在初级保健健康中心为患有多种疾病的居家老年人建立以患者为中心的跨专业护理模式：一项基于社区的研究。
Developing an interprofessional people-centred care model for home-living older people with multimorbidities in a primary care health centre: A community-based study.
作者信息
Kari Heini, Kortejärvi Hanna, Laaksonen Raisa
机构信息
Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Viikinkaari 5 E (P.O.Box 56), 00014 Helsinki, Finland.
Division of Pharmaceutical Biosciences, Faculty of Pharmacy, Viikinkaari 5 E (P.O.Box 56), 00014, University of Helsinki, Helsinki, Finland.
出版信息
Explor Res Clin Soc Pharm. 2022 Feb 5;5:100114. doi: 10.1016/j.rcsop.2022.100114. eCollection 2022 Mar.
BACKGROUND
The ageing population with multiple conditions and complex health needs has forced healthcare systems to rethink the optimal way of delivering services. Instead of trying to manage numerous diseases in a siloed approach, the emphasis should be on people-centred practice, in which healthcare services are tailored to people's needs and provided in partnership with them.
OBJECTIVE
The aim was to develop an interprofessional people-centred care model (PCCM), including the contribution of a clinically trained pharmacist for home-living multimorbid older people in primary care.
METHODS
Participatory action research method, including the active involvement of healthcare professionals, was utilised to develop the PCCM in a public health centre in Finland. The data comprised interview transcripts, workshop materials, field notes, surveys, and memos and were analysed using inductive content analysis.
RESULTS
The PCCM was developed in iterative phases, including planning, acting, observing, and reflecting. The PCCM comprised: 1) A self-management evaluation questionnaire sent before a home visit; 2) A person-centred patient interview at home with a named nurse and a pharmacist; 3) A nurse-led health review and a pharmacist-led clinical medication review; 4) An interprofessional (a GP, a pharmacist and a named nurse) case conference meeting; 5) A care plan, including health and medication plans; and 6) Health support and empowerment interventions. The PCCM shifted working practices in the health centre from towards and more holistic care. The patient's active involvement in their own care was encouraged. Healthcare professionals appreciated the advantages of the new skill-mix, including the clinically trained pharmacist. Building trust among healthcare professionals and between the professionals and the patients was essential.
CONCLUSION
The successfully developed PCCM improved holistic and more in primary care. Healthcare professionals appreciated the advantages of the skill mix and found that trust was essential for implementing the PCCM.
背景
老龄化人口患有多种疾病且有复杂的健康需求，这迫使医疗保健系统重新思考提供服务的最佳方式。不应试图以孤立的方式管理多种疾病，而应强调以人为本的实践，即根据人们的需求定制医疗保健服务并与他们合作提供服务。
目的
旨在开发一种跨专业的以人为本的护理模式（PCCM），包括临床培训的药剂师对初级保健中居家生活的多病老年患者的贡献。
方法
采用参与式行动研究方法，包括医疗保健专业人员的积极参与，在芬兰的一个公共卫生中心开发PCCM。数据包括访谈记录、研讨会材料、实地笔记、调查以及备忘录，并使用归纳性内容分析法进行分析。
结果
PCCM分阶段迭代开发，包括规划、行动、观察和反思。PCCM包括：1）家访前发送的自我管理评估问卷；2）由指定护士和药剂师在家中进行的以人为本的患者访谈；3）护士主导的健康评估和药剂师主导的临床用药评估；4）跨专业（全科医生、药剂师和指定护士）病例讨论会；5）护理计划，包括健康和用药计划；6）健康支持和赋权干预措施。PCCM使健康中心的工作实践从……转向……以及更全面的护理。鼓励患者积极参与自身护理。医疗保健专业人员认可新技能组合的优势，包括临床培训的药剂师。在医疗保健专业人员之间以及专业人员与患者之间建立信任至关重要。
结论
成功开发的PCCM改善了初级保健中的整体护理且更加……。医疗保健专业人员认可技能组合的优势，并发现信任对于实施PCCM至关重要。
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