新的过渡性护理临床路径提高了健康公平| Penn Nursing

New Transitional Care Clinical Pathway Improves Health Equity

分享智慧

共同成长

Full text

People with multiple chronic conditions require complex care management and often experience significant challenges when transitioning from hospital to home. This is especially true for people insured by Medicaid who are disproportionately Black, Indigenous, People of Color (BIPOC) and experience higher chronic disease burdens and adverse outcomes following hospitalization. For them, comprehensive transitional care support is a paramount, yet often absent aspect of care delivery that may result in health inequities.

Now, an innovative clinical pathway developed by clinicians, community partners and researchers, including those at the University of Pennsylvania School of Nursing (Penn Nursing), holds promise to improve health equity and support a growing population experiencing adverse outcomes resulting from complex chronic illness, poverty, and structural inequality.

The THRIVE clinical pathway provides intensive case management, care coordination, continuity of care, and communication across acute and community settings. Participants in the program receive a visit from a home-care nurse within 48 hours of discharge, as well as clinical support from their discharging physicians and social workers. Other clinical care services are provided as warranted, including occupational therapy, physical therapy, and community health worker services.

Early results from the THRIVE clinical pathway show that participants had fewer 30-day ED visits and fewer 30-day readmissions than those not enrolled in the program. This suggests the value of interdisciplinary and community- based collaborations and health care innovations that target health care delivery and system processes. The results of the first year of the intervention have been published in the article “Transitional Care Innovation for Medicaid- Insured Individuals: Early Findings,” set for publication in the journal BMJ Open Quality.

“Our findings of reductions in readmissions and ED utilization are clinically meaningful and may be linked to our intentional focus on addressing the social determinants of health and connecting THRIVE participants to primary and specialty care within the first month post-hospitalization,” says J. Margo Brooks Carthon, PhD, RN, FAAN, the Tyson Family Endowed Term Chair for Gerontological Research, Associate Professor of Nursing, Senior Fellow in the Leonard Davis Institute (LDI) of Health Economics, and lead developer of the intervention. “More importantly, through both home-care services and continued clinical oversight by hospital-based physicians, we are able to intensify the clinical services provided in the aftermath of an acute hospitalization while also attending to social needs that are often unaddressed after hospitalization.”

Co-authors of the article include Heather Brom of the College of Nursing at Villanova University; Rachel French, of the National Clinician Scholars Program Center for Mental Health, University of Pennsylvania; Marguerite Daus, Denver- Seattle Center of Innovation for Veteran- Centered and Value- Driven Care (COIN); Marsha Grantham- Murillo, Penn Medicine at Home; Jovan Bennett, Penn Center for Community Health Workers; Kira Ryskina, University of Pennsylvania Perelman School of Medicine; Eileen Ponietowicz, Penn Presbyterian Medical Center; and Pamela Cacchione, PhD, CRNP, BC, FGSA, FAAN, of Penn Nursing. LDI provided significant grant support for this research.

全文翻译（仅供参考）

患有多种慢性病的人需要复杂的护理管理，并且在从医院过渡到家庭时经常遇到重大挑战。对于由 Medicaid 投保的人来说尤其如此，他们的黑人、土著、有色人种 (BIPOC) 比例过高，并且在住院后经历了更高的慢性疾病负担和不良后果。对他们来说，全面的过渡性护理支持是最重要的，但往往是护理提供中缺少的方面，这可能导致健康不公平。

现在，由临床医生、社区合作伙伴和研究人员（包括宾夕法尼亚大学护理学院(Penn Nursing) 的研究人员开发的创新临床路径有望改善健康公平并支持日益增长的因复杂慢性疾病而遭受不良后果的人群，贫困和结构性不平等。

THRIVE 临床路径提供密集的病例管理、护理协调、护理连续性以及跨急性和社区环境的沟通。该计划的参与者在出院后 48 小时内接受家庭护理护士的访问，以及出院医生和社会工作者的临床支持。根据需要提供其他临床护理服务，包括职业治疗、物理治疗和社区卫生工作者服务。

THRIVE 临床路径的早期结果表明，与未参加该计划的人相比，参与者的 30 天 ED 就诊次数和 30 天再入院次数更少。这表明了针对医疗保健提供和系统流程的跨学科和基于社区的合作以及医疗保健创新的价值。干预第一年的结果已发表在“医疗补助受保人的过渡性护理创新：早期发现”一文中，该文章将在BMJ Open Quality杂志上发表。

“我们关于减少再入院和 ED 利用率的发现具有临床意义，并且可能与我们有意关注解决健康的社会决定因素以及在住院后第一个月内将 THRIVE 参与者与初级和专科护理联系起来，” J. Margo说Brooks Carthon，博士，注册护士，FAAN，泰森家族捐赠的老年学研究主席，护理学副教授，伦纳德戴维斯卫生经济学研究所 (LDI) 高级研究员，以及干预的主要开发者。“更重要的是，通过家庭护理服务和医院医生的持续临床监督，我们能够加强在急性住院后提供的临床服务，同时满足住院后通常未解决的社会需求。”

这篇文章的合著者包括维拉诺瓦大学护理学院的 Heather Brom；Rachel French，宾夕法尼亚大学国家临床医师学者计划心理健康中心；Marguerite Daus，丹佛 - 西雅图退伍军人中心和价值驱动护理创新中心 (COIN)；Marsha Grantham- Murillo，Penn Medicine at Home；Jovan Bennett，宾夕法尼亚州社区卫生工作者中心；Kira Ryskina，宾夕法尼亚大学佩雷尔曼医学院；Eileen Ponietowicz，宾夕法尼亚长老会医疗中心；和Pamela Cacchione，PhD，CRNP，BC，FGSA，FAAN，Penn Nursing。LDI 为这项研究提供了重要的赠款支持。

THE

END

打赏