Sadof Matthew, Carlin Stephanie, Brandt Sylvia, Maypole Jack
1 University of Massachusetts Medical School-Baystate, Springfield, MA, USA.
2 Wolfson Children's Hospital, Jacksonville, FL, USA.
Clin Pediatr (Phila). 2019 Jul;58(8):897-902. doi: 10.1177/0009922819849057. Epub 2019 May 16.
Children with medical complexity comprise a growing population that stresses existing models of pediatric care. This report will describe a care support project that delivered shared plans of care to providers and families of children with medical complexity. This program was built around carefully constructed care support teams where each member had clearly defined roles and responsibilities. The teams worked collaboratively to improve provider communication, create SMART (Specific, Measurable, Assignable, Realistic, and Timely) goals, and perform task tracking. This process created a scaffolding to support community physicians, allowing patients to remain in their local medical homes and to access services closer to home and reducing hospital admissions and emergency room overutilization.
患有复杂疾病的儿童数量不断增加，这给现有的儿科护理模式带来了压力。本报告将描述一个护理支持项目，该项目为患有复杂疾病儿童的医护人员和家庭提供了共享护理计划。该项目围绕精心组建的护理支持团队展开，团队中的每个成员都有明确界定的角色和职责。这些团队协同工作，以改善医护人员之间的沟通、制定SMART（具体、可衡量、可分配、现实、及时）目标并进行任务跟踪。这一过程创建了一个支持社区医生的框架，使患者能够留在当地的医疗场所，在家附近获得服务，减少住院次数和急诊室的过度使用。
