Baldwin Kathleen M, Black Denice, Hammond Sheri
Clin Nurse Spec. 2014 May-Jun;28(3):147-55. doi: 10.1097/NUR.0000000000000044.
This quality improvement project developed a community nursing case management program to decrease preventable readmissions to the hospital and emergency department by providing telephonic case management and, if needed, onsite assessment and treatment by a clinical nurse specialist (CNS) with prescriptive authority.
As more people reach Medicare age, the number of individuals with worsening chronic diseases with dramatically increases unless appropriate disease management programs are developed.
Care transitions can result in breakdown in continuity of care, resulting in increased preventable readmissions, particularly for indigent patients. The CNS is uniquely educated to managing care transitions and coordination of community resources to prevent readmissions.
After a thorough SWOT (strengths, weaknesses, opportunities, and threats) analysis, we developed and implemented a cost-avoidance model to prevent readmissions in our uninsured and underinsured patients.
The project CNS used a wide array of interventions to decrease readmissions. In the last 2 years, there have been a total of 22 less than 30-day readmissions to the emergency department or hospital in 13 patients, a significant decrease from readmissions in these patients prior to the program. Three of them required transfer to a larger hospital for a higher level of care.
Using advanced practice nurses in transitional care can prevent readmissions, resulting in cost avoidance. The coordination of community resources during transition from hospital to home is a job best suited to CNSs, because they are educated to work within organizations/systems.
The money we saved with this project more than justified the cost of hiring a CNS to lead it. More research is needed into this technology. Guidelines for this intervention need to be developed. Replicating our cost-avoidance transitional care model can help other facilities limit that loss.
本质量改进项目开发了一个社区护理病例管理项目，通过提供电话病例管理，并在需要时由具有处方权的临床护理专家（CNS）进行现场评估和治疗，以减少可预防的再次入院和急诊就诊情况。
随着越来越多的人达到医疗保险年龄，除非制定适当的疾病管理项目，患有慢性疾病且病情恶化的人数将大幅增加。
护理过渡可能导致护理连续性中断，从而增加可预防的再次入院情况，尤其是贫困患者。临床护理专家在管理护理过渡和协调社区资源以防止再次入院方面接受过独特的培训。
在进行全面的SWOT（优势、劣势、机会和威胁）分析后，我们开发并实施了一个成本规避模型，以防止未参保和参保不足的患者再次入院。
该项目的临床护理专家使用了多种干预措施来减少再次入院情况。在过去两年中，13名患者前往急诊科或医院的30天内再次入院情况总共减少了22次，与该项目实施前这些患者的再次入院情况相比有显著下降。其中3人需要转至更大的医院接受更高水平的护理。
在过渡性护理中使用高级实践护士可以防止再次入院，从而避免成本增加。从医院到家庭的过渡期间社区资源的协调工作最适合临床护理专家，因为他们接受过在组织/系统内工作的培训。
我们通过该项目节省的资金足以证明聘请一名临床护理专家来领导该项目的成本是合理的。需要对这项技术进行更多研究。需要制定该干预措施的指南。复制我们的成本规避过渡性护理模式可以帮助其他机构减少这种损失。
