Abstract：
Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients\' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.
摘要：
心力衰竭（HF）住院与高再入院率和死亡率相关，最脆弱的时期是出院后的最初几周。HF患者从医院到社区的有效护理过渡可以帮助降低脆弱时期的再入院率和死亡率。改善患者的长期预后，他们的家人或照顾者，和医疗保健系统。规划和沟通是护理无缝过渡的基础，通过确保在出院后和长期内继续实施在医院开始的患者管理变化。这份循证指南,由澳大利亚HF专家的多学科小组开发，讨论了在澳大利亚环境中实现HF住院患者向社区护理适当有效过渡的最佳实践。它就出院前后的关键因素提供指导，以及可用于促进护理平稳过渡的实用工具。
