本方案乃透過出院病患電話追蹤訪談，瞭解出院病患面臨的問題，提 供適切的諮詢服務，並建立「出院病患電話追蹤完成率」及「出院病患電話追蹤 後返診率」之監測指標，以達持續性品質改善的目的。在實施過程中除先制定出 院病患電話追蹤訪談記錄及出院病患電話訪談追蹤作業標準外，於八十七年九月 開始執行至今，經八十八年五月至十月評值成效得知，評值六個月期間共電話訪 談603人次，電話追蹤完成率平均為83.3%，比未建立指標監測前高17.3%；電 話追蹤後返診率亦由80%提昇至制定指標監測後之92.3%，大部份受訪病患及家 屬94.2%對此項服務反應非常良好，護理人員亦由其回饋中獲得另一方面之成就 感。未來應再加強電話追蹤完成率及分析未返診之原因，護理人員亦應將出院病 患可能面臨之適應問題列入出院準備計畫服務中，促進出院病患醫院與社區照護 之持續性服務。

　　　　　Psychiatric patients are facing increasing problems of postdischarge adjustments. To prevent rapid readmission, we provide a continuum of care for psychiatric patients by telephone follow-up. In the performance process, we standardized the record content and the interview procedures. We also developed quality control monitoring to improve the quality of telephone follow-up services. This project has been performed one year since the beginning. Evaluating the sixth months (from May to October 1999) of the telephone follow-ups, sbowed that 603 person discharged patients called. We can objectively monitor the quality of telephone follow-ups after the establishment of services standardization and development of quality monitoring indicator. The completed rate increased from 66% to 83.3%, and the outpatient rate of follow-ups also increased form 80% to 92.3%. Most patients and their families (94.2%) were satisfied with this service. Finally, the postdischarge contact with patients is a positive experience for the nurses. In the future we would concern the problems of postdischarge patient's adjustment, including those problems with their discharge plans, and to promote the quality of care for patients' transitions from the hospital to the community.