出版社：Utrecht University, Maastricht University, Groningen University
摘要：A Community Intervention Team (CIT) includes nurses with enhanced clinical skills who provide a rapid and integrated response to a patient with an acute episode of illness for a defined period of time. This may be provided at home, in a residential setting or in the community as deemed appropriate, thereby avoiding acute hospital admission or facilitating early discharge. CIT personnel have a strong liaison role with hospital and community clinicians and provide services in the patient’s home, primary care centres and in both public and private nursing homes. The purpose of a CIT service is to prevent unnecessary hospital admission or attendance and to facilitate/enable early discharge of patients appropriate for CIT care. The CIT, through its fast-tracked provision of services enhances the overall primary care system, providing access to nursing and home care support, usually from 8am to 10pm, seven days per week. The proportion of people aged above 65 years is increasing in Ireland. This combined with an increase in the proportion of people with one or more chronic conditions, requires that care needs to be co-ordinated between the range of health professionals. This may be a once off episode or it may be on a number of occasions as a person’s chronic disease progresses and their needs change. The CIT accepts referrals from Hospitals, General Practitioners, other Community Services including Public Health Nurses and Hospices. On acceptance of a referral a care plan is put in place on discussion with the patient, his/ her family, the medical team/ Consultant, GP, Public Health Nurse, other health professionals and the CIT. Patients may be referred for a variety of services and may complete their care with CIT or their care may be transferred to other services such as Public Health Nursing, specialist palliative care team or home care package support. CITs may take over patient care temporarily, e.g. facilitating patients receiving IV antibiotics at home who travel elsewhere to spend time with family or for a short break away. The CIT service accepted 27,663 referrals in 2016, a 40% increase on 2015. Patients report high levels of satisfaction with the service. In 2017, the plan is to identify outcome measures to measure the impact of CIT care. The patient’s needs are central to the work of the CIT and integration with other services is facilitated by these values, pathways of care and communication networks. Care coordination is a way of achieving integration at the patient level and is supported by systems and processes at organisational level which facilitate integrated care.
关键词：nursing ; integrated care ; co-ordination ; care plan
