Complex care and contradictions of choice in the safety net.
Complex care and contradictions of choice in the safety net.
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安全网中复杂的护理和选择的矛盾。
DOI：
10.1111/1467-9566.12661
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发表时间：
2018
影响因子：
2.9
通讯作者：
Shim,JanetK
中科院分区：
文献类型：
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作者：
VanNatta,Meredith;Burke,NancyJ;Yen,IreneH;Rubin,Sara;Fleming,MarkD;Thompson-Lastad,Ariana;Shim,JanetK
本文探讨了美国医疗安全网中复杂护理管理（CCM）计划中复杂且往往相互矛盾的选择概念。根据在城市安全网诊所进行的两年多的民族志实地调查收集的纵向数据，我们的研究探讨了CCM的目标，即将频繁使用急诊科（艾德）的患者转变为“活跃”患者，减少他们的服务使用，从而有助于建立一个更合理、更具成本效益的医疗保健系统。通过将我们的数据与哲学家Annemarie Mol（2008）对选择和护理的竞争逻辑的概念化一起考虑，我们认为这些前提往往会破坏CCM团队支持患者并提供他们所需护理的努力-不仅是为了防止医疗危机，而且还要克服社会经济障碍。我们断言，虽然CCM安全网计划对患者成功转变为自我管理，具有成本效益的参与者的程度负责，但CCM工作人员提供的大部分护理实际上涉及试图干预影响患者选择的结构性障碍。因此，CCM方案在让患者做出更好的健康选择的经济必要性和面对系统性社会忽视提供护理的道德必要性之间挣扎。（本文的虚拟摘要可在以下网址查看：https：//www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA）。
This article explores the complicated and often‐contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety‐net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into ‘active’ patients who will reduce their service utilisation and thereby contribute to a more rational, cost‐effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need – not only to prevent medical crises, but to overcome socio‐economic barriers as well. We assert that while safety‐net CCM programmes are held accountable for the degree to which their patients successfully transform into self‐managing, cost‐effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).