Post-discharge tracking system

Abstract

We will build an information sharing network between medical institutions, patients, and their families, and within this network, we will understand the patient's current illness, level of care, and facility transfer history, and provide advice on facility selection to ensure appropriate medical care and nursing care is received as needed. Also, by evaluating the actual medical care and nursing care received at the facility from the patient's and family's perspective, we will be able to appropriately select referral destinations for future discharged patients. Furthermore, when patients or their families request referrals for admission to facilities other than discharged patients, we will introduce appropriate facilities taking into account their medical condition and nursing care status. The system includes a facility registration means for registering the names of medical institutions and nursing care facilities, a discharged patient registration means, and a movement history management means for managing the movement history of patients at the facilities after they are discharged from the hospital.

Description

[Technical Field]

[0001] The present invention relates to a system for tracking the long-term history of patients who have been discharged from a medical institution such as a hospital and who have subsequently been transferred to another medical institution or admitted to a nursing home or the like. [Background technology]

[0002] Traditionally, patients discharged from the hospital returned to their normal lives at home. However, as our society ages, the number of patients requiring nursing care is increasing, resulting in a sharp increase in the number of patients who are unable to return to their homes after being discharged. For this reason, patients are increasingly being discharged to hospitals or nursing facilities that meet their requirements, such as the type of medical care and nursing care they require and whether they can afford the costs. Furthermore, patients are being moved to appropriate medical institutions and nursing facilities as their condition and the level of care they require change. Many of these patients suffer from chronic diseases such as diabetes, high blood pressure, and osteoporosis, and require continued appropriate treatment even after being discharged from the hospital. The following publications are known as techniques related to the present application. [Prior art documents] [Patent documents]

[0003] [Patent Document 1] Japanese Patent Application Laid-Open No. 2002-73803 [Patent Document 2] Japanese Patent Application Laid-Open No. 2005-339309 [Patent Document 3] Patent Application No. 2022-179989 [Patent Document 4] Patent application 2024-082976 Summary of the Invention [Problem to be solved by the invention]

[0004] Traditionally, discharge supporters such as MSWs (Medical Social Workers) would decide on the patient's discharge destination in consultation with the patient and their family, taking into consideration the patient's condition at the time of discharge, the level of care required, the location of the patient's home and relatives, the possible financial burden, etc. While the patient's immediate discharge destination is known, it is often difficult to know about subsequent transfers to other hospitals or facilities.

[0005] Many elderly people suffer from chronic diseases such as diabetes, high blood pressure, and osteoporosis, and require continued appropriate treatment even after being discharged from the hospital. However, as patients are moved between facilities and hospitals, it has been difficult to determine whether appropriate treatment is being continued. While a means of communication is needed to contact patients and their families as needed to check on the continuation of treatment and their living environment and provide appropriate advice, an organized communication system has not always been established. Referral medical institutions and nursing care facilities vary widely in the medical procedures and care levels they can provide. To select an appropriate referral destination, it is necessary to evaluate the actual medical procedures and care levels available from the perspective of the patient and family, but in the past, accurate evaluations have not always been made. When a family member has difficulty living at home due to dementia or other reasons, the family is looking for a facility for them to enter. However, there has been an increase in cases in recent years where for-profit companies introduce facilities that are not necessarily suitable to the families who consult with them, and receive large referral fees from the family or facility where the person is admitted. This has become a problem.

[0006] The present invention was made to solve these conventional problems. Its purpose is to establish an information-sharing network between medical institutions, patients, and their families, and to use this network to understand the patient's current illness, level of care, and facility movement history, and to provide advice on facility selection as needed to ensure appropriate medical care and nursing care are received. Furthermore, by evaluating the actual medical care and nursing care received at the facility from the patient's and family's perspective, it becomes possible to appropriately select a facility to refer discharged patients to. Furthermore, when patients or their families request a facility for admission, other than for discharged patients, the system can refer them to an appropriate facility taking into account their medical condition and the level of care they require. [Means for solving the problem]

[0007] As a means for achieving the above object, the post-discharge tracking system according to claim 1 is a post-discharge tracking system that builds an information sharing network between medical institutions, patients, and their families, and (1) A facility registration means for registering the names of medical facilities and nursing care facilities; (2) A means for registering discharged patients; and (3) A movement history management means for recording a movement history of a discharged patient after discharge from a facility by registering at least the name of the medical facility or nursing facility to which the patient is to be transferred and the name of the discharged patient in a history. Equipped with The movement history management means includes a movement history attribute recording means for recording at least the date and time of the movement, the facility from which the movement originated, the facility to which the movement originated, and the patient ID for each movement, and further recording movement attributes such as the discharge supporter and the status of negotiations at the time of the movement, as necessary. It is characterized by the fact that

[0008] In the post-discharge tracking system according to claim 2, in the post-discharge tracking system according to claim 1, the registration means The discharged patient The present invention is characterized by being equipped with a patient attribute recording means for recording at least one of the following: necessary medical treatment, activities of daily living (ADL), contact information, and financial situation.

[0009] In the post-discharge tracking system according to claim 3, in the post-discharge tracking system according to claim 1 or 2, the facility registration means facility The facility is characterized by being equipped with a facility attribute recording means for recording at least one of the following: medical treatments that can be performed at the facility, activities of daily living (ADL), contact information, necessary expenses, and evaluations from patients and their families. [Effects of the Invention]

[0011] The post-discharge tracking system described in claim 1 is equipped with (1) a facility registration means for registering the names of medical institutions and nursing care facilities, (2) a registration means for discharged patients, and (3) a movement history management means for managing the movement history of the patient to the facility after discharge from the hospital. This makes it possible to grasp the patient's current illness and level of care, as well as the movement history of the facility, and to provide advice on facility selection so that the patient can receive appropriate medical care and nursing care as needed.

[0012] The post-discharge tracking system according to claim 2 includes a patient attribute recording means, which records at least one of the following regarding the patient: necessary medical treatment, activities of daily living (ADL), contact information, and financial situation.

[0013] The post-discharge tracking system described in claim 3 is equipped with a facility attribute recording means, which records at least one of the following: medical treatments that can be performed at the facility, activities of daily living (ADL), contact information, necessary expenses, and evaluations from the patient or family.

[0014] The post-discharge tracking system according to claim 1. The system is equipped with a means for recording movement history attributes, and for each movement, at least the date and time of the movement, the facility from which the movement originated, the facility to which the movement originated, and the patient ID are recorded, and further, if necessary, movement attributes such as the discharge supporter and the status of negotiations at the time of the movement are recorded. [Brief explanation of the drawings]

[0015] [Figure 1] This is an explanatory diagram of the movement of patients to medical institutions and facilities after being discharged from the hospital. [Figure 2] 10 is an example of a master table of a facility registration means. [Figure 3] This is an example of a facility attribute recording means. [Figure 4] 10 is an example of the contents of a registration means for a discharged patient. [Figure 5] 10 is an example of the recorded contents of a patient attribute recording means. [Figure 6] 10 is an example of the contents of a movement history management means. [Figure 7] 1 is an example of a patient's movement history. DETAILED DESCRIPTION OF THE INVENTION

[0016] Figure 1 is an explanatory diagram of the movement of patients between medical institutions and facilities after being discharged from a hospital. A patient is discharged from the hospital to a rehabilitation hospital A (transfer 29856) and then transferred to a senior housing facility with support services D (transfer 78596). Another patient was discharged and moved to Group Home E (transfer 68295), and was subsequently admitted to Nursing Home B due to a worsening condition (transfer 87952). Here, "movement 29856" etc. is a movement ID in the movement history management means described later. As shown in this diagram, patients who have completed treatment at a hospital but are unable to live at home will be transferred to another medical institution or nursing facility depending on their condition and the level of care they require.

[0017] Figure 2 shows an example of a master table for facility registration, which lists the facility name and facility ID of the facility. FIG. 3 shows an example of the recorded contents of the facility attribute recording means. For each facility ID, the facility's capacity (in the case of a hospital, the type of ward and the number of beds in that ward), the types of medical treatments that can be performed, ADL (activities of daily living) restrictions upon admission, and evaluations from admitted patients and their families are recorded. Hospitals have a large number of full-time medical professionals, including doctors, nurses, and caregivers, so there are few medical procedures that are difficult to handle or restrictions on ADL. However, nursing homes often do not have full-time doctors, and nurses are often absent at night. For this reason, many nursing care facilities are unable to provide medical treatments such as administering oxygen, suctioning sputum, or changing bandages for bedsores. Additionally, nursing homes with a limited number of caregivers are often only able to accommodate admissions that do not require much care. The actual situation of hospitals and nursing care facilities often cannot be understood from numbers or pamphlets. The most accurate evaluations are those from patients who have actually been hospitalized or admitted to a facility and their families. By accumulating and recording information from a large number of patients and their families at each medical institution or nursing facility, this will become an important reference when referring discharged patients, etc.

[0018] FIG. 4 shows an example of the contents of the registration means for discharged patients. Following the patient ID, name, and date of birth, contact information and address are registered. The address is necessary for contacting you by post or other means. When visiting someone's home, you can search for the address using a map app to find the location of the home and the route from the hospital. Contact phone numbers (landline and mobile) and, for mobile phones, social network IDs (SNS-IDs) such as LINE (LINE is a registered trademark of Yahoo! Japan Corporation) are also registered. It is also useful to register contact information for not only the patient but also the patient's family. When a patient's condition worsens or their dementia progresses, it becomes difficult to contact the patient themselves, so it is also important to have contact with the patient's family.

[0019] If a hospital calls a patient or their family directly, the call may be rejected because it disrupts their work or is mistaken for a nuisance call. When a patient is discharged from the hospital, they can send a friend request via the QR code on the hospital's official account (QR code is a registered trademark of DENSO WAVE INCORPORATED) and a means of communication can be established by accepting the request. Sending messages via LINE or other services is a useful means of communication because it does not disrupt work and you can be sure that the sender is not a suspicious person. Also, compared to regular telephone calls, calls can be made for free or at a low cost. From the perspective of patients or their families, contacting the person in charge using the hospital's main number often requires multiple relays and is a hassle. In contrast, messaging using social networking sites such as LINE is highly useful because it ensures that messages are sent to the other party through asynchronous communication.

[0020] FIG. 5 shows an example of the recorded contents of the patient attribute recording means. Each patient has different ADL status, illnesses they are suffering from, medications they are taking, and medical treatments they require. Also, although not shown in the figure, economic status, such as low income, is an important factor when selecting a facility to transfer to. These patient attributes are recorded. When considering referral to a medical institution or nursing facility, the appropriate medical institution or nursing facility is selected by checking the list of ADLs and medical procedures that can be handled in the facility attribute record for each facility shown in Figure 3.

[0021] FIG. 6 shows an example of the contents of the movement history management means. As a means of recording movement history attributes, each time a patient moves between medical institutions or nursing facilities, a movement ID is assigned and the movement date, origin, destination, and patient ID are recorded. Furthermore, if necessary, attributes of the transfer, such as the person providing discharge support and the status of negotiations during the transfer, will be recorded. By keeping a record of any problems or complaints that occur during the move, it becomes easier to take measures to prevent problems during future moves.

[0022] FIG. 7 shows an example of a patient's movement history. The movement history of a specific patient can be obtained by searching the movement history management means using the patient ID and displaying the history in chronological order. Using similar procedures, it is easy to search for a list of patients who have been admitted to a particular medical facility / nursing home, a list of medical facilities / nursing homes from which patients flowed to a particular medical facility / nursing home, a list of medical facilities / nursing homes to which patients flowed from a particular medical facility / nursing home, and a list of patients to which each MSW is responsible for transferring patients. Conventionally, the activities of MSWs have been limited to deciding where patients will be discharged from hospitals, but by using the discharge and post-discharge tracking system of this invention, the scope of activities can be expanded to all local medical and nursing facilities, making it possible to practice community social work.

[0023] Although the embodiments have been described above, the specific configuration of the present invention is not limited to the above-described embodiments, and the present invention also includes design changes and the like that do not deviate from the gist of the invention. For example, in the figure, for convenience of explanation, there is only one hospital from which the patient is discharged, but there may be multiple hospitals. In addition to nursing homes, there may also be facilities for disabled people, etc.

Claims

1. This is a post-discharge tracking system that builds an information sharing network between medical institutions, patients, and their families. (1) A facility registration means for registering the names of medical facilities and nursing care facilities; (2) A discharged patient registration means; and (3) A movement history management means for recording the movement history of the discharged patient after discharge by registering at least the name of the medical facility or nursing care facility to which the patient will be transferred and the discharged patient in the history when the patient is discharged from the hospital. The post-discharge tracking system is characterized in that the movement history management means records at least the date and time of the movement, the facility from which the movement originates, the facility to which the movement originates, and the patient ID for each movement, and further includes a movement history attribute recording means, if necessary, for recording movement attributes such as the discharge supporter and the status of negotiations during the movement.

2. The post-discharge tracking system according to claim 1, characterized in that the registration means includes a patient attribute recording means for recording at least one of the following regarding the discharged patient: necessary medical treatment, activities of daily living (ADL), contact information, and financial status.

3. The post-discharge tracking system according to claim 1 or 2, characterized in that the facility registration means is equipped with a facility attribute recording means for recording at least one of the medical treatments available at the facility, activities of daily living (ADL), contact information, necessary expenses, and evaluations from the patient or family.

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