After Discharge management of Low Income Frail Elderly

低收入体弱老人出院后管理

• 批准号: 6921778
• 负责人: KYLE RICHARD ALLEN
• 金额: $ 28.16万
• 依托单位: SUMMA HEALTH
• 依托单位国家: 美国
• 财政年份: 2005
• 资助国家: 美国
• 起止时间: 2005-09-30 至 2008-09-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/6921778
• 关键词: behavioral /social science research tag; chronic disease /disorder; clinical research; comprehensive care; comprehensive medical planning; frail elderly; health care service evaluation; health services research tag; human subject; low socioeconomic status; outcomes research; patient care management; patient oriented research; posthospitalization care

DESCRIPTION (provided by the applicant): As the U.S. population ages, the health care system must change its emphasis from episodic acute illness treatment to a chronic illness management model to improve the quality, appropriateness, and effectiveness of health care services. Evidence-based guidelines and quality indicators have been developed to promote improvements in clinical practice for the vulnerable elderly; however primary care physicians (PCPs) rarely have the time, expertise, or incentive to provide the most effective evidence-based care. Referring these patients to the multiple specialists required to deal with the complex bio-psychosocial problems which often result in ineffective fragmented care and poor outcomes. Delivery of comprehensive care management using an interdisciplinary team (IT) that collaborates with the PCP has been shown to be an effective organizational model in chronic illness care. With this model, a care manager is usually assigned to provide patient follow up across all care settings and providers to ensure integration of medical and social issues. Use of this model to deliver healthcare services seems especially appropriate with frail elderly as a method to increase access to the expertise of the relatively few trained Geriatricians with the numerous PCPs who lack formal training in Geriatrics, yet care for increasing numbers of vulnerable older adults. Observational data from numerous care management programs indicate that this is a cost effective way to deliver optimal chronic illness care, however randomized trial evidence is lacking. This randomized trial will test the effectiveness of improved clinical practice through comprehensive care management in elderly patients with chronic illness and functional impairment discharged from an acute care hospital. For the intervention group, patient care will be coordinated by a nurse care manager who will perform a comprehensive in-home assessment and provide patient education and self-management support. The care manager will work with an IT to develop and implement a plan of care. Evidence based care plans will be implemented in collaboration with the patient, the PCP, the local Area Agency on Aging (AAoA), and other community social agencies. The care manager will provide frequent patient follow-up across all providers to ensure integration of medical and social issues. Control patients will be referred to the local AAoA with no IT follow up. Although control patients will receive, through the AAoA, referrals for care and psychosocial support, the absence of a care manager and IT will, we expect, result in functional decline, lower quality of life, and higher health care costs. The intervention (n=265) and control (n=265) groups will be compared at 1 year on a profile of health and well being using a multiple endpoint global hypothesis testing strategy. The global measure will be comprised of the following 5 domains: function, institutionalization, quality of life, quality of medical management and quality of self management. Priority populations identified by AHRQ who are targeted in this study include the elderly, patients with chronic illnesses, low income (dual eligible), and patients with disabilities. This study also includes minorities, women, and patients who live in the inner city. Cost effectiveness will be studied in a secondary analysis using incremental net benefit analysis. Economic analyses of benefits will inform policy makers about funding care management in AHRQ priority populations.

描述（由申请人提供）：随着美国人口老龄化，医疗保健系统必须将其重点从偶发性急性疾病治疗转变为慢性疾病管理模式，以提高医疗保健服务的质量、适当性和有效性。循证指南和质量指标已经制定，以促进改善临床实践中的弱势老年人，但初级保健医生（PCP）很少有时间，专业知识，或激励提供最有效的循证护理。将这些患者转介给处理复杂的生物心理社会问题所需的多个专家，这往往导致无效的零散护理和不良结果。 使用与PCP合作的跨学科团队（IT）提供综合护理管理已被证明是慢性病护理的有效组织模式。在这种模式下，护理经理通常被指派在所有护理环境和提供者中提供患者随访，以确保医疗和社会问题的整合。使用这种模式来提供医疗保健服务似乎特别适合体弱的老年人，作为一种方法，以增加获得相对较少的训练有素的老年病学家的专业知识，许多PCP缺乏老年病学的正规培训，但照顾越来越多的脆弱的老年人。来自众多护理管理项目的观察数据表明，这是一种提供最佳慢性病护理的具有成本效益的方法，但缺乏随机试验证据。 这项随机试验将测试通过综合护理管理改善慢性病和功能障碍老年患者从急性护理医院出院的临床实践的有效性。对于干预组，患者护理将由护理经理协调，护理经理将进行全面的家庭评估，并提供患者教育和自我管理支持。护理经理将与IT合作制定和实施护理计划。循证护理计划将与患者、PCP、当地地区老龄化机构（AAoA）和其他社区社会机构合作实施。护理经理将为所有提供者提供频繁的患者随访，以确保医疗和社会问题的整合。对照患者将转诊至当地AAoA，无IT随访。虽然对照组患者将通过AAoA获得护理和心理社会支持的转介，但我们预计，缺乏护理经理和IT将导致功能下降，生活质量降低和医疗保健费用增加。 将使用多终点总体假设检验策略，在1年时比较干预组（n= 265）和对照组（n=265）的健康状况。全球措施将是 包括以下5个领域：功能，制度化，生活质量，医疗管理质量和自我管理质量。AHRQ确定的本研究目标人群包括老年人、慢性病患者、低收入（双重资格）和残疾患者。这项研究还包括少数民族，妇女和住在市中心的病人。成本效益将在使用增量净效益分析的二次分析中进行研究。利益的经济分析将告知政策制定者关于资助AHRQ优先人群的护理管理。