 (70884550)
• Project Period (FY): 2020-09-11 – 2024-03-31
• Keywords: 移行期支援 / 在宅ケア

Outline of Final Research Achievements

Changes in care locations, like hospital admissions and discharges, impose significant burdens. Thus, transitional care, a collaboration between the community and hospitals, is vital. The COVID-19 pandemic had prompted a reconsideration of transitional care methods in hospitals. Specifically, hospitals were exploring transitional care with new tools like ICT. Despite challenges in introducing new transitional care, we’ve gained insights into the digital transformation (DX) of transitional care in this study. These include enhancing support for families anticipating post-discharge rehospitalization and real-time information sharing with related teams. We must consider a system that includes transitional care’s DX to prevent harmful events, such as immediate post-discharge rehospitalization.

Free Research Field

在宅ケア

Academic Significance and Societal Importance of the Research Achievements

COVID-19蔓延の影響を受け、当初予定していた移行期支援のモデル構築ならびに効果検証を目的とした介入研究の実施には至らなかった。しかし、全国の急性期病院における移行期支援の現状について調査を継続し、これまでほとんどDX化が進んでいなかった移行期支援の領域における、ICTツールを用いた支援の具体例や課題が、一部、明らかになった。このことは、再度訪れるかもしれない新興感染症等を見据えた新たな移行期支援、再入院をどのように予防していくかの手法をDX化していくうえで重要な知見になると考える。現在、これらの知見を国際誌へ投稿予定である。