J Korean Med Sci.  2020 Nov;35(42):e352. 10.3346/jkms.2020.35.e352.

Development of a Transitional Care Model Program for Patients with Pneumonia, Asthma, and Chronic Obstructive Pulmonary Disease: In-depth Interviews with Readmitted Patients

  • 1Department of Public Health Services, Kangwon National University Hospital, Chuncheon, Korea
  • 2Department of Health Policy and Management, Kangwon National University School of Medicine, Chuncheon, Korea
  • 3Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea


Community-based health management policies are needed considering societal aging. We aimed to develop a transitional care model (TCM) program for patients with pneumonia, asthma, and chronic obstructive pulmonary disease. First, we conducted in-depth interviews with patients who were hospitalized, released, and readmitted for those three conditions to identify issues with the current hospitalization/discharge system and post-discharge processes. Next, we developed a new TCM program suited to the realities of the current medical environment. Interviews revealed problems including inadequate awareness of disease and health management; insufficient information exchange between patients, caregivers, and primary medical institutions; and absence/low usage of community-based care services. The investigation applying the new TCM program to patients and following up on readmission rates and life satisfaction after discharge is ongoing. Reviewing these results and conducting further studies in the future will allow improvements to the model.


Pneumonia; Asthma; Chronic Obstructive Pulmonary Disease; Hospital Readmission; Transitional Care
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