Cohen Eyal, Bruce-Barrett Cindy, Kingsnorth Shauna, Keilty Krista, Cooper Anna, Daub Stacey
Division of Pediatric Medicine at The Hospital for Sick Children and the Departments of Pediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario.
Healthc Q. 2011;14 Spec No 3:64-70. doi: 10.12927/hcq.0000.22580.
Providing integrated care for children with medical complexity in Canada is challenging as these children are, by definition, in need of coordinated care from disparate providers, organizations and funders across the continuum in order to optimize health outcomes. We describe the development of an inter-organizational team constructed as a unique tripartite partnership of an acute care hospital, a children's rehabilitation hospital and a home/community health organization focused on children who frequently use services across these three organizations. Model building and operationalization within the Canadian healthcare system is emphasized. Key challenges identified to date include communication and policy barriers as well as optimizing interactions with families; critical enablers have been alignment with policy trends in healthcare and inter-organizational commitment to integrate at the point of care. Considerations for policy developments supporting full integration across service sectors are raised. Early indicators of success include the enrolment of 34 clients and patients and the securing of funds to evaluate and expand the model to serve more children.
在加拿大，为患有复杂疾病的儿童提供综合护理具有挑战性，因为根据定义，这些儿童需要不同提供者、组织和资助者在整个连续过程中进行协调护理，以优化健康结果。我们描述了一个跨组织团队的发展情况，该团队是由一家急症护理医院、一家儿童康复医院和一个专注于经常使用这三个组织服务的儿童的家庭/社区健康组织组成的独特三方合作伙伴关系。重点强调了在加拿大医疗保健系统内建立模型和实施模型的过程。迄今为止确定的主要挑战包括沟通和政策障碍以及优化与家庭的互动；关键推动因素是与医疗保健政策趋势保持一致以及跨组织在护理点进行整合的承诺。文中还提出了支持跨服务部门全面整合的政策发展考量。成功的早期指标包括34名客户和患者的登记注册，以及获得资金以评估该模式并将其扩展以服务更多儿童。
