Community Care of North Carolina, Raleigh, NC, USA.
Health Aff (Millwood). 2013 Aug;32(8):1407-15. doi: 10.1377/hlthaff.2013.0047.
Recurrent hospitalizations represent a substantial and often preventable human and financial burden in the United States. In 2008 North Carolina initiated a statewide population-based transitional care initiative to prevent recurrent hospitalizations among high-risk Medicaid recipients with complex chronic medical conditions. In a study of patients hospitalized during 2010-11, we found that those who received transitional care were 20 percent less likely to experience a readmission during the subsequent year, compared to clinically similar patients who received usual care. Benefits of the intervention were greatest among patients with the highest readmission risk. One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients. This study suggests that locally embedded, targeted care coordination interventions can effectively reduce hospitalizations for high-risk populations.
在美国，反复住院是一个巨大的负担，而且往往是可以预防的，给人力和财力都带来了负担。2008 年，北卡罗来纳州启动了一项全州范围内的基于人群的过渡性护理计划，以防止患有复杂慢性病的高风险医疗补助接受者再次住院。在对 2010-11 年住院患者的一项研究中，我们发现与接受常规护理的临床情况相似的患者相比，接受过渡性护理的患者在随后的一年中再次入院的可能性要低 20%。对于风险最高的患者，干预措施的益处最大。每六名接受过渡性护理服务的患者就可避免一次再入院，每三名风险最高的患者就可避免一次再入院。这项研究表明，本土化、有针对性的护理协调干预措施可以有效地减少高危人群的住院治疗。
