Scott Allison M, Li Jing, Oyewole-Eletu Sholabomi, Nguyen Huong Q, Gass Brianna, Hirschman Karen B, Mitchell Suzanne, Hudson Sharon M, Williams Mark V
Jt Comm J Qual Patient Saf. 2017 Sep;43(9):433-447. doi: 10.1016/j.jcjq.2017.02.012. Epub 2017 Jul 10.
Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models.
From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations-community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers.
Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in.
True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.
临床医生之间或不同医疗环境之间的照护过渡往往是碎片化的，且伴有不良事件。为提高患者安全并提供更高效、更有效的医疗服务，需要找到优化这些过渡的新方法。开展了一项研究，以确定在可能已采用或改编自已发表的循证模式的卫生系统中，实施过渡性照护服务的促进因素和障碍。
2015年3月至2015年12月期间，在美国各地对22个医疗保健组织进行了实地考察，这些组织包括社区医院、学术医疗中心、综合卫生系统以及更广泛的社区伙伴关系。在每个地点，进行了直接观察和文件审查，并对总共810名参与者（每个地点5至57名参与者）进行了半结构化访谈，这些参与者代表了包括管理层和领导层、过渡性照护团队成员、内部利益相关者、社区伙伴、患者和家庭照护者在内的各种利益相关者群体。
有效照护过渡的促进因素包括在组织内部和外部进行协作、根据患者和照护者的情况调整照护方式以及在工作人员中获得支持。常见的障碍包括过渡性照护服务整合不佳、患者或照护者的需求未得到满足、服务利用不足以及医生缺乏支持。
最终需要真正的社区伙伴关系、高质量的沟通、患者和家庭的参与以及对过渡性照护策略的持续评估和调整，以促进有效的照护过渡。医疗保健组织可以通过人员配置决策、将过渡性照护纳入组织的正式董事会议程以及激励提供卓越的过渡性照护服务，从战略上优先提供过渡性照护服务。
