关键词: 医院-居家；乳腺癌；淋巴水肿；医联体

Abstract: Objective: To construct a hospital-home linkage management model for lymphedema after breast cancer surgery and determine its effect. Methods: With the hospital as the center, the core team was set up to train specialized nurses to optimize the work process and system, and the lymphedema clinic was extablished to build an information communication platform which could link patients and their families at home, and finally to construct and implement the hospital-home linkage management model of lymphedema after breast cancer surgery. Indicators including the incidence of lymphedema after breast cancer surgery, the nurses' competency, and the self-management ability of lymphedema of patients in hospital and at home were compared before and after the implementation of this model. Results: After the implementation, the nurses' specialized competency and the patients' self-management ability over lymphedema in hospital and at home after breast cancer surgery were improved (P<0.05). The incidence of lymphedema decreased from 24.6% to 18.2%. Conclusion: Since the establishment and implementation of the hospital-home linkage management model of postoperative lymphedema for breast cancer can effectively improve the competency of breast specialist nurses, help patients with breast cancer to do better in postoperative lymphedema self-management so as to improve the clinical outcome, it is feasible and can be widely used in the future.

Key words: hospital-home; breast cancer; lymphedema; integrated health care organization