Enhanced integration of primary and secondary health systems and patient empowerment through improved continuity of patient care and clinical handover

社区（初级）和医院（二级）保健服务之间的有效整合对于需要超出初始发作的患者至关重要，并且需要下一级保健提供者提供更多护理。这可能包括如果初级保健医生无法控制病情或住院后继续在初级保健进行药物和检查，则转到医院。关键阶段是从一个护理人员与另一个护理人员或患者和家属之间进行患者特定信息的沟通，以确保患者护理的连续性和安全性，称为临床移交。对高收入国家证据的审查表明，无效移交的后果导致不正确的治疗、医疗诊断延误、危及生命的不良事件、患者投诉、卫生保健支出增加、住院时间延长、再入院人数增加以及对卫生系统的其他影响。虽然我们未能找到低收入和中等收入国家的类似数据，但经验以及与合作伙伴和专家的讨论表明，由于卫生服务提供者整合方面存在巨大差距，低收入和中等收入国家由于交接不当而导致的不良事件和其他不良后果的发生率甚至更高。因此，很可能存在相当大的范围，以一种具有成本效益的方式改进实践，甚至可能降低成本。这些方法可借鉴高收入国家已成功实施的方法（如检查清单、患者记录）。世卫组织将全球重点放在卫生系统发展上，这对于更好地应对突发事件、传染病和其他疾病的挑战至关重要。中低收入国家老年人口的增加和生活方式行为的恶化（例如吸烟率）增加了心脏病、糖尿病和其他长期疾病的负担。由于他们需要持续的护理，这些人尤其受到初级和二级保健之间缺乏整合的不利影响。因此，我们建议的主要驱动因素是以下证据：-临床移交过程是患者安全的核心，临床移交不充分的后果会导致患者预后不佳和卫生系统成本高-临床移交是世卫组织患者安全规划确定的全球优先事项。许多中低收入国家需要并有兴趣改善各级保健的一体化，但几乎没有证据指导地方决策者如何确定和克服改进做法的障碍——最初的干预措施在文化和政治上是可以接受的、负担得起的和可持续的，但这种干预措施尚未得到系统的探索、试验或实施。1)描述在转诊和出院期间初级保健和二级保健之间临床移交的政策、培训、活动和文化方面的现状；2)确定改善临床移交的障碍和促进因素（卫生保健系统和患者相关）；3)制定干预方案；4)建立卫生系统研究能力。这些目标将通过一系列复杂的研究方法来实现，这些方法将涉及从决策者到患者的所有利益攸关方。这一阶段的直接好处将是医院和社区卫生保健从业者和政策制定者，他们将能够利用这些发现开始解决一些确定的负担得起的解决方案，研究人员将学习对他们来说新颖的卫生系统评估技术，最终患者将通过开发和实施干预措施获得更好的无缝卫生保健。后续干预研究有望推广到能够显著改善初级保健和医院保健服务整合的长期方案中。

Effective integration of care between community (primary) and hospital care (secondary) health services is essential for a patient whose needs extend beyond the initial episode, and more care is required by the next level of health provider. This may include referral to a hospital if a primary care doctor cannot manage the condition or the continuation of medication and check-ups in the primary care after a hospital admission. The crucial stage is communication of patient-specific information from one caregiver to another or to the patient and family, for the purpose of ensuing patient care continuity and safety, termed clinical handover. A review of evidence in the high-income countries showed that the consequences of ineffective handover led to incorrect treatment, delays in medical diagnosis, life-threatening adverse events, patient complaints, increased health care expenditure, increased length of stay, increased re-admissions, and other impacts on health systems. Although we have not been able to find similar data for LMIC, experience and discussions with partners and experts indicate that the rate of adverse events and other unwanted outcomes due to poor handover are even greater in LMICs due to huge gaps in integration of health providers. It is likely therefore, that considerable scope exists to improve practice in a way that is cost-effective and potentially even cost releasing. These may be adapted from methods that have been successfully implemented in high-income countries (e.g. check-lists, patient held records). There is a global focus from the WHO on health systems development, critical for a better response to challenges of emergencies, infectious and other diseases. The rise in elderly populations and deteriorating lifestyle behaviours (e.g. smoking rates) in LMICs have increased the burden of heart related, diabetes and other long term diseases. Due to their need for on-going care, these are particularly adversely affected by poor integration between primary and secondary care. Thus the main drivers for our proposal are evidence for the following: -clinical handover processes are at the core of patient safety and consequences of inadequate clinical handover result in poor patient outcome and high cost to the health system- Clinical handover is a global priority identified by the WHO Patient Safety Programme. There is need and interest in many LMICs to improve integration between-levels of health care, but little evidence to guide local decision makers in how to identify and overcome barriers to improved practice -initial interventions can be culturally and politically acceptable, affordable and sustainable, but that such interventions have not been systematically explored, tested or implementedThe objectives of this one year project (part of a extensive five-year programme) are: 1) describe existing situation in terms of policies, training, activities, and culture for clinical handover between primary and secondary care during referrals and discharge 2)identify barriers and facilitators (health care system and patient related) for improving clinical handover 3)develop options for intervention 4)build health systems research capacity. These will be achieved through a range of complex research methods that would involve all stakeholders from policy makers to patients.The immediate benefits of this phase will be for the hospital and community health care practitioners and policy makers who will be able to use the findings to start addressing some of the affordable solutions identified, researchers who will learn health system assessment techniques novel to them, and ultimately the patients who will receive a better seamless health care through the development and implementation of interventions. The follow-on intervention study is hoped to roll out into long-term programmes that could dramatically improve integration of primary and hospital care services.