Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd,, Room 6144, Rockville, MD 20852, USA.
Implement Sci. 2011 Oct 21;6:118. doi: 10.1186/1748-5908-6-118.
Much has been written about how the medical home model can enhance patient-centeredness, care continuity, and follow-up, but few comprehensive aids or resources exist to help practices accomplish these aims. The complexity of primary care can overwhelm those concerned with quality improvement.
The RE-AIM planning and evaluation model was used to develop a multimedia, multiple-health behavior tool with psychosocial assessment and feedback features to facilitate and guide patient-centered communication, care, and follow-up related to prevention and self-management of the most common adult chronic illnesses seen in primary care.
The Connection to Health Patient Self-Management System, a web-based patient assessment and support resource, was developed using the RE-AIM factors of reach (e.g., allowing input and output via choice of different modalities), effectiveness (e.g., using evidence-based intervention strategies), adoption (e.g., assistance in integrating the system into practice workflows and permitting customization of the website and feedback materials by practice teams), implementation (e.g., identifying and targeting actionable priority behavioral and psychosocial issues for patients and teams), and maintenance/sustainability (e.g., integration with current National Committee for Quality Assurance recommendations and clinical pathways of care). Connection to Health can work on a variety of input and output platforms, and assesses and provides feedback on multiple health behaviors and multiple chronic conditions frequently managed in adult primary care. As such, it should help to make patient-healthcare team encounters more informed and patient-centered. Formative research with clinicians indicated that the program addressed a number of practical concerns and they appreciated the flexibility and how the Connection to Health program could be customized to their office.
This primary care practice tool based on an implementation science model has the potential to guide patients to more healthful behaviors and improved self-management of chronic conditions, while fostering effective and efficient communication between patients and their healthcare team. RE-AIM and similar models can help clinicians and media developers create practical products more likely to be widely adopted, feasible in busy medical practices, and able to produce public health impact.
有很多关于医疗之家模式如何增强以患者为中心、护理连续性和随访的文章，但很少有全面的辅助工具或资源来帮助实践实现这些目标。初级保健的复杂性可能会让那些关注质量改进的人感到不知所措。
使用 RE-AIM 规划和评估模型开发了一种多媒体、多种健康行为工具，具有心理社会评估和反馈功能，以促进和指导与预防和自我管理常见成人慢性病相关的以患者为中心的沟通、护理和随访，这些疾病在初级保健中很常见。
Connection to Health 患者自我管理系统是一种基于网络的患者评估和支持资源，是使用 RE-AIM 因素开发的，包括可及性（例如，通过选择不同的模式允许输入和输出）、有效性（例如，使用基于证据的干预策略）、采用（例如，协助将系统集成到实践工作流程中，并允许实践团队自定义网站和反馈材料）、实施（例如，确定和针对患者和团队的可操作优先行为和心理社会问题）和维护/可持续性（例如，与当前的国家质量保证委员会建议和临床护理路径集成）。Connection to Health 可以在各种输入和输出平台上运行，并评估和提供对成年初级保健中经常管理的多种健康行为和多种慢性疾病的反馈。因此，它应该有助于使患者与医疗保健团队的接触更加明智和以患者为中心。与临床医生的形成性研究表明，该计划解决了许多实际问题，他们赞赏该计划的灵活性以及如何根据他们的办公室情况自定义 Connection to Health 计划。
基于实施科学模型的这种初级保健实践工具有可能指导患者采取更健康的行为，并改善慢性疾病的自我管理，同时促进患者与其医疗团队之间的有效和高效沟通。RE-AIM 和类似模型可以帮助临床医生和媒体开发人员创建更有可能被广泛采用的实用产品，这些产品在繁忙的医疗实践中是可行的，并且能够产生公共卫生影响。
