Guided Care: Integrating High Tech and High Touch

描述(由申请人提供)：患有慢性病的美国老年人的医疗保健通常是支离破碎的，以提供者为中心。作为回应，约翰·霍普金斯大学的一组研究人员将7项成功的慢性护理创新的科学原则转化为1项以患者为中心的交付系统。在循证指南和最先进的信息技术的支持下，“指导性护理”目前正在对有复杂需求的老年初级保健患者进行为期12个月的试点测试。一名受过专门培训的指导护理护士(GCN)，以初级保健实践为基础，与2名初级保健医生合作，为40-60名高危患者提供7项服务：全面评估和护理规划，提示慢性病的“最佳做法”，促进自我管理，鼓励健康的生活方式，协调护理，教育和支持无偿护理人员，以及获取社区资源。我们建议的多点研究将衡量指导性护理对高危老年人、他们的无偿照顾者和他们的初级保健医生的护理质量和结果的影响。将对6个诊所的22名医生组成的小组进行筛查，以确定1350名高危老年患者。在850名医生给予知情同意和基线访谈后，每个执业地点的1-3名医生将被随机分组，为他们同意的患者提供指导护理或常规护理。每个被分配到指导医疗小组的医生群将把GCN纳入其实践中；被分配到对照组的医生群将继续提供没有GCN的“日常护理”。对行政数据库的约谈和查询将以基线和12个月和24个月的后续行动间隔提供评价数据。主要结果变量是参与者的身心健康(SF-36身体健康和精神健康简明量表)。次要结果变量包括：参与者的护理质量；无偿照顾者的负担、费用、健康和满意度；以及初级保健医生对慢性护理的满意度。意向治疗分析将有85%的力量(范围为70%-97%)来检测两组患者的身心健康之间有临床意义的差异。这项研究旨在促进指导护理的迅速传播，如果试验结果有利的话。一个利益相关者咨询委员会，代表美国消费者、提供者、递送系统、保险公司、监管机构和政策制定者，将为这项研究的运作和评估提供信息-它将促进随后在整个美国医疗保健中传播指导性护理工具和技术。

DESCRIPTION (provided by the applicant): Health care for older Americans with chronic conditions is often fragmented and provider-centric. In response, a team of investigators at Johns Hopkins University has translated the scientific principles of 7 successful innovations in chronic care into 1 patient-centered delivery system. Supported by evidence-based guidelines and state-of-the-art information technology, "Guided Care" is now undergoing a 12-month pilot test on older primary care patients with complex needs. A specially trained Guided Care Nurse (GCN), based in a primary care practice, collaborates with 2 primary care physicians to provide 7 services for 40-60 high-risk patients: comprehensive assessment and care planning, prompting "best practices" for chronic conditions, promoting self-management, encouraging healthy life styles, coordinating care, educating and supporting unpaid caregivers, and accessing community resources. The multi-site study we propose will measure the effects of Guided Care on the quality and outcomes of care for high-risk older persons, their unpaid caregivers, and their primary care physicians. The panels of 22 physicians in 6 practices will be screened to identify 1350 high-risk older patients. After 850 have given informed consent and baseline interviews, clusters of 1-3 physicians at each practice site will be randomized to provide either Guided Care or usual care to their consenting patients. Each physician cluster assigned to the Guided Care group will incorporate a GCN into its practice; the physician clusters assigned to the control group will continue providing "usual care" without GCNs. Interviews and queries of administrative databases will provide evaluative data at baseline and at 12-and 24-month follow-up intervals. The primary outcome variable is the participants' physical and mental health (SF-36 Physical Health and Mental Health Summary Scales). Secondary outcome variables include: participants' quality of care; unpaid caregivers' burden, costs, health, and satisfaction; and primary care physicians' satisfaction with chronic care. Intention-to-treat analyses will have 85% power (range 70-97 percent) to detect clinically meaningful differences between the 2 groups' physical and mental health. The study is designed to facilitate the prompt dissemination of Guided Care, if the results of the trial are favorable. A Stakeholders' Advisory Board, representing U.S. consumers, providers, delivery systems, insurers, regulators and policy-makers, will inform the operation and evaluation of the study-and it will facilitate the subsequent dissemination of Guided Care tools and technology throughout American health care.