The Changing Landscape of Post-Acute Care and Health Outcomes for Older Adults

项目摘要 这个职业发展奖的博士迈克尔L。巴内特是布里格姆的一名初级保健医生， 妇女医院和哈佛T.H.卫生政策和管理助理教授。学院 公共卫生，将建立博士巴内特作为一个临床研究者的专业知识，提高质量和 照顾老年人的价值。这个建议是建立在巴内特博士的有前途的早期职业生涯的研究质量 和分散的护理提供，并侧重于一个日益重要和研究不足的领域， 为老年人提供分散的护理：急性期后护理（PAC）。这项K23奖将使巴内特博士能够 追求这一研究领域，并通过支持三个培训目标成长为一个独立的调查员： 1)获得大型数据集中因果推理的高级定量方法的技能，2）开发 专业知识PAC为老年患者，3）获得定性研究和调查设计的技能。博士 巴内特将追求这些培训目标的指导下，多学科的教师团队领导的主要导师博士。 阿诺德爱泼斯坦，经验丰富的初级教师导师与经验进行高影响力的研究， 保健质量和保健政策。巴内特博士的共同导师是大卫格拉博夫斯基博士，一个后， 急性护理政策和老龄化研究以及Ateev Mehrotra博士，他在基于事件的支付方面具有专业知识 和卫生服务研究。巴内特博士还将与杰出的科学顾问合作， 统计、老年医学和定性方法方面的培训和指导。 PAC在老年人中的使用正在迅速增长，但对PAC是否改善健康知之甚少 住院老年人的结果。新的支付模式，如捆绑支付，越来越多地 促使供应商减少PAC的使用，但这一变化的潜在健康影响尚不清楚。巴内特医生会 检查PAC的变化景观与三个综合目标：第一，巴内特博士将使用医疗保险 检查PAC使用率低与健康结果之间关系的行政索赔 利用准随机分配的病人住院医师（目标1）。接下来，他将测量 全下关节置换术国家捆绑支付模式对PAC使用和健康结果的影响 在高风险易受伤害的老年人中，他们可能会受到PAC使用量减少的负面影响（目标2）。他总算 将对医院进行一系列案例研究，这些医院在使用PAC后发生了对比变化。 捆绑支付实施，以确定与适应新支付模式相关的实践（Aim 3）。本研究可直接为现行政策及老年人支付改革提供参考，以提高老年人的安全性 有效使用PAC。这项工作的结果将构成R01提案的基础， 医院PAC整合与住院老年人护理质量之间的关系。

PROJECT SUMMARY This career development award for Dr. Michael L. Barnett, a primary care physician at Brigham and Women’s Hospital and an assistant professor of health policy and management at the Harvard T.H. School of Public Health, will establish Dr. Barnett as a clinician investigator with expertise on improving the quality and value of care for older adults. This proposal builds on Dr. Barnett’s promising early career researching quality and fragmentation of care delivery and focuses on an increasingly important and understudied domain of fragmented care delivery for older adults: post-acute care (PAC). This K23 award will enable Dr. Barnett to pursue this research area and grow into an independent investigator through support for three training goals: 1) Acquiring skills in advanced quantitative methods for causal inference in large datasets, 2) Developing expertise in PAC for older patients, and 3) Acquiring skills in qualitative research and survey design. Dr. Barnett will pursue these training goals guided by a multidisciplinary faculty team led by primary mentor Dr. Arnold Epstein, an experienced junior faculty mentor with experience performing high-impact research in health care quality and health policy. Dr. Barnett’s co-mentors are Dr. David Grabowski, an expert in post- acute care policy and aging research and Dr. Ateev Mehrotra, who has expertise in episode-based payments and health services research. Dr. Barnett will also partner with distinguished scientific consultants to provide training and mentorship in statistics, geriatrics and qualitative methods. Use of PAC for older adults is growing rapidly, but little is known about whether PAC improves health outcomes for hospitalized older adults. New payment models, such as bundled payments, are increasingly driving providers to lower PAC use, but the potential health impact of this change is unknown. Dr. Barnett will examine the changing landscape of PAC with three integrated aims: first, Dr. Barnett will use Medicare administrative claims to examine the relationship between low rates of PAC use and health outcomes exploiting quasi-random assignment of patients to hospitalist physicians (Aim 1). Next, he will measure the impact on PAC use and health outcomes of a national bundled payment model for total lower joint replacement among high-risk vulnerable older adults who may be negatively impacted by lower PAC use (Aim 2). Finally, he will conduct a comparative series of case studies of hospitals with contrasting changes in PAC use after bundled payment implementation to identify practices associated with adapting to a new payment model (Aim 3). This research can directly inform current policy and payment reform for older adults to enhance the safe and effective use of PAC. Results from this work will form the basis of an R01 proposal to study the relationship between hospital-PAC integration and quality of care for hospitalized older adults.