Hartati Anita, Jarrett Madison, McDougall Brendon, Kent Megan, Ljubojevic Maja, Stolzenhein Kylie
Keeping Well in Community, Primary and Community Health, South Western Sydney Local Health District, AU.
Keeping Well in Community, Primary and Community Health, South Western Sydney Local Health District, US.
Int J Integr Care. 2024 Jul 10;24(3):7. doi: 10.5334/ijic.7739. eCollection 2024 Jul-Sep.
Complex and siloed health and social service systems can be difficult for people to navigate. The fragmented and poorly linked services leads to ineffective communication between care teams, delayed access to services, concerns regarding quality and safety of patient care, as well as patient frustration and disengagement.
Planned Care for Better Health (PCBH) is a community-based care navigation and coordination program for people with complex health and psychosocial needs who are at risk of future hospitalisation. It focuses on early identification and holistic care to remove barriers and improve access to healthcare. By including a persons', family and carers in planning, listening to their needs, supporting the person to achieve their goals, and empowering them to make decisions on their own health, PCBH aims to enhance clients' healthcare experience and reduce preventable hospital utilisation.
Building trusting and collaborative relationships with clients, families, carers, and health service providers requires commitment. Acknowledging and addressing psychosocial needs is critical for enhancing health outcomes. Equipping patients with self-management skills and knowledge to navigate and engage support services may generate lasting effects, even post-program enrolment.
PCBH is associated with a notable reduction in unplanned hospitalisations and total bed days. However, reduction in ED presentations is similar between the intervention and comparison cohorts. Future initiatives should focus on a shared vision of integrated care, robust leadership, and participative co-creation with service-level stakeholders. Sustained program establishment, a multidisciplinary care coordinator team, and an early creation of robust evaluation strategy must be considered.
复杂且分散的健康和社会服务系统可能让人们难以应对。服务的碎片化和关联性差导致护理团队之间沟通不畅、获得服务延迟、对患者护理质量和安全的担忧，以及患者的沮丧和疏离感。
“为了更好的健康进行计划护理”（PCBH）是一项针对有复杂健康和心理社会需求且有未来住院风险的人群的基于社区的护理导航和协调项目。它侧重于早期识别和整体护理，以消除障碍并改善医疗服务的可及性。通过让个人、家庭和护理人员参与规划，倾听他们的需求，支持个人实现目标，并赋予他们对自身健康做出决策的权力，PCBH旨在提升客户的医疗体验并减少可预防的住院率。
与客户、家庭、护理人员和健康服务提供者建立信任和协作关系需要付出努力。认识并满足心理社会需求对于改善健康结果至关重要。使患者具备自我管理技能和知识以应对和利用支持服务可能会产生持久影响，即使在项目注册之后。
PCBH与非计划住院率和总住院天数的显著降低相关。然而，干预组和对照组在急诊就诊减少方面相似。未来的举措应侧重于综合护理的共同愿景、强有力的领导以及与服务层面利益相关者的参与式共同创造。必须考虑持续的项目设立、多学科护理协调员团队以及早期制定强有力的评估策略。
