Post-discharge tracking system

Abstract

[Problem] To construct a network for sharing information between medical institutions and a patient or patient's family, ascertain, within this network, the present state of an illness of the patient, the degree of nursing care therefor, and a history of transfer between facilities, and to give advice related to facility selection so that appropriate medical care and nursing care can be received as necessary. Additionally, to facilitate appropriate selection of a future referral destination of a discharged patient by evaluating actual conditions of medical care and nursing care received at facilities from the viewpoint of the patient or patient's family. Furthermore, to refer an appropriate facility in consideration of the medical condition and state of nursing care to a discharged patient, as well as when a request for a referral to an in-patient facility has been received from a patient or patient's family. [Solution] Provided are: a facility registration means for registering facility names of medical institutions and care facilities; a registration means for discharged patients; and a transfer history management means for managing the history of transfer between the facilities after discharge of the patient.

Description

Post-discharge tracking system

[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.

[0002] Traditionally, patients discharged from a hospital would return to their normal lives at home. However, as the aging society progresses, 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, hypertension, and osteoporosis, and require continued appropriate treatment even after being discharged from the hospital. The following publications are known as technologies related to the present application.

[0003] JP 2002-73803 A JP 2005-339309 A JP 2024-69787 A

[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 discharge. However, as patients move between facilities and hospitals, it can be difficult to determine whether appropriate treatment is continuing. While communication methods are necessary to contact patients and their families as needed to confirm the continuation of treatment and their living environment and provide appropriate advice, organized communication systems are not always in place. Referral medical institutions and nursing care facilities vary widely in the medical procedures and care levels they provide. Selecting an appropriate referral destination requires evaluating the actual medical procedures and care levels available from the patient's and family's perspective, but in the past, accurate evaluations have not always been made. When living at home becomes difficult due to dementia or other conditions, families seek residential care. Recently, there has been an increasing number of cases in which for-profit companies refer families to inappropriate facilities and receive high referral fees from the family or facility. 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.

[0007] As a means for achieving the above-mentioned objective, the post-discharge tracking system described in claim 1 is a post-discharge tracking system that builds an information sharing network between medical institutions, patients, and their families, and is equipped with: (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 that, when a patient is discharged from the hospital, records 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, thereby recording the movement history of the discharged patient after discharge from the facility.The movement history management means records at least the date and time of the movement, the facility from which the patient is transferred, the facility to which the patient is transferred, and the patient ID for each movement, and is further equipped with a movement history attribute recording means that records movement attributes such as the discharge supporter and the status of negotiations during the movement, as necessary.

[0008] In the post-discharge tracking system of claim 2, in the post-discharge tracking system of claim 1, the registration means is characterized by having a patient attribute recording means for recording at least one of the necessary medical treatment, activities of daily living (ADL), contact information, and financial status of the discharged patient.

[0009] The post-discharge tracking system of claim 3 is characterized in that, in the post-discharge tracking system of claim 1 or 2, the facility registration means is equipped with a facility attribute recording means for recording at least one of 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.

[0010] The post-discharge tracking system described in claim 1 includes (1) a facility registration means for registering the names of medical institutions and nursing care facilities, (2) a discharged patient registration means, and (3) a movement history management means for managing the movement history of the patient from the facility after discharge from the hospital, so that the patient's current illness and level of care level and the movement history of the facility can be grasped, and advice on facility selection can be provided as needed so that appropriate medical care and nursing care can be received. Also, a movement history attribute recording means is provided, so that for each movement, at least the date and time of the movement, the facility from which the movement occurred, the facility to which the movement occurred, and the patient ID can be recorded, and further, as necessary, movement attributes such as the discharge supporter and the status of negotiations during the movement can be recorded.

[0011] The post-discharge tracking system according to claim 2 is provided with a patient attribute recording means, which records at least one of the following regarding the patient: required medical treatment, activities of daily living (ADL), contact information, and financial situation.

[0012] 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 available at the facility, activities of daily living (ADL), contact information, necessary expenses, and evaluations from the patient or family.

[0013] FIG. 1 is an explanatory diagram of a patient's movement between medical institutions and facilities after discharge from a hospital. FIG. 2 is an example of a master table of a facility registration means. FIG. 3 is an example of a facility attribute recording means. FIG. 4 is an example of the contents of a discharged patient registration means. FIG. 5 is an example of the recorded contents of a patient attribute recording means. FIG. 6 is an example of the contents of a movement history management means. FIG. 7 is an example of the movement history of a certain patient.

[0014] The post-discharge tracking system of the present invention includes a server device, a database, and a terminal. The server device is a known computer device and includes an arithmetic unit, a main memory device, an auxiliary memory device, an input device, an output device, and a communication device. The arithmetic unit, the main memory device, the auxiliary memory device, the input device, the output device, and the communication device are connected to each other via a bus interface. The arithmetic unit includes a known processor capable of executing an instruction set. The main memory device includes volatile memory such as RAM capable of temporarily storing the instruction set. The auxiliary memory device includes non-volatile data storage capable of recording an OS and programs. The data storage may be, for example, a HDD or a SSD. The input device is, for example, a keyboard. The output device is, for example, a display such as an LCD. The communication device includes a network interface connectable to a network. The server device includes means for registering facilities, registering discharged patients, managing movement history, recording movement history attributes, recording patient attributes, and recording facility attributes. The processor of the server device performs the functions and effects of the means. The database according to the present invention may be configured in an auxiliary storage device of the server device, or may be configured in a separate auxiliary storage device independent of the server device. The database stores information handled by the post-discharge tracking system. The terminal according to the present invention, like the server device, has a known computer hardware configuration. The server device, database, and terminal according to the present invention can communicate with each other via a network.

[0015] Figure 1 is an explanatory diagram of patient transfers between medical institutions and facilities after discharge. One patient was discharged from the hospital to rehabilitation hospital A (transfer 29856) and then transferred to senior housing with support services D (transfer 78596). Another patient moved to group home E after discharge (transfer 68295), and was subsequently admitted to convalescent hospital B due to a worsening condition (transfer 87952). Here, "transfer 29856" and other numbers are transfer IDs in the transfer history management means described later. As shown in this diagram, patients who have completed treatment at the hospital but are unable to live at home directly are transferred to other medical institutions or nursing facilities depending on the patient's condition and the level of care required.

[0016] Figure 2 shows an example of a master table for the facility registration means. It lists the facility name and facility ID. Figure 3 shows an example of the contents recorded in the facility attribute recording means. For each facility ID, the facility capacity (for hospitals, the ward type and the number of beds in the ward), the types of medical procedures available, ADL (Activities of Daily Living) restrictions upon admission, and evaluations from admitted patients and their families are recorded. Because hospitals employ a large number of medical professionals, including full-time doctors, nurses, and caregivers, there are few difficult medical procedures or ADL restrictions. However, nursing homes often lack full-time doctors and are often absent at night. As a result, many nursing homes are unable to provide medical procedures such as oxygen administration, sputum suction, and pressure ulcer bandage changes. Furthermore, nursing homes with few caregivers often only accommodate less demanding admissions. The true nature of a hospital or nursing home is often unclear from figures or brochures. Evaluations from actual patients and their families who have been admitted or admitted are the most accurate. 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.

[0017] Figure 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 when contacting the patient by mail, etc. When visiting the patient's home, the address can be searched using a map app to find the patient's location and 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! 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 dementia progresses, it can be difficult to contact the patient themselves, so contact information for the patient's family is also important.

[0018] Direct calls from the hospital to patients or their families can be rejected due to disruption to work or misidentification as nuisance calls. When a patient is discharged, 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 accept the request to establish contact. Sending messages via LINE or other social media platforms is useful because it avoids disruption to work and ensures that the call is not from a suspicious source. Furthermore, calls are free or inexpensive compared to regular phone calls. From the perspective of patients or their families, contacting a staff member via the hospital's main number often requires multiple relays and is cumbersome. In contrast, messaging using SNS platforms such as LINE is highly useful because it ensures asynchronous communication and ensures that messages are delivered to the recipient.

[0019] Figure 5 shows an example of the contents recorded in the patient attribute recording means. Each patient has different ADL status, current illness, current medications, and required medical treatments. Also, although not shown in the figure, economic status, such as low income, is an important factor when selecting a destination facility. 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 comparing the medical institution or nursing facility that can accommodate the patient's attributes with the list of ADLs and medical treatments that can be accommodated in the facility attribute record for each facility shown in Figure 3.

[0020] Figure 6 shows an example of the contents of the transfer history management means. As a transfer history attribute recording means, a transfer ID is assigned each time a transfer occurs between medical institutions or nursing facilities, and the transfer date, transfer origin, transfer destination, and patient ID are recorded. Furthermore, if necessary, transfer attributes such as the discharge supporter and the status of negotiations at the time of transfer are recorded. By recording the details of any problems or complaints that occur during the transfer, it becomes easier to take measures to prevent problems during future transfers.

[0021] Figure 7 shows an example of a patient's travel history. The travel history management unit can be searched by the patient's ID and displayed in chronological order to obtain a specific patient's travel history. Using similar procedures, it is possible to easily search for a list of patients who have been admitted to a particular medical facility or nursing home, a list of medical facilities or nursing homes from which patients flowed to a particular medical facility or nursing home, a list of the next medical facility or nursing home to which patients flowed out of a particular medical facility or nursing home, and a list of patients to which each MSW is responsible for transporting patients. While traditionally, MSW activities were limited to determining discharge destinations from hospitals, the use of the discharge and post-discharge tracking system of the present invention expands the scope of MSW activities to include all local medical facilities and nursing homes, enabling the practice of community social work.

[0022] 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 within the scope 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, facilities for disabled people may also be used.

Claims

1. A post-discharge tracking system that builds an information sharing network between medical institutions, patients, and their families, comprising: (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 that, when a patient is discharged from the hospital, records the facility 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, wherein the movement history management means records at least the date and time of the transfer, the facility from which the patient is transferred, the facility to which the patient is transferred, and the patient ID for each transfer, and further comprises a movement history attribute recording means, as necessary, for recording attributes of the transfer such as the discharge supporter and the status of negotiations at the time of the transfer.

2. The post-discharge tracking system according to claim 1, characterized in that the registration means is provided with 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. A post-discharge tracking system as described in 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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