Purpose: To see if there is a change in survival of patients with respiratory diseases (pneumonia, COPD, asthma)  when, the medical providers plan for post-discharge continuous medical and care services in the community after discharge. 

METHODS: 1) Allocation of test and control groups: Allocate test and control groups according to the room where the patient is admitted.

2) Basic data collection: All patients who are hospitalized should conduct a basic patient interview using a structured questionnaire.

3) In-patient education: The nurse and the social worker prepare a medical problem list and a social welfare problem list for the patient in the test group and prepare goals and plans accordingly. The social worker explains the overall business to the patient and the caregiver, and the nurse provides individualized education on the disease and management, which takes about 30 minutes to the patient and the caregiver within 3 days of admission.

4) Management of patients during hospitalization: The nurse in charge checks the patient's important events through daily electronic medical records and interviews every three days.

5) Discharge Education and Discharge: The nurse in charge provides discharge training materials and provides personalized training for 60 minutes. Your caseworker introduces, links, and registers community care programs available to patients after discharge.
For the control group, the nurse in charge presents the discharge education materials pamphlet for the inpatient diagnosis of the patient.

6) Fill out and provide the discharge patient form: The nurse and the social worker fill out the discharge patient form for the patient in the test group.The discharge patient form is registered in the public medical cooperation network established by the National Medical Center. The primary medical institutions, public health centers, and welfare service providers who use the hospitals to identify the medical condition and care status of the patients and provide appropriate services. Make this form available to medical institutions and services that are not registered at

7) Post-discharge patient management: The nurse / social worker in charge 1 and 2 weeks after the discharge of the patient confirms and encourages the management status after discharge by phone.

8) Confirmation of results: Confirmation of the outcome variables by telephone 30, 90 and 6 months after the patient was discharged.

 Health Services Research

For the trial group, provide patient education prior to discharge, provide community services after discharge, and provide phone management after discharge.
Only discharge training materials brochure is provided for the control group

Arm Label

Target Number of Participant

Arm Type

Arm Description

1) In-patient education: The nurse and the social worker prepare a medical problem list and a social welfare problem list for the patient in the test group and prepare goals and plans accordingly. The social worker explains the overall business to the patient and the caregiver, and the nurse provides individualized education on the disease and management, which takes about 30 minutes to the patient and the caregiver within 3 days of admission.

2) Management of patients during hospitalization: The nurse in charge checks the patient's important events through daily electronic medical records and interviews every three days.

3) Discharge Education and Discharge: The nurse in charge provides discharge training materials and provides personalized training for 60 minutes. Your caseworker introduces, links, and registers community care programs available to patients after discharge.

4) Fill out and provide the discharge patient form: The nurse and the social worker fill out the discharge patient form for the patient in the test group.The discharge patient form is registered in the public medical cooperation network established by the National Medical Center. The primary medical institutions, public health centers, and welfare service providers who use the hospitals to identify the medical condition and care status of the patients and provide appropriate services. Make this form available to medical institutions and services that are not registered at

5) Post-discharge patient management: The nurse / social worker in charge 1 and 2 weeks after the discharge of the patient confirms and encourages the management status after discharge by phone.

Arm Label

Target Number of Participant

Arm Type

Arm Description

The nurse in charge presents the discharge education materials pamphlet for the inpatient diagnosis of the patient.

Gender

Age

Description

Adults 18 years of age and older who were hospitalized under the following diagnoses in Ward 82, Room 01~10, Respiratory Center, Kangwon National University Hospital during the study period
Chronic obstructive pulmonary disease (COPD)
- asthma
- Pneumonia

-Patients who refuse to participate in this study
-Patients who are being treated separately from general patients due to infection

re-admission

1 month, 3 months, 6 months after discharge

Emergency department visit

1 month, 3 months, 6 months after discharge

Patients' satisfaction

1 month, 3 months, 6 months after discharge

Survival

1 month, 3 months, 6 months after discharge

OPD compliance

1 month, 3 months, 6 months after discharge