Parrish Monique M, O'Malley Kate, Adams Rachel I, Adams Sara R, Coleman Eric A
LifeCourse Strategies, Orinda, California 94563, USA.
Prof Case Manag. 2009 Nov-Dec;14(6):282-93; quiz 294-5. doi: 10.1097/NCM.0b013e3181c3d380.
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.
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.
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.
在护理转接过程中，即患者从一位医疗从业者或一种医疗环境转至另一位医疗从业者或另一种医疗环境时，患者极易在医疗护理的质量和安全方面出现严重失误。护理转接干预措施（CTI）是一项为期4周、低成本、低强度的自我管理项目，旨在为从急性护理环境出院的患者提供技能、工具以及转接教练的支持，以确保满足他们的健康和自我管理需求。该项目在加利福尼亚州10个基于医院 - 社区的合作站点实施，为期12个月。其中5个合作站点由医院主导，5个由县主导。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）评估每个站点的实施特征以及该站点继续开展该项目的可能性；（2）征求站点的反馈意见；（3）分析站点和患者特征数据以及来自CTI测量工具（3项护理转接测量指标[CTM - 3]和患者激活评估[PAA]工具）的数据。
CTI在加利福尼亚州10个医院和社区组织中实施，这些组织接受了实施该干预措施的培训和技术支持。
领导力支持的存在被确定为报告对CTI有长期支持兴趣和能力的站点的关键因素。各站点认为让医院和社区的领导者参与、提供额外的转接教练培训以及安排稳定且专职（有资金支持）的转接教练是宝贵的经验教训。测量工具的主要研究结果表明，未来CTI的实施应关注药物管理、患有心血管疾病和糖尿病的患者、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，对于有全面继续开展计划的站点的患者，其平均PAA得分略高于有部分或小规模继续开展CTI计划的站点的患者。
CTI的此次实施，其灵活的设计能响应患者、医院和社区组织的多样化需求，提供了一系列关于如何改善和维持护理环境之间有效患者转接的实际经验。对改善护理转接感兴趣的医疗系统有充分理由探索实施该干预措施的可行性，同时要关注发展或解决以下方面：强大的护理转接领导力；医院 - 社区的合作关系；不同社区的特殊需求；患者层面的用药核对与管理；以及根据患有心血管疾病和糖尿病患者的独特需求调整模式。
