Care Transitions App for Patients with Multiple Chronic Conditions

针对多种慢性病患者的护理转变应用程序

• 批准号: 10365310
• 负责人: Patricia C Dykes
• 金额: $ 40万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-30 至 2027-07-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10365310
• 关键词: Care; Transitions; App; Patients; Multiple

The goal of this project is to create an interoperable care transitions application (Care Transitions App) for patients with multiple chronic conditions that will bridge the care transition between hospital, home, and primary care clinic in order to reduce adverse events in the first 30 days after discharge. We propose to develop a Care Transitions App which will engage patients and caregivers at the two trial sites, Brigham and Women’s Hospital and Vanderbilt University Medical Center, in both inpatient and primary care settings. The Care Transitions App will incorporate components from our prior work, specifically falls-reduction content. We propose to create three new modules: 1) a digital post-discharge transitional care plan, 2) modules for multiple chronic conditions (MCC: diabetes, congestive heart failure, and/or chronic kidney disease), including condition-specific post-discharge care plans with relevant lab values and medication education, and 3) a module for patients to enter their questions and their own goals for recovery prior to the post-discharge clinic visit. This project will include usability testing and integration of the application with Epic via the fast healthcare interoperability resources (FHIR) and SMART on FHIR technology at Brigham and Women’s Hospital (BWH) in Year 1. Aim 1: Utilize participatory design to develop the Care Transitions App and a multi-component intervention, including person-based and task-based interventions delivered by a Digital Navigator. Aim 2: Pilot test the Care Transitions App at BWH and disseminate to VUMC. 2a. We will pilot test the Care Transitions App and use the RE-AIM framework to iteratively refine the intervention before launching the clinical trial at BWH in Aim 3 (Y2). Later, we will pilot test the Care Transitions App at VUMC (Y5). 2b. We will disseminate the Care Transitions App at VUMC (Y5) and use the RE-AIM framework to understand barriers and facilitators at VUMC. Lessons learned at both sites will inform a dissemination toolkit. Aim 3: Evaluate the effectiveness of the Care Transitions App through a cluster randomized trial enrolling patients over the age of 65 years old with MCC including diabetes, congestive heart failure, and/or chronic kidney disease. We will test the following hypotheses: a. The Care Transitions App will be associated with a decrease in the primary outcome, post- discharge adverse events (falls, adverse drug events, other adverse events) within 30 days of discharge. b. The Care Transitions App will be associated with improvements in secondary outcomes: 30-day readmissions, completion of post-discharge phone calls, and completion of post-discharge primary care clinic visits. c. The Care Transitions App will be associated with improvements in patient-centered outcomes: global health, self- efficacy for managing chronic conditions, out of pocket costs, Care Transitions Measure 3, patient experience. Outcome: Our team will develop, evaluate, and disseminate a multicomponent intervention including a Care Transitions App and Digital Navigator training aimed at supporting safe care transitions for patients with multiple chronic conditions and a toolkit to support widespread dissemination.

该项目的目标是创建一个可互操作的护理过渡应用程序（护理过渡应用程序） 患有多种慢性病的患者将在医院、家庭和医院之间架起护理过渡的桥梁 初级保健诊所，以减少出院后前 30 天内的不良事件。我们建议 开发一个护理过渡应用程序，该应用程序将吸引布里格姆和布里格姆两个试验地点的患者和护理人员 妇女医院和范德比尔特大学医疗中心的住院和初级保健机构。这 护理过渡应用程序将纳入我们之前工作的组件，特别是减少跌倒的内容。我们 建议创建三个新模块：1）数字化出院后过渡护理计划，2）多个模块 慢性病（MCC：糖尿病、充血性心力衰竭和/或慢性肾病），包括 针对具体情况的出院后护理计划，包括相关实验室值和药物教育，以及 3) 患者在出院后门诊之前输入问题和康复目标的模块 访问。该项目将包括可用性测试以及通过快速医疗保健将应用程序与 Epic 集成 布莱根妇女医院 (BWH) 的互操作性资源 (FHIR) 和 SMART FHIR 技术 第一年。目标 1：利用参与式设计开发护理过渡应用程序和多组件 干预，包括数字导航器提供的基于人的干预和基于任务的干预。目标 2：试点 在 BWH 测试护理过渡应用程序并分发给 VUMC。 2a.我们将试点护理转变 在启动临床试验之前，使用应用程序并使用 RE-AIM 框架迭代完善干预措施 目标 3 (Y2) 中的 BWH。稍后，我们将在 VUMC (Y5) 试点测试护理过渡应用程序。 2b.我们将传播 VUMC (Y5) 的护理过渡应用程序，并使用 RE-AIM 框架来了解障碍和促进因素 在VUMC。两个站点吸取的经验教训将为传播工具包提供信息。目标 3：评估有效性 Care Transitions 应用程序通过一项集群随机试验招募了 65 岁以上的患者 MCC 包括糖尿病、充血性心力衰竭和/或慢性肾病。我们将测试以下内容 假设：a.护理过渡应用程序将与主要结局的下降相关，之后 出院后 30 天内发生不良事件（跌倒、药物不良事件、其他不良事件）。 b. 护理过渡应用程序将与次要结果的改善相关：30 天再入院、 完成出院后电话通话，以及完成出院后初级保健诊所就诊。 c.这 护理转变应用程序将与以患者为中心的结果的改善相关：全球健康、自我护理 管理慢性病的功效、自付费用、护理过渡措施 3、患者体验。 结果：我们的团队将开发、评估和传播多成分干预措施，包括护理 Transitions 应用程序和数字导航器培训旨在支持患有以下疾病的患者进行安全护理过渡 多种慢性病和支持广泛传播的工具包。