School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Health Aff (Millwood). 2011 Apr;30(4):746-54. doi: 10.1377/hlthaff.2011.0041.
Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.
根据 2010 年平价医疗法案，已经建立了各种过渡性护理计划和服务，以提高质量和降低成本。这些计划帮助患有复杂慢性疾病的住院患者——通常是最脆弱的患者——安全、及时地从一个护理级别转移到另一个级别，或从一种护理环境转移到另一种护理环境。我们对研究文献进行了系统回顾，并总结了 21 项针对慢性疾病成人的过渡性护理干预的随机临床试验。我们确定了九项干预措施，这些措施对与医院再入院相关的措施产生了积极影响——这是医疗改革的一个关键重点。大多数干预措施通过至少三十天的出院后减少了再入院。许多成功的干预措施具有相似的特征，例如指派一名护士作为临床经理或护理负责人，并对出院患者进行家访。基于这些发现，我们建议采取几种策略来指导平价医疗法案下的过渡性护理实施，例如通过社区为基础的护理过渡计划和医疗保险共享储蓄以及支付捆绑试验等项目，鼓励采用最有效的干预措施。
