Applications of Chronic Care and Transitional Care Models to Surgical Populations: A Scoping Review.

内容摘要

Over 75% of adults in the United States live with at least one chronic condition, many of whom require surgery and need to see clinicians from multiple specialties. Literature on chronic care rarely describes the role of surgical teams in chronic disease management and, similarly, literature on transitions of care in surgery rarely examines long-term patient care needs. The objective of this study was to review how models of chronic disease management and transitions of care have been applied to surgical populations. Two reviewers independently screened the results from MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus. Data from eligible articles were systemically extracted and summarized quantitatively and qualitatively to identify key concepts, themes, and knowledge gaps. The search yielded 4503 results, of which 34 articles were included. Seven conceptual models were described. Core components of the models included relationships with patients and families, communication and collaboration, continuity, patient education, medication management, and promoting self-management. Nurses played key roles in many of the programs. Adaptations to address the surgical context included pain management, early detection of postoperative complications, and wound care. Conceptual models developed for medical populations can be successfully applied to surgical populations and offer actionable recommendations for best practices. Future research to improve long-term postoperative outcomes should consider not only known aspects of high-quality surgical care (e.g., pain management, hydration, wound care) but also core components of chronic care (e.g., continuity and follow up, medication management, promoting patient-self management, coordination with primary care).