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连接护理（TLC-C）在复杂医疗保健需求患者护理中的有效性，定义为患有多种慢性疾病的患者，他们增加了医疗保健利用率和其他社会经济脆弱性，经常从住院患者过渡到门诊患者。目标是减少可预防的医院使用率，改善生活质量，提高对门诊护理的满意度，改善特定疾病的指标，降低付款人净成本。TLC-C是对现有TLC-MD系统的改进，针对多种慢性疾病患者结合出院后干预（TLC-RED-Lit）。TLC-C使用会话式计算机电话来监测患者在门诊就诊期间的多种疾病。该系统可在常规（患者稳定）和恶化（患者不稳定）模式下工作。该系统通过“虚拟访问”监控患者，发现并通知临床医生需要处理的重要临床问题。它还促进患者的自我护理（例如，服药依从性和预约准备）。通过薄层色谱- 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，系统建议去当地的急诊科。在紧急情况下，系统会向临床医生或他/她的覆盖范围发送警报。当患者从医院住院部或急诊科出院或症状恶化时，使用加重模式。它集中于病情恶化和监测患者状态（改善、稳定或恶化）。维持每日接触，直至病人病情好转。常规模式发生在患者处于基线状态时，监测疾病和患者的自我保健行为。提出了一项对患者、提供者和实践进行多方法评估的研究。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与常规护理的两组随机临床试验，这些患者在过去12个月内至少有一次急性住院治疗，从城市医院出院。该随机对照试验将对440名患者进行为期6个月的随访。主要结局是急性住院治疗的利用（计划外住院和急诊）。次要结局包括患者生活质量（EQ-5D）、满意度（G-CAHPS）、门诊预约显示率和净付款人费用。将探讨疾病特异性指标（如HbA1c或血压）。还需要对该系统的实施、使用情况和长期表现以及对患者、提供者和整个实践的影响进行形成性和总结性定性研究

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