In order to increase the continuity of care quality after patients are discharged and admitted to care institutions and promote bidirectional exchange between our hospital and post-hospital care institutions, National Cheng Kung University Hospital constructed Taiwan’s first “Care Institution Referral Platform” on March 2007 and complete revision and optimization were carried out in 2019 to become the currently used “Post-hospital Care Platform”. This increased the overall care continuity quality between our hospital and institutions.
The characteristics of this “Post-hospital Care Platform” are: 1. If the patient is considering transfer to care institution after discharge, the discharge planning case manager will discuss with the patient’s family and upload medical record summaries onto the referral platform. The institution director can download the document and assess whether the patient can be admitted through the platform. 2. After the patient is discharged and admitted to the institution, the institution director can check the patient’s medical information (including basic information, outpatient time, indwelling catheters, wound status, discharge summary, physical examination report, and post-hospital care key points) to improve the care continuity between hospital and care institutions. Further, 3. After the patient has stayed in the institution for 1 week, the institution director must upload the patient’s care status on the platform to achieve bidirectional information transmission and exchange between our hospital and referred institutions.
Besides decreasing time and manpower for manual transmission of information, this revision also provides care details required by the care institution. In response to the COVID-19 pandemic, the platform will update patient test items so the institution director can check the latest patient care information at any time to improve the timeliness of information transmission.
In addition to setting up the Post-hospital Care Platform, the discharge planning service team conducts two post-hospital care institution seminars every year. In these seminars, lecturers in our hospital (such as infection control team, hospice care team, and wound care team) and the institution directors will discuss referred patients and conduct professional courses and opinions exchange. The professional knowledge and suggestions discussed in meetings will be compiled into records and uploaded onto the platform for the institution directors to download and read. We suggest that a quality consultation system be set up between our hospital and care institutions to jointly maintain patient care quality.
