Implementation of the Care Transitions Intervention Sustainability and Lessons Learned
Implementation of the Care Transitions Intervention Sustainability and Lessons Learned
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DOI：
10.1097/ncm.0b013e3181c3d380
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发表时间：
2009-11-01
影响因子：
1.5
通讯作者：
Coleman, Eric A.
中科院分区：
文献类型：
--
作者：
Parrish, Monique M.;O'Malley, Kate;Coleman, Eric A.
目的：在护理过渡期间，即病人从一名医护人员或环境转移到另一名医护人员的过程中，病人很容易在医疗质量和安全方面出现严重失误。护理过渡干预(CTI)是一项为期4周、低成本、低强度的自我管理计划，旨在为从急性护理环境中出院的患者提供技能、工具和过渡教练的支持，以确保他们的健康和自我管理需求得到满足，该计划在加州的10个医院-社区合作网站实施，为期12个月。其中5个合作伙伴是医院主导的网站，5个是县主导的网站。该项目的主要目标是通过以下方式确定促进干预措施可持续性的因素：(1)评估每个站点实施的特点和该站点继续该计划的可能性；(2)征求站点的反馈；(3)分析现场和患者特征数据，以及来自CTI测量工具(3项护理过渡措施和患者激活评估工具)的数据。初级实践环境(S)：CTI在10个接受了实施干预的培训和技术支持的加州医院和社区组织中实施。结果：领导支持的存在被确定为站点报告对CTI的兴趣和长期支持能力的关键因素。网站认为，让医院和社区的领导者参与进来，提供额外的过渡教练培训，以及指派一致和专门的(资助的)过渡教练，都是宝贵的经验教训。测量仪器的主要发现表明，未来的CTI实施应侧重于药物管理、心血管疾病和糖尿病患者、85岁以上的患者以及非裔美国人和拉丁裔患者。来自医院主导站点的患者的平均PAA得分略高于来自县主导站点的患者，来自具有完整继续计划的站点的患者的平均PAA得分略高于来自部分或次要计划继续实施CTI的站点的患者。对病例管理实践的影响：CTI的实施，其灵活的设计响应了患者、医院和社区组织的多样化需求，提供了许多关于如何改善和维持有效的患者在护理环境之间的过渡的真实经验。对改善护理过渡感兴趣的医疗保健系统有一个令人信服的理由来探索实施干预措施的可行性，同时注意发展或解决以下问题：强大的护理过渡领导力；医院与社区的协作伙伴关系；不同社区的特殊需求；患者级别的药物调节和管理；以及针对心血管疾病和糖尿病患者的独特需求量身定做该模式。
Purpose: During care transitions, the movement of patients from one healthcare practitioner or setting to another, patients are vulnerable to serious lapses in the quality and safety of their medical care. The Care Transitions Intervention (CTI), a 4-week, low-cost, low-intensity self-management program designed to provide patients discharged from the acute care setting with skills, tools, and the support of a transition coach to ensure that their health and self-management needs are met, was implemented in 10 hospital-community-based partnership sites in California over a 12-month period. Five of the partnerships were hospital-led sites, and 5 were county-led sites. The primary goal of the project was to identify factors that promote sustainability of the intervention by (1) assessing features of each site's implementation and the site's likelihood of continuing the program; (2) soliciting feedback from the sites; and (3) analyzing site and patient characteristic data and data from the CTI measurement instruments (the 3-item Care Transition Measure [ CTM-3] and the Patient Activation Assessment [ PAA] tool).Primary practice setting(s): The CTI was implemented in 10 California hospital and community-based organizations that received training and technical support to implement the intervention.Findings: Presence of leadership support was determined to be the critical factor for sites reporting interest in and capacity for long-term support of the CTI. Sites identified engaging hospital-and community-based leaders, providing additional transition coach training, and the assigning of consistent and dedicated (funded) transition coaches as valuable lessons learned. Key findings from the measurement instruments indicate that future CTI implementations should focus on medication management, patients with cardiovascular conditions and diabetes, patients older than 85 years, and African American and Latino patients. Mean PAA scores were moderately higher for patients from hospital-led sites than for patients from county-led sites and moderately higher for patients from sites with full plans for continuation than for patients from sites with partial or minor plans to continue the CTI.Implications for case management practice: This implementation of the CTI, with its flexible design responsive to the diverse needs of patients, hospitals, and community organizations, provides a host of real-world lessons on how to improve and sustain effective patient transitions between care settings. Healthcare systems interested in improving care transitions have a compelling reason to explore the viability of implementing the intervention with attention to developing or addressing the following: strong care transitions leadership; collaborative hospital-community partnerships; the particular needs of diverse communities; patient-level medication reconciliation and management; and tailoring the model to the unique needs of patients with cardiovascular conditions and diabetes.