Decision Support: Optimizing Post Acute Referrals and Effect on Patient Outcomes

描述（由申请人提供）：优化急性后转诊和对患者结局的影响医疗保险和医疗补助中心对21世纪急性后护理的愿景是一个以患者为中心的系统，该系统围绕个人的需求而不是围绕接受护理的环境进行组织。每年，临床医生做出超过1300万个关于医疗保险受益人出院后是否需要紧急服务的决定;然而，没有经验得出的临床指南来帮助做出这些常见和重要的决定。急诊后护理转诊过程有多个步骤，需要仔细、全面的评估，以确定患者目前的需求，预测未来的需求，做出适当的决定，并协调后续服务。该提案侧重于这一过程的前三个步骤，以实现CMS的目标，即每次都为每个人提供正确的护理。该研究小组和其他研究小组的研究结果一致表明，急性期后转诊决策的质量受到住院时间缩短、评估不一致、沟通不畅以及决策中专业知识和风险承受能力水平不同的负面影响。我们的团队最近完成的NINR研究（RO 1-NR 007674）显示，专家在提供高质量信息和考虑时间的情况下，将52%以上的患者转诊到急诊后护理，而不是由临床医生转诊。拟议的竞争性更新将在几个重要方面推进这些发现。使用从4家医院的电子记录中获得的1200多个患者场景，将从老年患者的社会人口统计学和临床代表性样本中分析大量患者特征。此外，一大群临床和学术专家将确保多学科的观点。该模型被标记为“专家出院决策支持系统”（D2 S2），将嵌入电子记录中，并对其对患者结局的影响进行现场测试。具体目标是：1）确定与专家决定转诊住院老年人进行急诊后护理显著相关的患者特征（因素）。2)定义并验证最显著的因素预测模型，以模拟专家的推荐决策。3)评价D2 S2对决策制定和患者结局的影响。研究结果将确定和提供专家的知识，以标准化和促进确定需要急性后护理的老年患者。结果将提高急性后转诊决策的质量和一致性，减少转诊发生所需的时间，并降低与未满足的出院后需求相关的不良结局相关的成本。除了解决知识和护理质量方面的差距外，拟议的研究还符合医学研究所报告和国家质量论坛概述的提高质量和安全性的建议战略，其中将患者需求与服务提供相匹配是一项高度优先事项。 公共卫生相关性：目前，将老年人转介到医院后护理（如家庭护理）的决定是由各种临床医生使用各种标准做出的。这项研究将开发和测试一个计算机化系统，为临床医生提供有关这些重要决定的建议。其目标是改善对需要急性后护理的人的识别，使他们得到最适当的护理，并防止再次住院。

DESCRIPTION (provided by applicant): Optimizing Post Acute Referrals and Effect on Patient Outcomes The Centers for Medicare and Medicaid's vision for post acute care in the 21st century is a system that is patient centered and organized around the individual's needs rather than around the setting in which the care is received. Each year clinicians make more than 13 million decisions about the need for post acute services following hospital discharge of Medicare beneficiaries; yet, there are no empirically derived, clinical guidelines to assist in making these common and important decisions. The post acute care referral process has multiple steps that require careful, comprehensive assessment to determine patients' present needs, anticipate future needs, make appropriate decisions, and coordinate follow-up services. This proposal focuses on the first three steps of this process to achieve the CMS goal of getting the right care for every person every time. The findings of this research team and others have consistently shown that the quality of post acute referral decision making is negatively impacted by shortened lengths of stay, inconsistent assessment, poor communication, and varying levels of expertise and risk tolerance in decision-making. Our team's recently completed NINR study (RO1-NR007674) revealed that experts, given high quality information and the time to deliberate, refer 52% more patients for post acute care than were referred by clinicians. The proposed competing renewal will advance these findings in several important ways. Using over 1200 patient scenarios obtained from the electronic records at 4 hospitals, large numbers of patient characteristics will be analyzed from a socio-demographic and clinically representative sample of elderly patients. In addition, a large group of clinical and scholarly experts will assure multidisciplinary perspectives. The model, labeled as the "expert discharge decision support system" (D2S2), will be embedded in the electronic record and field tested for its effects on patient outcomes. The specific aims are: 1) To identify the patient characteristics (factors) that are significantly correlated with experts' decisions to refer hospitalized elders for post acute care. 2) To define and validate the most significantly predictive model of factors to mimic experts' referral decisions. 3) To evaluate the effects of the D2S2 on decision making and patient outcomes. Study findings will identify and make available the knowledge of experts to standardize and facilitate the identification of older patients in need of post acute care. Results will improve the quality and consistency of post acute referral decisions, reduce the time required for referrals to occur, and decrease the costs associated with poor outcomes related to unmet post discharge needs. In addition to addressing gaps in knowledge and care quality, the proposed study meets recommended strategies for improving quality and safety outlined by the Institute of Medicine reports and the National Quality Forum where matching patient needs with service delivery is a high priority. PUBLIC HEALTH RELEVANCE: Currently the decision to refer older adults for post hospital care, such as home care, is made by a variety of clinicians using a variety of criteria. This study will develop and test a computerized system that will provide advice to clinicians about these important decisions. The goal is to improve the identification of who needs post acute care, to get them to the most appropriate care, and to prevent rehospitalization.