门诊环境中的过渡性护理管理。

BMJ quality improvement reports Pub Date : 2017-04-27 eCollection Date: 2017-01-01 DOI:10.1136/bmjquality.u212974.w5206
Analiza Baldonado, Ofelia Hawk, Thomas Ormiston, Danielle Nelson
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引用次数: 12

摘要

高风险、高成本(HRHC)患者、有严重或多重医疗问题的患者以及老年慢性病患者是医疗成本上升的主要驱动因素患有复杂健康状况和功能限制的HRHC患者可能会去急诊室和医院,需要更多的支持性服务,并使用长期护理设施因此,这些患者群体很容易受到支离破碎的护理和“从裂缝中掉落”美国加利福尼亚州的一个大型县卫生和医院系统根据Triple AIM3引入了循证干预措施,重点关注以患者为中心的卫生保健、预防、健康维护和整个护理连续体的安全过渡。试点项目在门诊家庭医学诊所内嵌入了一名过渡护理经理(TCM),以主动协助HRHC患者提供外联援助、解决问题并促进护理的顺利过渡。这一举措得到了一个包括医生、护士、专家、健康教育工作者和药剂师在内的协作小组的支持。最初的50名患者显示急诊科(ED)就诊次数(干预前和干预后分别为33次和17次)和住院次数(干预前和干预后分别为32次和11次)减少,患者预后改善,并节省了费用。例如,1例患者在干预前6个月内有1次急症就诊,5次住院,总费用为217,355.75美元,在中医入组6个月内无急症复发或住院。初步结果显示,以患者为中心的结果、护理质量和资源利用有所改善,但需要更多的数据。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Transitional care management in the outpatient setting.

Transitional care management in the outpatient setting.

Transitional care management in the outpatient setting.

Transitional care management in the outpatient setting.

Patients who are high risk high cost (HRHC), those with severe or multiple medical issues, and the chronically ill elderly are major drivers of rising health care costs.1 The HRHC patients with complex health conditions and functional limitations may likely go to emergency rooms and hospitals, need more supportive services, and use long-term care facilities.2 As a result, these patient populations are vulnerable to fragmented care and "falling through the cracks".2 A large county health and hospital system in California, USA introduced evidence-based interventions in accordance with the Triple AIM3 focused on patient-centered health care, prevention, health maintenance, and safe transitions across the care continuum. The pilot program embedded a Transitional Care Manager (TCM) within an outpatient Family Medicine clinic to proactively assist HRHC patients with outreach assistance, problem-solving and facilitating smooth transitions of care. This initiative is supported by a collaborative team that included physicians, nurses, specialists, health educator, and pharmacist. The initial 50 patients showed a decrease in Emergency Department (ED) encounters (pre-vs post intervention: 33 vs 17) and hospital admissions (pre-vs post intervention: 32 vs 11), improved patient outcomes, and cost saving. As an example, one patient had 1 ED visit and 5 hospital admission with total charges of $217,355.75 in the 6 months' pre-intervention with no recurrence of ED or hospital admissions in the 6 months of TCM enrollment. The preliminary findings showed improvement of patient-centered outcomes, quality of care, and resource utilization however more data is required.

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