Department of Family Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.
Rutgers University School of Nursing, Newark, NJ, USA.
J Interprof Care. 2020 Mar-Apr;34(2):269-271. doi: 10.1080/13561820.2019.1643297. Epub 2019 Aug 8.
This project addressed interprofessional team-based care to improve management and outcomes of complex patients with diabetes. A collaborative model between Family Medicine and Nursing was developed to determine if having nursing students as case managers would improve the quality of care. From 2015-2016, patients with diabetes at greatest risk for poor outcomes (N = 58) received an intervention from senior nursing students (N = 6) at a Family Practice Center. Nursing students shared responsibilities with physicians, medical students, and medical assistants to deliver high quality care. For the intervention, nursing students reviewed charts, called patients for follow-up visits, and facilitated patients' adherence to providers' recommendations. Students also conducted group education sessions on nutrition, medication adherence, obesity, and exercise for patients. The control group included 61 randomly selected patients with diabetes who did not receive the intervention during the same period of time. Compared to the control group, the intervention group showed significantly improved outcomes in HgA1C levels (66% vs. 40.8%; = .009), blood pressure control (61.1% vs. 36.8%; = .009), and urine microalbumin test completion (87.5% vs. 48.3%; < .0001). Outpatient practices offer an optimal opportunity for nursing students to practice case management. This team-based care approach suggests better outcomes for patients with diabetes.
本项目针对跨专业团队合作式护理,以改善患有糖尿病的复杂患者的管理和预后。家庭医学与护理之间建立了一种协作模式,以确定让护理专业的学生担任个案管理者是否会提高护理质量。在 2015-2016 年期间,患有糖尿病且预后不良风险最高的患者(N=58)在家庭实践中心接受了高级护理学生(N=6)的干预。护理学生与医生、医学生和医疗助理共同承担责任,以提供高质量的护理。在干预过程中,护理学生查看病历、为随访患者打电话,并帮助患者遵医嘱。学生还为患者开展了关于营养、药物依从性、肥胖和运动的小组教育课程。对照组包括在同一时期未接受干预的 61 名随机选择的糖尿病患者。与对照组相比,干预组的 HbA1C 水平(66%比 40.8%;=0.009)、血压控制(61.1%比 36.8%;=0.009)和尿微量白蛋白检测完成率(87.5%比 48.3%;<0.0001)显著改善。门诊实践为护理学生提供了实践个案管理的最佳机会。这种基于团队的护理方法为糖尿病患者带来了更好的预后。