过渡护理护士在一个小型农村社区中不断演变的角色。

Evolving role of the transitional care nurse in a small rural community.

作者信息

Fels Jennifer, Allard Billie Lynn, Coppin Karen, Hewson Karen, Richardson Barbara

机构信息

Jennifer Fels, MS, RN, is a Director Bennington Blueprint, Health Resource Management, Social Services and Clinical Documentation Improvement, United Health Alliance and Southwestern Vermont Medical Center, Bennington, Vermont. Billie Lynn Allard, MS, RN, is an Administrative Director Ambulatory Services and Transitional Care Program, Southwestern Vermont Medical Center, Bennington, Vermont. Karen Coppin, MSN, RN, CEN, is a Transitional Care Nurse, Southwestern Vermont Medical Center, Bennington, Vermont. Karen Hewson, MSN, RN, is a Transitional Care Nurse, Southwestern Vermont Medical Center, Bennington, Vermont. Barbara Richardson, MSN, RN-BC, CCRN, Transitional Care Nurse, Southwestern Vermont Medical Center, Bennington, Vermont.

出版信息

Home Healthc Now. 2015 Apr;33(4):215-21. doi: 10.1097/NHH.0000000000000219.

DOI:10.1097/NHH.0000000000000219

PMID:25828613

Abstract

The shift in focus from individual episodes of illness to a focus on health and wellness, and population health, has created a need for care coordination to address the complex needs of high-risk patients as they transition through the healthcare continuum. A Vermont medical center identified the Clinical Nurse Specialist as having the requisite skills to fill the role of care coordinator. This article describes the development of the Transitional Care Nurse (TCN) program and includes case studies that exemplify how the TCN can intervene to improve care coordination.

摘要

从关注个体疾病发作到关注健康与 wellness 以及人群健康的转变，产生了对护理协调的需求，以满足高危患者在整个医疗保健连续过程中过渡时的复杂需求。佛蒙特州的一家医疗中心确定临床护理专家具备担任护理协调员角色所需的技能。本文描述了过渡护理护士（TCN）项目的发展，并包括案例研究，例证了 TCN 如何进行干预以改善护理协调。