Movin' On Up: An Innovative Nurse-Led Interdisciplinary Health Care Transition Program

被引：27

作者：

Betz, Cecily L. ^{[1
,2
]}

Smith, Kathryn A. ^{[3
,4
]}

Van Speybroeck, Alexander ^{[3
,4
]}

Hernandez, Francisco V. ^{[5
,6
]}

Jacobs, Robert A. ^{[3
,7
,8
]}

机构：

[1] Univ So Calif, Keck Sch Med, Pediat Clin, Los Angeles, CA 90033 USA

[2] Childrens Hosp Los Angeles, Spina Bifida Program, Movin Hlth Care Transit Program, Los Angeles, CA 90027 USA

[3] Univ So Calif, Keck Sch Med, Pediat, Los Angeles, CA 90033 USA

[4] Childrens Hosp Los Angeles, Spina Bifida Program, Los Angeles, CA 90027 USA

[5] Childrens Hosp Los Angeles, Div Endocrinol, Los Angeles, CA 90027 USA

[6] Childrens Hosp Los Angeles, Spina Bifida Program Serv, Los Angeles, CA 90027 USA

[7] USC, Mrs TH Chan Div Occupat Sci & Occupat Therapy, Los Angeles, CA USA

[8] Childrens Hosp Los Angeles, Gen Pediat Serv, Los Angeles, CA 90027 USA

来源：

JOURNAL OF PEDIATRIC HEALTH CARE | 2016年 / 30卷 / 04期

关键词：

Health care transition; adolescents and emerging adults with special health care needs; advanced practice nursing; FAMILY EXPERT PANEL; YOUNG-ADULTS; ADOLESCENTS; QUALITY; SERVICE; NEEDS; CHILD; MODEL;

D O I：

10.1016/j.pedhc.2015.08.005

中图分类号：

R19 [保健组织与事业（卫生事业管理）];

学科分类号：

摘要：

This article provides an overview of an innovative nurse-led interdisciplinary health care transition (HCT) model of care entitled Movin' On Up for adolescents and emerging adults (AEAs) with spina bifida (SB) that was originally implemented in 2011. The components of the HCT service model include an HCT nursing specialist, who is an advanced practice nurse; interdisciplinary health care transition plans based on the individualized needs of AEAs; an interdisciplinary HCT team that meets on a weekly basis; direct HCT services provided in the weekly SB clinic; and telephonic follow-up with AEAs, families, and providers. The characteristics of this nurse-led HCT program can be described as an integrated, interdisciplinary, and comprehensive model of care based on a life span approach. To date, a total of 210 AEAs with SB, ages 10 to 20 years, have been enrolled into the program. An important feature of this HCT service model is that it is self-supporting; it generates the revenue needed for sustainability and, unlike other HCT programs, is not reliant on extramural programmatic support. Other accomplishments of Movin' On Up include the development of a transfer protocol wherein 35 AEAs with SB have been supported in their transfer to adult care; implementation of a standardized process to ensure that service referrals to community-based services for postsecondary education, employment, training, and initiation of conservatorships are made; timely performance of evaluations; close tracking of needs and outcomes of self-management knowledge and skills instruction; and attention to equipment needs prior to transfer.

引用

页码：323 / 338

页数：16

共 35 条

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