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What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study

机译：实施密集型初级保健的关键要素是什么？ 多路退伍军人健康管理案例研究

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ABSTRACT Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.
机译：摘要许多综合卫生系统和负责人护理组织已转向密集的初级保健计划，以提高护理质量，降低高需求高成本患者的成本。如何最好地实施此类计划仍然是一个有效的讨论领域。 2014年，退伍军人卫生管理局（VHA）实施了五个不同的密集密集初级保健计划，作为示范项目的一部分，以获得最高风险的退伍军人。我们发现计划随着时间的推移演变，最终会聚以下元素的实施：1）跨学科护理团队，2）慢性病管理，3）综合患者评估和评估，4）护理和案例管理，5）转型护理支持，6）预防性家庭访问，7）药品服务，8）慢性疾病自助，9）护理人员支持服务，10）卫生教练和11）先进的护理计划。该团队还发现，包括跨学科团队的社会工作者和心理健康保险公司对有效地解决这些复杂患者的心理社会需求至关重要。具有中央实施协调员促进了各种演示网站上这些程序功能的融合。在未来的这些计划的迭代中，VHA打算标准化人员配置和关键特征，以开发一个可以在整个系统中传播的可扩展计划。

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