Aliotta Sherry L, Grieve Kathleen, Giddens Jean F, Dunbar Linda, Groves Carol, Frey Katherine, Boult Chad
S.A. Squared of Tennessee, Inc., Evansville, IN 47701, USA.
Prof Case Manag. 2008 May-Jun;13(3):151-8; quiz 159-60. doi: 10.1097/01.PCAMA.0000319968.76605.b3.
This article describes "Guided Care," a promising new model of case management that includes disease management, self-management, transitional care, and caregiver support for multimorbid patients and their families.
Guided Care nurses, based at primary care practices, extend services to the home and all the other settings where their patients receive care.
Guided Care nurses take responsibility for 50-60 multimorbid patients. For each patient, the nurse performs a home assessment and creates an evidence-based plan of care. In partnership with the primary physician, the Guided Care nurse then monitors and coaches the patient monthly, coordinates the patient's transitions between providers and sites of care, educates and supports family caregivers, and facilitates access to community resources.
As a next stage in the evolution of case management, Guided Care may be supported by Medicare and, therefore, adopted widely throughout the American healthcare.
本文介绍了“指导式护理”，这是一种颇具前景的新型病例管理模式，包括疾病管理、自我管理、过渡性护理以及为患有多种疾病的患者及其家庭提供照护者支持。
基于初级保健机构的指导式护理护士将服务扩展至患者家中以及患者接受护理的所有其他场所。
指导式护理护士负责照顾50至60名患有多种疾病的患者。对于每位患者，护士会进行家庭评估并制定基于证据的护理计划。然后，指导式护理护士与初级医生合作，每月对患者进行监测和指导，协调患者在不同医疗服务提供者和护理场所之间的转诊，对家庭照护者进行教育和支持，并协助患者获取社区资源。
作为病例管理发展的下一阶段，指导式护理可能会得到医疗保险的支持，因此可在美国医疗保健领域广泛采用。
