Accountable Care for Persons with Advanced Dementia

项目摘要 一个重要的公共政策挑战是如何为日益增长的患者提供以患者和家庭为中心的护理 患有阿尔茨海默病和相关痴呆症(ADRD)的美国人数。建议数 研究小组已经证明，尽管家庭对护理的偏好会使舒适度最大化，但患者也是如此 通常在生命的最后几天接受繁重的治疗和不必要的医疗过渡。在某种程度上， 基于数量的补偿激励多个过渡和医疗服务的碎片化 患有ADRD的人。这导致护理价值有限，这可能与患者先前的护理不一致 声明的意愿或其家人知情的偏好。责任关怀组织(ACO)是 最近在医疗保险支付和医疗保健提供方面的最大变化。ACO是一组 卫生保健提供者根据以下优势对特定人群的质量和成本负责 去看初级保健提供者。通过加强护理协调和改善相互之间的沟通 卫生保健提供者和家庭关于预后和护理目标，ACO具有改善护理的潜力 在生命的最后阶段。在单一ACO进行的初步研究，使用基于家庭的姑息性药物 CARE计划发现，在被认为是高需求的人中，住院时间减少了，住院延迟了， 成本很高。然而，还没有研究研究ACOs和晚期ADRD患者的护理之间的交叉。 这项建议的首要目标是加深我们对相对较新的ACO如何 提供护理的方法影响患有晚期疾病的弱势老年人的体验和结果 通过解决以下三个问题来解决痴呆：1)晚期ADRD患者在多大程度上 集成在ACOS中？(目标1)；2)ACOS是否改善晚期ADRD患者的临终护理结果？ (目标2)；以及3)ACO的哪些特征与晚期ADRD患者的更好护理有关？(目标 3)。我们将利用我们团队广泛的内容和方法专业知识来使用MDS评估来 确定患有晚期ADRD的人，这些人在住院后曾住过养老院(NH)或居住过 在NH中，以及链接的国家数据集的方案项目赠款基础设施(最小数据集， Medicare索赔数据)来解决姑息治疗的交叉领域中的这些关键健康政策问题， 痴呆症和健康服务研究。我们提议的研究将是第一个关于这一角色的全国性研究 急性呼吸窘迫综合征对晚期ADRD患者护理的影响此外，它还将利用丰富的临床数据。 从MDS评估创建ADRD晚期患者的前瞻性和追溯性队列， 使用新的跨时间倾向匹配方法，并检查ACOs的增长，增强我们的 从观察性研究中得出因果推理的能力。通过这项研究获得的知识将提供 关于ACOS在终极痴呆患者护理中的作用的重要答案 目标是提供高价值的护理，尊重患者对医疗保健做出选择的权利。

Project Summary An important public policy challenge is how to provide patient- and family-centered care for an increasing number of Americans afflicted with Alzheimer’s Disease and Related Dementias (ADRD). The proposed research team has documented that, despite family preferences for care that maximize comfort, patients too often receive burdensome treatments and unnecessary health care transitions in the last days of life. In part, volume-based compensation incentivizes multiple transitions and the fragmentation of care experienced by people with ADRD. This contributes to care of limited value that is potentially inconsistent with patients’ prior stated wishes or the informed preferences of their family. Accountable Care Organizations (ACOs) are one of the largest recent changes in Medicare payment and reforms in health care delivery. An ACO is a group of health care providers responsible for quality and cost of a defined population based on the preponderance of visits to a primary care provider. Through enhanced care coordination and improved communication between health care providers and families about prognosis and goals of care, ACOs have the potential to improve care during the last stages of life. Preliminary research conducted at a single ACO with a home-based palliative care program found reduced hospitalization and delayed institutionalization in persons considered high-need, high-cost. Yet, no study has examined the intersection of ACOs and the care of persons with advanced ADRD. The overriding objective of this proposal is to further our understanding of how the relatively new ACO approach to care delivery impacts the experience and outcomes of vulnerable older persons with advanced dementia by addressing the three following questions: 1) To what extent are advanced ADRD patients integrated in ACOs? (Aim 1); 2) Do ACOs improve end-of-life care outcomes for advanced ADRD patients? (Aim 2); and 3) Which ACO characteristics are associated with better care of advanced ADRD patients? (Aim 3). We will leverage our team’s extensive content and methodological expertise to use MDS assessments to identify persons with advanced ADRD that either had a nursing home (NH) stay post-hospitalization or resided in a NH, as well as the Program Project Grant infrastructure of linked national datasets (Minimum Data Set, Medicare Claims data) to address these key health policy issues in the intersecting fields of palliative care, dementia, and health services research. Our proposed research will be the first national study of the role and impact of ACOs in the care of persons with advanced ADRD. Furthermore, it will capitalize on rich clinical data from MDS assessments to create prospective and retrospective cohorts of persons with advanced ADRD, employ novel cross-temporal propensity matching methods, and examine the growth of ACOs, enhancing our ability to draw causal inferences from an observational study. Knowledge gained from this research will provide important answers about the role of ACOs in the care of persons with advanced dementia with the ultimate goal of delivering high-value care that respects patients’ rights to make choices about their medical care.