关键词: 三元联动；延续护理；腹膜透析

Abstract: Objective: To analyze the implementation and influence of transitional care model under the linkage of hospital-community-family in Peritoneal Dialysis (PD) patients. Methods: 15 streets were divided into 2 groups using the random number table method. PD patients of the control group were given routine follow-ups by PD clinic and telephone followed ups, while PD patients of the experimental group received transitional care services under the linkage of hospital-community-family aside from routine follow-ups. After one year of intervention, parameters including the treatment of PD patients, the occurrence of complications, the time of peritonitis and the peritoneal dialysis adequacy of the two groups were compared. Results: Through comparing the two groups, the Drop-Out Rate (DOR) declined, the Time Of Treatment (TOT) increased; the incidence of peritonitis, the time when peritonitis appeared, the urea removal index (Kt/V), the weekly abdominal penetration adequacy (CCL) and the medical expenses of patients were improved (P<0.05). Conclusion: The development of transitional care model under the linkage of hospital-community-family can increase the availability of PD continuous care, improve the participation degree of PD patients and bridge the vacancy of community service function, which has achieved good social and economic benefits. And thus this mode can be promoted for wider use.

Key words: the linkage of hospital-community-family; transitional care; peritoneal dialysis