Van Cleave Jeanne, Boudreau Alexy Arauz, McAllister Jeanne, Cooley W Carl, Maxwell Andrea, Kuhlthau Karen
Division of General Pediatrics/MGH Center for Child and Adolescent Health Research & Policy, MassGeneral Hospital for Children, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
Children's Health Services Research, Indiana University Medical School, Indianapolis, Indiana; Center for Medical Home Improvement, Crotched Mountain Foundation, Greenfield, New Hampshire; and.
Pediatrics. 2015 Jun;135(6):1018-26. doi: 10.1542/peds.2014-1067. Epub 2015 May 11.
To explore how care coordination changes conceptually and practically in primary care practices when implementing the medical home and to identify reasons for different types of changes.
Six years after a 2003-2004 national learning collaborative to implement the medical home model for children with special health care needs, we examined care coordination in 12 pediatric practices with the highest postintervention Medical Home Index scores, indicating high level of adoption of the model. Data included interviews of 48 clinicians, care coordinators, and parents and medical record reviews of 60 patients with special health care needs receiving care in these practices.
Initially, care coordination activities were prompted by patients' acute problems, and over time activities, tools, and policies were implemented to avert many such problems and expand the scope of services offered to patients. Example activities were making previsit calls with families, writing care plans, developing relationships with community agencies, and tracking referrals. Although some activities were common across practices, the persons involved and efforts toward different activities varied with practice context. Drivers included motivation and creativity of medical home teams, organizational changes, funding to expand care coordinator positions, protected time for such activities, and adoption of electronic record systems.
In high-performing medical homes, care coordination activities changed from being mostly reactive to patients' episodic needs to being more systematically proactive and comprehensive. This shift was promoted by factors external and internal to the practice. Ensuring these factors in medical home implementation may accelerate adoption of proactive care coordination activities.
探讨在实施医疗之家模式时，初级保健机构中的护理协调在概念和实践上如何变化，并确定不同类型变化的原因。
在2003 - 2004年全国学习协作组织实施针对有特殊医疗需求儿童的医疗之家模式六年后，我们对干预后医疗之家指数得分最高的12家儿科机构的护理协调情况进行了研究，这些得分表明该模式的采用程度很高。数据包括对48名临床医生、护理协调员和家长的访谈，以及对在这些机构接受护理的60名有特殊医疗需求患者的病历审查。
最初，护理协调活动是由患者的急性问题引发的，随着时间的推移，实施了各种活动、工具和政策，以避免许多此类问题，并扩大向患者提供的服务范围。示例活动包括与家庭进行访前通话、撰写护理计划、与社区机构建立关系以及跟踪转诊情况。虽然有些活动在各机构中很常见，但参与的人员以及针对不同活动的努力因机构背景而异。推动因素包括医疗之家团队的积极性和创造力、组织变革、扩大护理协调员职位的资金、此类活动的受保护时间以及电子记录系统的采用。
在高效的医疗之家中，护理协调活动从主要对患者的偶发性需求做出反应转变为更加系统地积极主动和全面。这种转变受到机构内部和外部因素的推动。在医疗之家实施过程中确保这些因素可能会加速积极主动的护理协调活动的采用。
