Di Palo Katherine E, Patel Khusbu, Assafin Manaf, Piña Ileana L
Montefiore Medical Center, Bronx, NY, United States.
St. John's University Queens, NY, United States.
Prog Cardiovasc Dis. 2017 Sep-Oct;60(2):259-266. doi: 10.1016/j.pcad.2017.07.004. Epub 2017 Jul 22.
With increasing awareness to provide personalized care our institution applied the American College of Cardiology (ACC) Patient Navigator Program to identify hospitalized heart failure (HF) patients and improve transitions and outcomes. Utilizing a Navigator Team (NT) composed of a nurse and clinical pharmacist, we delivered evidenced-based interventions and hypothesized this approach would improve identification of HF inpatients and reduce the 30-day all-cause readmission rate. Patients were followed from admission to discharge and received at least one intervention, tailored to the patient's health literacy and social needs. The 30-day all-cause readmission rate was 17.6% for the Patient Navigator Program and 25.6% for the medical center. Compared to the medical center there was a statistically significant increase in education and follow-up. For patients who received specific NT interventions of education and follow-up the readmission rate was 10.3% and 6.1% respectively. Hospital programs can easily embed a NT into existing initiatives to further reduce the readmission rate.
随着提供个性化护理的意识不断提高，我们机构应用了美国心脏病学会（ACC）患者导航计划，以识别住院心力衰竭（HF）患者，并改善转诊情况和治疗结果。我们组建了一个由护士和临床药师组成的导航团队（NT），实施循证干预措施，并推测这种方法将改善对HF住院患者的识别，并降低30天全因再入院率。对患者从入院到出院进行跟踪，并根据患者的健康素养和社会需求提供至少一项量身定制的干预措施。患者导航计划的30天全因再入院率为17.6%，医疗中心为25.6%。与医疗中心相比，教育和随访方面有统计学上的显著增加。对于接受了教育和随访等特定NT干预措施的患者，再入院率分别为10.3%和6.1%。医院项目可以轻松地将NT纳入现有计划，以进一步降低再入院率。
