为镰状细胞病患者实施急诊科筛查及护理管理转诊流程

Implementation of an Emergency Department Screening and Care Management Referral Process for Patients With Sickle Cell Disease.

作者信息

Rushton Sharron, Murray Debbie, Talley Charles, Boyd Sandra, Eason Kern, Earls Marian, Tanabe Paula

机构信息

Sharron Rushton, DNP, MS, RN, CCM, CNE, is an assistant clinical professor of nursing at Duke University School of Nursing. She serves as faculty leader for the Population Care Coordinator Program and is experienced in care coordination. Scholarly interests include collaborations, interprofessional education, population health, and care coordination for biologically and socially vulnerable populations. Debbie Murray, RN, CMAC, CHC, CPN, CNM, is the director of Population Health Outreach and Care Coordination Services at CCNC. Her team of health educators and health coaches works to make sure that all patients have the access to appropriate care and the resources needed to improve self-management of their health concerns. Charles Talley, BS, is a health educator in Population Health Outreach and Care Coordination Services at CCNC. He maintains the sickle cell referral database and contacts patients following their visit to the ED to ensure that they have access to appropriate care and the resources needed to improve self-management of their health concerns. Sandra Boyd, MA, is the NC Sickle Cell Syndrome Program supervisor. Her team of educator counselors provides counseling, care coordination, and education to individuals with sickle cell disease and their families throughout the life course. Sandra works with her team to ensure that patients with sickle cell disease who visit an emergency department are contacted within 3 days of receipt of a referral by a CCNC care manager. The program's goal is to ensure that each client has a plan of care, is connected with a primary care provider and hematologist, and is linked to resources necessary that help improve his or her quality of life. Kern Eason, MBA, is the pediatric program manager at Community Care of North Carolina. He oversees CCNC Pediatric Program activities, particularly in coordination of CCNC's systems, practice, and patient-facing work on behalf of patients with sickle cell disease. Kern has specific skills in pediatric information technology and sees this as a key driver of quality in pediatric health care. Marian Earls, MD, MTS, FAAP, is the director of Pediatric Programs and deputy chief medical officer for Community Care of North Carolina and has led the CCNC Sickle Cell Project since 2013. She is board-certified in both General and Developmental & Behavioral Pediatrics. She is a clinical professor of pediatrics for the University of North Carolina Medical School. Paula Tanabe, PhD, MSN, MPH, RN, FAEN, FAAN, is a professor in the Schools of Nursing (SON) and Medicine at Duke University. Dr. Tanabe is the associate dean for Faculty Development and Data Science, SON. Her program of research is focused on improving systems of care, health outcomes, and quality of life for individuals with sickle cell disease.

出版信息

Prof Case Manag. 2019 Sep/Oct;24(5):240-248. doi: 10.1097/NCM.0000000000000356.

DOI:10.1097/NCM.0000000000000356

PMID:31369486

Abstract

PURPOSE OF STUDY

The purpose of the project was to describe the implementation and evaluation of a care management referral program from emergency departments (EDs) to care management services for patients with sickle cell disease (SCD).

PRIMARY PRACTICE SETTING

Patients were referred to Community Care of North Carolina (CCNC), which is a private-public collaboration providing care management services and served as a referral hub for the program. Patients received follow-up from either CCNC or the North Carolina Sickle Cell Syndrome Program.

METHODOLOGY AND SAMPLE

A multidisciplinary, multiorganizational group streamlined the referral process for patients with SCD who have ongoing care needs by linking patients from the ED to care management services. The article presents a review of program implementation and evaluation over a 3½-year period. The target population were patients who had a diagnosis of SCD and presented to the ED for treatment. Emergency department staff used a modified version of the Emergency Department Sickle Cell Needs Assessment of Needs and Strengths tool to screen for social behavioral health needs in areas such as emotional, financial, pain management, and resources. All forms were faxed to a central number at CCNC for follow-up care management services. Community Care of North Carolina then linked the patient with the appropriate agency and staff for follow-up.

RESULTS

More than 900 referrals were received in 3½ years. Pain was the most common reason for referral. An increase in care management intensity was observed over time. All levels of care management intensity saw an increase in the number of patients.

IMPLICATIONS FOR CASE MANAGEMENT

Care management occurred across organizations after careful planning among stakeholders. The interagency cooperation permitted the development of a streamlined process. In particular, the creation of a single point for referral was an important component to allow for population-level monitoring and ease of making referrals. Patients with ongoing care needs were identified and there was an increase in the intensity of outpatient care management services delivered.

摘要

研究目的

该项目的目的是描述一项针对镰状细胞病（SCD）患者的从急诊科（ED）到护理管理服务的护理管理转诊计划的实施与评估情况。

主要实践机构

患者被转诊至北卡罗来纳州社区护理组织（CCNC），该组织是一个公私合作机构，提供护理管理服务，并作为该计划的转诊中心。患者接受CCNC或北卡罗来纳州镰状细胞综合征项目的后续跟进。

方法与样本

一个多学科、多组织的团队通过将急诊科的患者与护理管理服务相联系，简化了有持续护理需求的SCD患者的转诊流程。本文呈现了对该计划在3年半期间的实施与评估情况的回顾。目标人群是被诊断为SCD且前往急诊科接受治疗的患者。急诊科工作人员使用了《急诊科镰状细胞病需求与优势评估工具》的修改版，以筛查在情绪、财务、疼痛管理和资源等领域的社会行为健康需求。所有表格都被传真至CCNC的一个中心号码，以获得后续护理管理服务。北卡罗来纳州社区护理组织随后将患者与合适的机构和工作人员联系起来进行后续跟进。