Lindquist Lee A, Miller Rachel K, Saltsman Wayne S, Carnahan Jennifer, Rowe Theresa A, Arbaje Alicia I, Werner Nicole, Boockvar Kenneth, Steinberg Karl, Baharlou Shahla
Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive - 10th floor, Chicago, IL, 60611, USA.
Division of Geriatric Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
J Gen Intern Med. 2017 Feb;32(2):199-203. doi: 10.1007/s11606-016-3850-8. Epub 2016 Oct 4.
We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.
我们组建了一个跨领域专家团队，成员包括初级保健医生（PCP）、家庭护理医生、在熟练护理机构看诊的医生（熟练护理机构医生）、熟练护理机构医疗主任、人因工程师、过渡性护理研究人员、老年病学家、内科医生、家庭医生，以及三个主要组织：美国医学主任协会（AMDA）、内科医学教师学会（SGIM）和美国老年医学会（AGS）。这项工作由专科医生协会（ASP）提供的一笔赠款资助。团队成员梳理了患者从熟练护理机构出院进入社区以及后续由其门诊初级保健医生进行护理的流程。在AMDA护理过渡委员会的前期工作和团队成员经验的基础上，确定了四个流程改进领域。团队识别出问题并制定了被认为熟练护理机构医生和初级保健医生的实践能够完成的可行最佳实践。这些基于共识的推荐最佳实践的目标是为在熟练护理机构医生和初级保健医生的护理之间转换的患者提供安全且高质量的过渡。
