A Longitudinal Telephone and Multiple Disease Management System to Improve Ambula

描述（由申请方提供）：本研究的目的是评估复杂患者电话联系护理（TLC-C）在护理具有复杂医疗保健需求的患者方面的有效性，复杂医疗保健需求定义为患有多种慢性疾病的患者，这些患者的医疗保健利用率增加，其他社会经济脆弱性增加，经常从住院治疗过渡到门诊治疗。其目的是减少可预防的医院利用，提高生活质量，提高对门诊护理的满意度，改善疾病特异性指标，降低净支付者成本。TLC-C是对现有TLC-MD系统的改进，该系统针对患有多种慢性疾病的患者，并结合出院后干预（TLC-RED-Lit）。TLC-C使用对话式计算机电话来监测患者在门诊护理访视之间的多种疾病。系统在常规（患者稳定）和加重（患者不稳定）模式下工作。该系统通过“虚拟访问”监测患者，并检测和通知临床医生需要注意的重要临床问题。它还促进了患者的自我护理（例如，药物依从性和预约准备）。通过TLC-C收集的数据被集成到患者的电子健康记录（EHR）中。在紧急情况下，系统建议前往当地ED。在紧急情况下，警报将发送给临床医生或他/她的覆盖范围。当患者从医院住院服务或艾德出院或症状恶化时，使用加重模式。它专注于恶化的疾病，并监测患者状态（改善，稳定或恶化）。每天保持联系，直到病人的状况有所改善。常规模式在患者处于基线状态时发生，并监测疾病和患者的自我护理行为。一个多方法的评估研究的病人，供应商，并提出了实践。这包括一项针对患有两种或两种以上慢性疾病的患者的TLC-C与常规护理的双臂随机临床试验，这些患者在过去12个月内至少有一次急性医院使用，从城市医院出院。RCT将在440例患者中评价该系统，随访6个月。主要结局是急性医院护理利用率（计划外住院和艾德访视）。次要结局包括患者生活质量（EQ-5D）、满意度（G-CAHPS）、门诊预约就诊率和净支付者成本。疾病特异性指标（例如，HbA 1c或血压）。还将进行系统实施的形成性和总结性定性研究，其使用和性能随时间的推移，以及其对患者，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