Hong Clemens S, Siegel Allison L, Ferris Timothy G
General Medicine Division, Massachusetts General Hospital
Issue Brief (Commonw Fund). 2014 Aug;19:1-19.
Provider groups taking on risk for the overall costs of care in accountable care organizations are developing care management programs to improve care and thereby control costs. Many such programs target "high-need, high-cost" patients: those with multiple or complex conditions, often combined with behavioral health problems or socioeconomic challenges. In this study we compared the operational approaches of 18 successful complex care management programs in order to offer guidance to providers, payers, and policymakers on best practices for complex care management. We found that effective programs customize their approach to their local contexts and caseloads; use a combination of qualitative and quantitative methods to identify patients; consider care coordination one of their key roles; focus on building trusting relationships with patients as well as their primary care providers; match team composition and interventions to patient needs; offer specialized training for team members; and use technology to bolster their efforts.
在负责医疗组织中承担整体医疗成本风险的医疗服务提供方团体，正在制定护理管理计划，以改善护理质量从而控制成本。许多此类计划针对“高需求、高成本”患者：即患有多种或复杂病症的患者，这些病症通常还伴有行为健康问题或社会经济挑战。在本研究中，我们比较了18个成功的复杂护理管理计划的运作方法，以便为医疗服务提供方、支付方和政策制定者提供复杂护理管理最佳实践的指导。我们发现，有效的计划会根据当地情况和病例数量调整其方法；使用定性和定量方法相结合来识别患者；将护理协调视为其关键作用之一；注重与患者及其初级护理提供者建立信任关系；使团队构成和干预措施与患者需求相匹配；为团队成员提供专门培训；并利用技术来加强他们的工作。
