Farris Karen B, Côté Isabelle, Feeny David, Johnson Jeffrey A, Tsuyuki Ross T, Brilliant Sandra, Dieleman Sherry
College of Pharmacy, University of Iowa, Iowa City 52240, USA.
Can Fam Physician. 2004 Jul;50:998-1003.
Communication between community-based providers is often sporadic and problem-focused.
To implement collaborative community-based care among providers distant from one another and to improve or maintain the health of high-risk community-dwelling patients, with a focus on medication use.
Six primary health care teams were formed of a family physician, a pharmacist, and a home care case manager (nurse). Three of these teams also had a family physician's office nurse. Teams received training and decided on processes of care that included a home visit, medication history, and weekly 1.5-hour face-to-face team meetings. In 151 team conferences, 705 medication or health issues were identified for 182 patients over 6 months. Medication adherence was improved at 3 and 6 months. After 6 months, all providers had a greater understanding of the roles of the other providers.
Primary health care teams developed in this study require few structural changes to existing health care systems, but will require more reimbursement options.
社区医疗服务提供者之间的沟通往往是零散的且以问题为导向。
在彼此距离较远的医疗服务提供者之间实施基于社区的协作式护理，并改善或维持高危社区居家患者的健康状况，重点关注药物使用情况。
由一名家庭医生、一名药剂师和一名家庭护理个案经理（护士）组成了六个初级医疗保健团队。其中三个团队还配备了一名家庭医生办公室护士。各团队接受了培训，并确定了护理流程，包括家访、用药史以及每周1.5小时的面对面团队会议。在151次团队会议中，6个月内为182名患者识别出705个用药或健康问题。在3个月和6个月时，药物依从性得到了改善。6个月后，所有医疗服务提供者对其他提供者的角色有了更深入的了解。
本研究中组建的初级医疗保健团队对现有医疗保健系统几乎不需要进行结构调整，但需要更多的报销选择。
