Campagna Vivian, Nelson Sheila A, Krsnak Jean
Vivian Campagna, MSN, RN-BC, CCM, is the Chief Industry Relations Officer (CIRO) for the Commission for Case Manager Certification, the first and largest nationally accredited organization that certifies more than 45,000 professional case managers and more than 2,600 disability management specialists. Vivian has been involved in case management for more than 25 years, holding staff and administrative positions on both the independent and acute care side of the industry. Sheila A. Nelson, MSN, RN, CCM, is a CCMC Commissioner and also a Clinical Practice Specialist, Care Management Programs and Strategies, for Kaiser Permanente Washington, supporting clinical practice innovation, education, and program development to achieve cost, quality, safety, and service outcomes. Sheila has been involved in case management for more than 18 years, including holding leadership positions with large national health plans. Jean Krsnak, MSN/MBA, RN, CCM, is a CCMC Commissioner. She is also an Acute Care Case Manager at UC Irvine Medical Center, the only Level I trauma and burn center in Orange County, California. Her experience is primarily in academic centers and across settings including critical care, medical and surgical telemetry, and oncology.
Prof Case Manag. 2019 Nov/Dec;24(6):297-305. doi: 10.1097/NCM.0000000000000387.
The purpose of this article is to examine how case managers can support positive outcomes during care transitions by focusing on the goals of the Triple Aim () and Coleman's Four Pillars (). Case managers can play a pivotal role to ensure high-quality transitions by assessing patients and identifying those who are at high risk; coordinating care and services among providers and settings; reconciling medications; and facilitating education of patients and their support systems to improve self-management. These activities are congruent with an underlying value of case management as defined by the Code of Professional Conduct for Case Managers: "improving client [i.e., patient] health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation" ().
Case managers across health or human services must assess for, identify, and understand the vulnerability of patients during care transitions and must adopt best practices to support successful care transitions. This includes case managers in acute care, primary care, rehabilitation, home health, community-based, and other settings.
Two frameworks that support care transitions are the Triple Aim of improving the individual's experience of care, advancing the health of populations, and reducing the costs of care (), and Coleman's "Four Pillars" of care transition activities of medication management, patient-centered health records, follow-up visits with providers and specialists, and patient knowledge about red flags that indicate worsening conditions or drug reactions (). From a case management perspective, these approaches and their goals are interrelated. As an advocate for the individual and at the hub of the care team, the professional case manager engages in important activities such as facilitating communication across multiple providers and care settings, arranging "warm handoffs," undertaking medication reconciliation, and engaging in follow-up, particularly with high-risk patients. To support successful transitions of care, case managers must adopt best practices and advocate within their organizations for systematic approaches to care transitions to improve outcomes.
本文旨在探讨病例管理人员如何通过关注“三重目标”（Triple Aim）和科尔曼的“四大支柱”（Four Pillars）的目标，在护理过渡期间支持取得积极成果。病例管理人员可通过评估患者并识别高风险患者；协调各医疗机构和不同环境之间的护理及服务；核对药物；以及促进对患者及其支持系统的教育以改善自我管理，从而在确保高质量护理过渡方面发挥关键作用。这些活动与病例管理的一项基本价值观相一致，正如《病例管理人员职业行为准则》所定义的：“通过宣传、沟通、教育、识别服务资源和促进服务，改善客户（即患者）的健康、福祉和自主性”。
医疗卫生或人类服务领域的病例管理人员必须在护理过渡期间评估、识别并了解患者的脆弱性，且必须采用最佳实践来支持成功的护理过渡。这包括急症护理、初级护理、康复、家庭健康、社区及其他环境中的病例管理人员。
支持护理过渡的两个框架分别是“三重目标”，即改善个人护理体验、促进人群健康和降低护理成本；以及科尔曼护理过渡活动的“四大支柱”，即药物管理、以患者为中心的健康记录、与医疗服务提供者及专科医生的随访，以及患者对表明病情恶化或药物反应的危险信号的了解。从病例管理的角度来看，这些方法及其目标是相互关联的。作为个人的倡导者和护理团队的核心，专业病例管理人员要开展重要活动，如促进多个医疗服务提供者和护理环境之间的沟通、安排“温馨交接”、进行药物核对以及开展随访，尤其是对高风险患者的随访。为支持护理的成功过渡，病例管理人员必须采用最佳实践，并在其组织内倡导采用系统性护理过渡方法以改善结果。
