A Longitudinal Telephone and Multiple Disease Management System to Improve Ambula

描述(由申请人提供)：本研究的目的是评估复杂患者电话联系护理(TLC-C)在护理有复杂保健需求的患者方面的有效性，复杂保健需求的定义是指患有多种慢性病的患者，他们的卫生保健利用率增加，其他社会经济脆弱，经常从住院护理过渡到门诊护理。其目标是减少可预防的医院利用率，提高生活质量，增加对门诊护理的满意度，改善特定疾病的指标，减少净支付者成本。TLC-C是对现有TLC-MD系统的修改，该系统针对患有多种慢性病的患者，并结合医院后出院干预(TLC-RED-LIT)。TLC-C使用对话式计算机电话来监控患者在门诊护理期间的多种疾病。该系统在常规(患者稳定)和恶化(患者不稳定)两种模式下工作。该系统通过“虚拟访问”来监控患者，并检测并通知临床医生需要关注的重要临床问题。它还促进患者的自我护理(例如，坚持服药和预约准备)。通过TLC-C收集的数据被整合到患者的电子健康记录(EHR)中。在紧急情况下，系统建议去当地急诊室。在紧急情况下，向临床医生或他/她的覆盖范围发送警报。当患者从医院住院服务或急诊室出院或症状恶化时，使用加重模式。它集中在恶化的疾病上，并监测患者的状态(改善、稳定或恶化)。每天都会保持联系，直到病人的病情好转。常规模式发生时，患者处于基线状态，并监控疾病和患者的自我护理行为。提出了对患者、提供者和实践者进行多方法评价的研究。这包括一项针对患有两种或两种以上慢性病患者的TLC-C与常规护理的双臂随机临床试验，其中至少有一例在过去12个月中出现急性医院利用，并已从城市医院出院。RCT将对440名患者进行为期6个月的评估。主要结果是急性医院护理利用(计划外住院和急诊室就诊)。次要结果包括患者生活质量(EQ-5D)、满意度(G-CAHPS)、门诊预约显示率和净支付者成本。将探索疾病特定指标(例如，HbA1c或血压)。还将进行形成性和终结性的定性研究，研究该系统的实施情况、随时间的使用和性能，以及它对患者、提供者和整个实践的影响

DESCRIPTION (provided by the applicant): The aim of this study is to assess the effectiveness of Telephone-Linked Care for Complex Patients (TLC-C) in the care of patients with complex health care needs, defined as patients with multiple chronic diseases who have increased health-care utilization and other socio-economic vulnerabilities, frequently transitioning from inpatient to ambulatory care. The objective is to reduce preventable hospital utilization, improve quality of life, increase satisfaction with ambulatory care, improve disease-specific metrics, reduce net payer costs. TLC-C is a modification of an existing TLC-MD system that targets patients with multiple chronic diseases combined with a post-hospital discharge intervention (TLC-RED-Lit). TLC-C uses conversational computer telephony to monitor patients' multiple diseases between their ambulatory care visits. The system works in both routine (patient stable) and exacerbation (patient unstable) modes. The system monitors patients through "virtual visits" and detects and notifies clinicians about important clinical problems to attend to. It also promotes patient self-care (e.g., medication adherence and appointment preparation). Data collected through TLC-C are integrated into the patient's electronic health record (EHR). In emergent situations the system recommends going to the local ED. In urgent situations, an alert is sent to the clinician or to his/her coverage. Exacerbation mode is used when the patient is discharged from a hospital inpatient service or ED or has worsening symptoms. It concentrates on the exacerbating disease and monitors patient status (improved, stable, or deteriorating). Daily contact is maintained until the patient's status improves. Routine mode occurs with the patient at their baseline status and monitors the disease and the patients' self-care behaviors. A multi-method evaluation study of the patients, the providers, and the practice is proposed. This includes a two-arm randomized clinical trial of TLC-C versus usual care for patients with two or more chronic diseases, with at least one previous episode of acute hospital utilization over the last 12 months, being discharged from an urban hospital. The RCT will evaluate the system in 440 patients followed for 6 months. The primary outcome is acute hospital care utilization (unplanned hospitalizations and ED visits). Secondary outcomes include patient quality of life (EQ-5D), satisfaction (G-CAHPS), ambulatory appointment show rate and net payer costs. Disease-specific metrics (e.g., HbA1c or blood pressure) will be explored. Also to be performed are formative and summative qualitative studies of the implementation of the system, its use and performance over time, and its impact on the patients, providers, and the practice as a whole