出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In 2013, Children’s Health Queensland Hospital and Health Service implemented the Connected Care Program (CCP), a statewide network of care coordinators to support children with medical complexity and their families. The coordinators, as part of the CCP, have worked in partnership with families, caregivers and health care teams across Queensland to improve communication and coordination of care, ensuring a child’s care program is managed seamlessly across the various services, specialists and facilities. Eligibility for CCP is children <16 for new patients or <18 for continuing patients, or until discharged from paediatric care. Eligibility criteria are based on chronicity, complexity, fragility and intensity of care needs. A referral is required from a clinical specialist. Practice Changes, Aims : The aim of the CCP is to coordinate access to health care providers and support services families need for their child, from their local hospital and health service (HHS) and, if required, across the state. CCP provides a single point of contact for families for support and assistance, which is done locally by a care coordinator or centrally by a team of coordinators for each child enrolled in the CCP. All medical specialists regularly involved in the care of the child are engaged as part of the child’s care team, including a General Practitioner. The creation of the care coordinator role, in partnership with lead specialists has enhanced clinical and family decision-making. Highlights : In the last two years of operations (2015-17), this statewide service delivered the following sustained improvements to patients’ care outcomes: 56.5% reduction in total aggregated length of stay across all admissions; 56.6% reduction in average inpatient length of stay; 19.48% reduction in unplanned emergency department presentations; 61.7% improvement in coordinated scheduling of Outpatient Department appointments; 6% increase in patient visits to Lady Cilento Children’s Hospital (LCCH) where >2 outpatient services were combined; The 2015 pilot evaluation also identified the following outcomes: 25.25% reduction patients needing to fly from regional, rural or remote communities to LCCH to access specialist paediatric services; 18% increase in pharmacist medication reviews (eLMS) 35% increase in pharmacy liaison support with local pharmacies to deliver local solutions; 95% patient/family satisfaction; and 92% Care Coordinator role satisfaction. Format/Model Structure : Through the CCP’s hub-and-spoke model, all 16 Queensland HHSs have access to the service via in-situ care coordinators or outreach provided by the LCCH Hub. 20 FTE Care Coordinators (Clinical Nurses) located across Queensland 1 FTE Senior Allied Health Coordinator 1 FTE Welfare Officer (statewide support) 1 FTE Senior Pharmacist (statewide support) 1 FTE Allied Health Assistant 1 FTE Indigenous Health Liaison Officer Conclusions/Learnings/Take away :Care coordination across Queensland can be delivered in a centrally-managed hub-and-spoke model to effect positive health outcomes for children with medical complexity. Local coordination can improve the way statewide services deliver care from a patient outcome and satisfaction perspective. How rewarding the work can be for health professionals when patient outcomes and satisfaction are realised through coordinating enhanced patient and family-centred services. Patients and families from across Queensland are highly satisfied with the model.
关键词：care coordination ; connect ; rural ; remote ; medical complexity ; complex care ; coordination ; care coordinator ; Connected Care Program ; statewide ; nursing ; hub-and-spoke
