出版社：Utrecht University, Maastricht University, Groningen University
摘要：Key lessons learned : -Empowering patients requires clear directives and strategies from all their network of support: hospital clinicians, GPs, nursing support, family support – “singing form the same hymn sheet” - Continuous engagement and education of clinicians and key stakeholders is vital to keep integrated services to the fore of the mind whether they are new or well established - Constant feedback from users of the service, patients and referring clinicians, and a commitment to develop and change the service as required is essential Purpose : To advance and expand the delivery of Caredoc healthcare services by ensuring continuous integration between, hospitals, primary care, and community care while keeping patient well-being at the core of all decisions. Objectives : - Expand the services delivered by the Caredoc including out-of-hours GP services and community intervention teams (CITs) - To develop these services in line with national guidelines and national procurement processes - To develop the patient experience as a holistic joint integrated care pathway not episodic “hospital care” or “community care” - To support clinicians continuously – not just in the implementation and roll out phases of integrated services - To engage patients, carers and their families in the development of services - To ensure technology supports the services as an enabler Caredoc provides healthcare services to approximately ½ the population of Ireland (~ 2 million people). Services have expanded over the last number of years and it is vital that patients are always the focus and their experience of care pathways becomes more seamless and integrated between hospital and community care. Achieving the objectives : The Caredoc team work with all stakeholders and patients when providing services to develop a synergy of cooperation and integration. The ethos of the team is to promote patient-centred care throughout all the services delivered. To achieve this it requires continuous communication with staff delivering services on the ground in hospitals, community settings and GPs. When the patient is kept at the centre of their healthcare decisions and can see their care pathway as a seamless journey of care not as a “hospital visit” or a “community visit” it promotes shared decision making and co-development of their care plans. Caredoc is a not-for-profit healthcare provider who provides services to patients through service level arrangements with the Health Services Executive (HSE). The HSE provide all of Ireland's public health services, in hospitals and communities across the country. The HSE tender for new services as required. Over the last number of years the Caredoc team have worked to increase the services that are delivered to patients throughout Ireland by tendering for services from the HSE and implementing the Caredoc model of integrated care. For example, to foster and keep the integrated care focus the Caredoc team ensure that if a patient is referred from hospital to the CIT, the hospital consultants, the GPs, the CIT nurses, the patient and their family see the care pathway as one holistic pathway and not as separate “discharge from the hospital” and then “entering the CIT service”. This is achieved on two distinct levels: 1) by the CIT nurses working on the ground becoming part of the hospital meetings and community meetings (GPs, public health nurses, community nurses etc.) and 2) by the Caredoc management team raising awareness of the services at high management levels throughout the hospital and community. At the launch of a new service, the Caredoc management team engage with hospital managers and organise and plan information meetings throughout the hospital with consultants, discharge planners, nurse specialists, ward staff, and any hospital team members that need to be aware of the new service. These information meetings are the beginning of a long term collaboration between the hospital staff and the CIT nurses. The CIT nurses arrange to meet with ward staff on the ground on a daily basis when the service is starting, this includes joining ward rounds and appropriate meetings, and continue these meetings on a weekly or more regular basis when required. The CIT nurses work with the hospital staff to identify suitable patients and plan their discharge and future care. This can range from short-term care for IV-antibiotics for a specific time-frame or longer term repeat care for oncology patients receiving chemotherapy treatment. Conclusion : The objectives are achieved by a constant cognisance of the Caredoc team that all services, whether they are new or well established, must continually foster an integrated care approach by keeping clinicians involved and updated on the services provided to their patients and present them in a seamless, joined up approach. Families and carers must feel they are part of these services and be invited to provide feedback at all stages in their care journey.
关键词：integrated care ; patient-centered ; continous communication
