Robinson D K, Mead M J, Boswell C R
Clin Nurse Spec. 1995 Jul;9(4):227-9, 235.
The Portland Veterans Affairs Medical Center provides a range of health care services for an aging population. The chronic, multiple health problems of veterans and the complexity of the health care delivery system often lead to fragmented and discontinuous care. The innovative model of advanced practice nursing described here involves using hospital-based community health CNSs in the role of community health coordinators. The three CNSs described here each have unique and overlapping responsibilities. Based primarily in the medical center, they are able to facilitate a smooth patient transition from the hospital to the community using knowledge and experience to assess, plan, implement, and evaluate care needs of three defined populations. In this article, responsibilities of the community health CNS are defined and the Portland VA Medical Center and population served are described. The history of the community health coordinator role is outlined, followed by the current role description and targeted populations, and role impacts to date.
波特兰退伍军人事务医疗中心为老龄人口提供一系列医疗服务。退伍军人的慢性、多种健康问题以及医疗服务提供系统的复杂性常常导致医疗护理支离破碎且不连续。本文所描述的高级实践护理创新模式涉及利用医院社区健康临床护理专家（CNSs）担任社区健康协调员的角色。这里所描述的三位临床护理专家各自有着独特且相互重叠的职责。他们主要以医疗中心为基地，能够利用知识和经验来评估、规划、实施和评估三个特定人群的护理需求，从而促进患者从医院到社区的平稳过渡。在本文中，定义了社区健康临床护理专家的职责，并描述了波特兰退伍军人事务医疗中心及其所服务的人群。概述了社区健康协调员角色的历史，接着是当前的角色描述、目标人群以及迄今为止该角色所产生的影响。
