"It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU)
"It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU)
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DOI：
10.1370/afm.2464
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发表时间：
2019-11-01
影响因子：
4.4
通讯作者：
Saha, Somnath
中科院分区：
文献类型：
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作者：
Chan, Brian;Hulen, Elizabeth;Saha, Somnath
高需要高费用（HNHC）患者消耗了大量的卫生资源，但在传统的初级保健中往往得到不理想的护理。强化门诊护理干预试图更好地满足这些患者的需求，但我们对在为社会复杂的患者群体服务的诊所中提供这些干预措施的团队如何看待他们的工作知之甚少。方法我们对联邦合格卫生中心（WHC）的多学科工作人员的经验进行了定性研究。在持续实施流动重症监护病房（A-ICU）干预的背景下，照顾主要无家可归的HNHC患者。我们进行了半结构化的采访，9个门诊重症监护团队成员和6个“常规护理”的成员。我们进行了专题分析，使用归纳法，在语义level.RESULTS工作人员认为复杂的社会，行为和医疗挑战，导致病人的医疗保健系统不匹配的组合。工作人员认为以下是照顾HNHC患者的关键因素：同时解决心理社会和临床需求;在混乱时期坚持与患者保持联系;跨学科团队成员之间的共同承诺和凝聚力;以及根据患者的个人情况灵活调整护理。参与者对成功的定义更多地集中在提高患者的参与度，而不是减少利用率或cost.CONCLUSION HNHC工作人员与HNHC患者感知医疗保健系统和患者的临床和社会需求之间的不匹配作为这些患者的不良结局的关键驱动因素。强化门诊护理团队可以通过提供心理社会支持，灵活的护理服务和培养团队凝聚力来支持患者参与来弥补不匹配。
PURPOSE High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients' needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work.METHODS We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 "usual care" members. We conducted a thematic analysis, using an inductive approach, at a semantic level.RESULTS Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient-health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients' individual situations. Participants' definitions of success focused more on improving patient engagement than reducing utilization or cost.CONCLUSION FQHC staff working with HNHC patients perceive mismatch between the health care system and patients' clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.