Virginia Commonwealth University, Richmond, VA, USA.
University of Colorado, Aurora, CO, USA.
J Prim Care Community Health. 2022 Jan-Dec;13:21501319221134754. doi: 10.1177/21501319221134754.
To help better control chronic conditions we need to address root causes of poor health like unhealthy behaviors, mental health, and social needs. However, addressing these needs in primary care is difficult. One solution may be connecting patients with a navigator for support creating a personal care goal.
As part of an RCT to evaluate a feasible approach to care planning, 24 clinicians from 12 practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) and 87 intervention patients with uncontrolled chronic conditions participated in a care planning intervention. We had a structured process to guide patients, train navigators, and adapt the navigation process to meet the needs of each practice.
Only 1 practice had bandwidth for staff to serve as a patient navigator, even for extra pay. For the other 11 practices, a research team member needed to provide navigation services. On average, patients wanted 25 weeks of support to complete care plans. The average time patients needed to speak with navigators on the phone was 7 min and 3 s. In exit interviews, patients consistently shared how motivational it was to have a caring person check in on them, offer help, and hold them accountable.
Patient navigation to address care plans should be feasible. The time commitment is minimal. It does not require intensive training, and primary care is already doing much of this work. Yet, given the burden and competing demands in primary care, this help cannot be offered without additional resources.
为了更好地控制慢性病，我们需要解决健康不良的根本原因，如不健康的行为、心理健康和社会需求。然而，在基层医疗中解决这些需求很困难。一种解决方案可能是为患者配备一名导航员，以支持他们制定个人护理目标。
作为评估可行的护理计划方法的 RCT 的一部分，来自弗吉尼亚州门诊护理结果研究网络（ACORN）的 12 个实践中的 24 名临床医生和 87 名患有未控制的慢性疾病的干预患者参与了护理计划干预。我们有一个结构化的流程来指导患者、培训导航员，并调整导航流程以满足每个实践的需求。
只有 1 个实践有足够的带宽让员工担任患者导航员，即使是额外付费。对于其他 11 个实践，需要研究团队成员提供导航服务。平均而言，患者需要 25 周的支持才能完成护理计划。患者与导航员通过电话沟通的平均时间为 7 分钟 3 秒。在离职访谈中，患者一致表示，有一个关心他们的人检查他们的进展、提供帮助并对他们负责，这是非常有动力的。
为解决护理计划提供患者导航是可行的。所需的时间投入很少。它不需要密集的培训，而且基层医疗已经在做很多这样的工作。然而，考虑到基层医疗的负担和竞争需求，如果没有额外的资源，就无法提供这种帮助。
