2Thomas EJ, Brennan TA. Incidence and types of preventable ad- verse events in elderly patients:Population based review of medical records[J]. BMJ, 2000,320 ( 7237) : 741 - 744.
3Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial [J]. Ann Intern Med,1994,120(12) :999 - 1006.
4Naylor MD,Mccauley KM. The effects of a discharge planning and home follow - up intervention on elders hospitalized with common medical and surgical cardiac conditions:'J'l. J Cardiovase Nuts, 1999,14(1) :44 - 54.
5Mary D,Dorothy A,Robertal L,et al. Transitional care of older a- dults hospitalized with heart failure: A randomized, controlled trial [J3. J Am Geriatr Soc,2004,52(5) :675 - 676.
6Shortell SM,Rundall TG, Hsu J. Improving patient care by linking evidence- based medicine and evidence- based management[J3. JAMA,2007,98(6) :673 - 676.
8Parker SG. WHO Regional Office for Europe' Health Evidence Network. Do current discharge arrangements from inpatient hospi- tal care for the elderly reduce readmissin rates,the length of inpa- tient stay or mortality, or improve health status? [EB/OL]. ht- tp://www, euro. who. int/Document/E87542, pdf.
9Landefeld CS. Improving health care for older persons[J]. Annals of Internal Medicine, 2003,139(5) : 421 - 424.
10Sommers A, Cunningham PJ. Physician visits after hospital dis- charge:Implications for reducing readmissionsEJ]. National Insti- tute for Health Care Reform(Research Brief),2011,2(6) : 1 -6.
4Dicenso A,Guyatt G, Cfliska D. Evidence-based nursing: a guide to clinical practice [ M ]. St. Louis, Mo. London: Mosby, 2005,15-16.
5Tu SP,McDonell MB,Spertus JA,et al. A new self-administered questionnaire to monitor health-related quality of life in patients with COPD[J]. Chest, 1997,112,614-622.
6Wong KY,Mok PH,Chan T,et al. Nurse follow-up of patients with diabetes:randomized controlled trial[J]. Journal of Advanced Nursing, 2005,50(4) :391-402.
7Martin KS. The Omaha System[M]. St Louis: Elsevier Saunders,2005: 23-57.
8Borg GA. Psychophysical basis for perceived exertion[J]. Med Sci Sports Exerc, 1982,14(5) : 377-381.
9Marshall M. Strategies for success: bringing evidence-based practice to bedside[J]. Clinical Nurse Specialist,2006,20:124-127.
10Naylor MD. A decade of Transitional Care Research with Vulnerable Elders[J]. The Journal of Cardiovascular Nursing,2000,14(3):1-14.
4Sommers A, Cunningham P J. Physician visits after hospital discharge : Implications for reducing readmissions [J] 1. National Institute for Health Care Reform( Research Brief) ,2011,2 (6) : 1 - 6.
5Hepperd S, MeClaran J, Phillips CO, et al. Discharge planning from hospital to home [J]. Cochrane Database of Systematic Re-views, 2010(1) :313.
