Achieving Coordinated Care for Patients With Complex Cases of Cancer: A Multiteam System Approach
Achieving Coordinated Care for Patients With Complex Cases of Cancer: A Multiteam System Approach
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DOI：
10.1200/jop.2016.013664
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发表时间：
2016-11-01
影响因子：
--
通讯作者：
Balasubramanian, Bijal A.
中科院分区：
文献类型：
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作者：
Lee, Simon J. Craddock;Clark, Mark A.;Balasubramanian, Bijal A.
患有多种慢性病的癌症患者对初级保健和专科护理团队如何提供协调良好的以患者为中心的护理提出了独特的挑战。这些护理团队在提供最佳卫生保健方面的有效性取决于他们作为多团队系统(MTS)的组成部分协调其目标和知识的程度。本文概述了MTS背景下护理协调面临的挑战，通过帕克兰达拉斯县综合安全网系统中的患者“富恩特斯先生”的护理经验进行了说明。作为一名慢性疾病持续患者，所讨论的患者通过Parkland社区导向的初级保健诊所之一进行管理。然而，一次癌症诊断引发了他的不同提供者团队之间加强协调的额外需要。进一步的研究和实践应该调查MTS在共享护理管理、专科护理转送、治疗依从性、护理障碍、慢性并存疾病的健康结果以及癌症控制和监测方面的协调关系。
Patients with cancer with multiple chronic conditions pose a unique challenge to how primary care and specialty care teams provide well-coordinated, patient-centered care. Effectiveness of these care teams in providing optimal health care depends on the extent to which they coordinate their goals and knowledge as components of a multiteam system (MTS). This article outlines challenges of care coordination in the context of an MTS, illustrated through the care experience of "Mr Fuentes," a patient in the Dallas County integrated safety-net system, Parkland. As a continuing patient with chronic illnesses, the patient being discussed is managed through one of the Parkland community-oriented primary care clinics. However, a cancer diagnosis triggered an additional need for augmented coordination between his different provider teams. Further research and practice should investigate the relationships of MTS coordination for shared care management, transfer to and from specialty care, treatment compliance, barriers to care, and health outcomes of chronic comorbid conditions, as well as cancer control and surveillance.