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檢視重複的心臟衰竭轉銜，並判斷下次出院前最有力的個案管理回應。

Trend

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Time	Data
First discharge	Client received written heart-failure instructions but had no home scale and could not identify whom to call for increasing dyspnea.個案收到書面心臟衰竭指導，但家中沒有體重計，也不知道呼吸困難加劇時該聯絡誰。
Readmission 18 days later	Client could not afford two prescriptions and missed follow-up because the available bus route did not reach the clinic.個案無法負擔兩種處方藥，且因可搭乘的公車路線未到達診所而錯過追蹤。
Second readmission 24 days later	Client reports limited food choices, difficulty reading the medication calendar, and no home-health contact after discharge.個案表示食物選擇有限、閱讀藥物日曆有困難，且出院後沒有居家健康聯絡。

Q1. How should the team interpret this trend?團隊應如何解讀此趨勢？

The client simply refuses all care個案只是拒絕所有照護 More printed pages will solve the problem更多衛教單張就能解決問題 Each admission is unrelated每次入院彼此無關 Repeated transition failures are driven by unresolved access, equipment, and understanding barriers重複的轉銜失敗源於未解決的取得、設備與理解障礙

Q2. Which response is the priority before the next discharge?下次出院前，哪項回應是優先事項？

Build a patient-centered plan with pharmacy, social work, transport, nutrition, home health, and follow-up coordination建立以病人為中心的計畫，協調藥局、社工、交通、營養、居家健康與追蹤 Repeat the same instructions more loudly更大聲地重複相同指導 Schedule discharge before assessing resources在評估資源前就安排出院 Ask the client to solve every barrier independently要求個案獨立解決所有障礙

Q3. Which finding best demonstrates readiness for discharge?哪項發現最能證明已準備好出院？

A discharge form contains a signature出院表單上有簽名 All referrals were entered into the electronic record所有轉介都已輸入電子紀錄 The client uses teach-back and medications, scale, transport, appointments, and contact pathways are confirmed個案使用回覆示教，且藥物、體重計、交通、約診與聯絡管道均已確認 The client promises not to return to the hospital個案承諾不會再回醫院

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