Patient follow- up unit

Head of unit: Dr. Saed Fallah Tafti

Introduction:
Considering the advances in health care systems and increase in individual expectations of different human population, patients believe that after discharge from hospital they should fully regain their health and should be able to continue with their normal lives, occupations and social communications. But chronic diseases, especially in old age, along with accompanying disorders such as hypertension, diabetes, and osteoarthritis prevent fulfilling this expectation easily after discharge from hospital.
Studies have repeatedly shown that aged people are prone to various complications, especially during the first few weeks after discharge. Physical disability, decrease in attention, and therefore inability to take care of health are major reasons for various complications which threaten the patients. Therefore, offering a thorough and accessible health service by a separate unit in the hospital will not only decrease costs but will also increase patient satisfaction and prognosis.
Considering the above-mentioned, patient follow up program was initiated in 2005 by direct order from director of hospital with the aim of decrease in readmission and increase in time interval between readmission of patients. Initially patients admitted to wards 3 and 9 and thereafter all patients admitted to medical wards were enrolled into our study.

Objectives:           
One of the main aims of this study was maintenance of communication between patient and physician in charge in a way that the cycle of patient management and physician order is maintained after discharge. Such a communication results in sincere relationship, patient satisfaction and sense of security which results in appropriate drug consumption and therefore better outcome.
On this basis our other aims for performing patient follow up were:
1- Evaluation of patient's physical, emotional, and social needs regarding his illness
2- Designing patient home care similar to hospital care
3- Gaining cooperation of patient and relatives considering better education and appropriate care
4- Evaluation of treatment outcome and disease process
5- Evaluation of results of activities of this unit considering health progression and disease control.

Patientcare Activities

Educational Activities

Research Activities