Thomas Paul, Stoddart Gilly, Nota Johnny, Teh Ling, Wells Victoria, Dhillon Gouri, Leese Yvonne
Clinical Director, NHS Ealing Primary Care Trust, Southall, UK.
NHS Ealing Applied Research Unit Facilitator.
London J Prim Care (Abingdon). 2010 Dec;3(2):98-104. doi: 10.1080/17571472.2010.11493311.
Background Poor communication between community matrons (CMs), in-hours and out-of-hours (OoH) general practitioners (GPs) causes uncertainty and inefficiencies. Setting A practice-based commissioning group in West London and the associated CMs who case manage high users of hospital services. Question What helps good communication between CMs, GPs and OoH services to ensure that the right patients are case managed and hospital admissions are avoided? Methods Whole system participatory action research, with four stages: 1) identify communication problems as perceived by a wide range of stakeholders; 2) draw a diagram of the existing communication system, and with stakeholders redraw this to overcome its weaknesses; 3) pilot the changes proposed; 4) gain consensus among stakeholders about policy. Results Stakeholders agreed that standards should be adopted to improve communication for the care of patients who are case managed by CMs. Routine passage of information between GP, CMs and the OoH services would achieve this, and is feasible. Specifically: routine information (termed Special Patient Notes) should be sent to the OoH service about vulnerable patients, including those who are case managed by CMsclear information about CM attachment to general practices and how to refer to them should be easily accessibleGPs and CMs should meet quarterly for mutual learning and to discuss patientsthe OoH service electronically should cascade information to GPs, CMs and others named in the Special Patient Notescommissioners should routinely gather data to compare clusters of general practices for i) referrals to CMs, ii) posting Special Patient Notes, iii) unscheduled consultations and hospital admissions of all patients including those being case managed. Discussion This project revealed system-wide communication problems for the care of patients being case managed by CMs, and ways to overcome these. Commissioners could insist that these are adopted locally, and gather data to prompt compliance and evaluate the consequential cost savings.
社区护士长（CMs）与工作时间内和非工作时间的全科医生（GPs）之间沟通不畅会导致不确定性和效率低下。
伦敦西部一个基于实践的委托小组以及相关的社区护士长，这些社区护士长对医院服务的高使用患者进行个案管理。
什么有助于社区护士长、全科医生和非工作时间服务之间的良好沟通，以确保对合适的患者进行个案管理并避免患者住院？
全系统参与式行动研究，分为四个阶段：1）识别广泛利益相关者所察觉到的沟通问题；2）绘制现有沟通系统的示意图，并与利益相关者重新绘制以克服其弱点；3）试行提议的变革；4）在利益相关者之间就政策达成共识。
利益相关者一致认为应采用标准来改善对由社区护士长进行个案管理的患者的护理沟通。全科医生、社区护士长和非工作时间服务之间的常规信息传递将实现这一点，并且是可行的。具体而言：应向非工作时间服务发送关于弱势患者的常规信息（称为特殊患者记录），包括由社区护士长进行个案管理的患者；应易于获取关于社区护士长与全科诊所的关联以及如何联系他们的清晰信息；全科医生和社区护士长应每季度会面进行相互学习并讨论患者；非工作时间服务应通过电子方式将信息传递给全科医生、社区护士长以及特殊患者记录中指定的其他人；委托方应定期收集数据，以比较各全科诊所集群在以下方面的情况：i）转介给社区护士长的情况；ii）发送特殊患者记录的情况；iii）所有患者（包括正在接受个案管理的患者）的非预约会诊和住院情况。
该项目揭示了在对由社区护士长进行个案管理的患者护理方面全系统的沟通问题以及克服这些问题的方法。委托方可以坚持在当地采用这些方法，并收集数据以促使各方遵守并评估由此带来的成本节约。
