Background

Effective patient care transitions require consideration of social and clinical context, yet how these factors and relational processes in care coordination relate remains poorly described. This case report aims to describe provider networks and the clinical care and social context involved during longitudinal care transitions across settings.

Case

We examined the utilization and provider networks of an oldest old woman with heart failure (HF) before and after her first hospitalization for HF. She used primary care for care management and had insurance, strong caregiver support, and comprehensive discharge planning; however, after the hospitalization, Mrs. A's ambulatory provider networks were more diverse yet sparser and less strongly connected.

Conclusions

Turbulence in care transition can result from sources other than transitioning between settings. The data-driven case report approach using electronic health records uncovered relational processes important for care coordination and may inform patient-centered approaches to improve care for patients with HF.

中文翻译：

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心力衰竭护理过渡中的关系过程：数据驱动的病例报告

背景

有效的患者护理过渡需要考虑社会和临床背景，但这些因素和护理协调中的关系过程如何相关仍不清楚。本案例报告旨在描述提供者网络以及跨环境纵向护理过渡期间所涉及的临床护理和社会背景。

案件

我们检查了一位患有心力衰竭 (HF) 的老妇人在第一次因 HF 住院之前和之后的利用率和提供者网络。她使用初级保健进行护理管理，并有保险、强大的护理人员支持和全面的出院计划；然而，住院后，A 女士的门诊服务网络更加多样化，但也更加稀疏，联系也不太紧密。

结论

护理过渡中的动荡可能源于环境之间的过渡以外的其他来源。使用电子健康记录的数据驱动的病例报告方法揭示了对护理协调很重要的关系过程，并可能为以患者为中心的方法提供信息，以改善对 HF 患者的护理。