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Improving Transitional Care for Veterans Discharged to Post-acute Care Facilities

改善出院到急性后护理机构的退伍军人的过渡护理

基本信息

批准号：
8985224
负责人：
Robert Edward Burke
金额：
--
依托单位：
VA EASTERN COLORADO HEALTH CARE SYSTEM
依托单位国家：
美国
项目类别：
财政年份：
2015
资助国家：
美国
起止时间：
2015-10-01 至 2020-09-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/8985224
关键词：
Accident and Emergency department Accident and Emergency department Activities of Daily Living Activities of Daily Living Acute Acute Address Address Admission activity Admission activity Advance Care Planning Advance Care Planning Affect Affect Aftercare Award Award Back Back Caring Caring Cessation of life Cessation of life Chronic Chronic Clinical Clinical Code Code Colorado Colorado Communities Communities Contracts Contracts Data Data Data Analyses Data Analyses Data Set Data Set Development Development Disabled Persons Disabled Persons Discharge Plannings Elderly Emergency department visit Emergency department visit Ensure Ensure Evaluation Evaluation Frail Elderly Funding Funding Geriatrics Geriatrics Guidelines Guidelines Health Health Health Services Accessibility Health Services Accessibility Health care facility Healthcare Systems Healthcare Systems Home environment Home environment Hospital Mortality Hospital Mortality Hospital Planning Hospital Planning Hospitalists Hospitalists Hospitalization Hospitalization Hospitals Hospitals Independent Living Independent Living Intervention Intervention Interview Interview K-Series Research Career Programs K-Series Research Career Programs Lead Lead Length of Stay Length of Stay Link Link Literature Literature Long-Term Care Long-Term Care Measures Measures Medicare Medicare Mentors Mentors Mentorship Mentorship Methods Methods Mission Mission Monitor Monitor Myocardial Ischemia Myocardial Ischemia Nurses Nurses Nursing Homes Nursing Homes Outcome Outcome Outcomes Research Outcomes Research Patient Monitoring Patient Monitoring Patient Monitoring System Patient Monitoring System Patient risk Patient risk Patients Patients Personal Satisfaction Personal Satisfaction Pharmaceutical Preparations Pharmaceutical Preparations Physician Executives Physician Executives Physicians Physicians Population Population Process Process Process Measure Process Measure Provider Publishing Publishing Qualitative Methods Qualitative Methods Recording of previous events Recording of previous events Recurrence Recurrence Rehabilitation therapy Rehabilitation therapy Research Research Research Personnel Research Personnel Research Support Research Support Resources Resources Risk Adjustment Risk Adjustment Safety Site Site Skilled Nursing Facilities Skilled Nursing Facilities Structure Structure System System Testing Testing Time Time Training Training Universities Universities Veterans Veterans Work Work base base care outcomes care providers career career career development career development community living community living cost cost cost effective cost effective design design deviant disability disability experience experience functional loss functional outcomes functional outcomes functional status functional status high risk high risk hospital readmission hospital readmission hospital utilization hospital utilization implementation science implementation science improved improved improved outcome indexing indexing innovation innovation medication safety mortality mortality multi-component intervention multi-component intervention novel novel premature premature primary outcome primary outcome public health relevance public health relevance readmission rates secondary outcome secondary outcome

项目摘要

DESCRIPTION (provided by applicant): There is perhaps no more crucial time period for the health and functional outcomes of Veterans than an acute hospitalization followed by a stay in a post-acute care (PAC) facility (rehabilitatio or skilled nursing facility). The population of Veterans who undergo this transition are generally elderly, frail, ill, and disabled. As a result, many are sent back to the Emergency Department or readmitted to the hospital. This is often the start of a downward spiral of recurrent admissions, worsening functional status resulting in long-term care placement, and early mortality. For example, our preliminary data indicates Veterans discharged to PAC were readmitted or sent to the Emergency Department 5 times on average in the 12 months following their index admission. Transitions from the hospital to PAC are becoming more and more common, but poor outcomes may be preventable. In our preliminary data, we found nearly half of all readmissions from PAC facilities occurred in the first seven days after hospital discharge. Substantial research supports the idea that poorly-executed transitions of care from the hospital to the post-acute care facility underlie many poor outcomes of Veterans who undergo this transition. However, little is known about the outcomes of Veterans discharged to post-acute care, nor what factors contribute to these outcomes. To identify which factors might affect outcomes in these transitions of care, the proposal uses the Ideal Transitions of Care framework, developed by the nominee, to identify key domains that may affect transitional care outcomes. In this proposal, our Aims include: Aim 1: Assess the impact of five key domains of the ITC framework on 7-day hospital utilization and mortality. Domains and examples include: discharge planning (hospital plan for delivery of high-intensity interventions in PAC), information transfer (PAC access to hospital EMR), medication safety (medication reconciliation and monitoring of high-risk medications), advance care planning (addressing and communicating code status), and patient monitoring (time to initial PAC physician evaluation). Aim 2: Determine modifiable transitional care processes that help explain positive deviance in high-performing hospital-PAC sites. Aim 3: Pilot test a nurse-directed transitional care intervention in a hospital PAC site based on key domains of the ITC framework identified in Aims 1 and 2. This work is of crucial importance to Veterans and the VA healthcare system nationally and has the support of the Office of Geriatrics and Extended Care. Three accomplished investigators will guide the nominee's project work and development as an independent investigator. Dr. Michael Ho is the primary mentor with expertise in mixed methods, multicomponent interventions, and implementation science. He is the Co-Director of the Ischemic Heart Disease QUERI, Co-Director of the Denver-Seattle COIN, and a widely-published and well- funded expert in health outcomes research. Dr. Cari Levy is a co-mentor with significant content expertise relevant to the proposal, including experience with the main dataset used in the proposal, as a geriatrician and prior nursing home medical director, and as an accomplished researcher in the PAC setting. Dr. Allan Prochazka is a senior investigator with substantial Career Development Award mentorship experience as Director of Mentorship and Career Development at the Denver-Seattle COIN. Career development activities include gaining expertise in longitudinal and clustered data analysis, qualitative data methods, and implementation science. This will be facilitated by mentorship with two content experts (Dr. Jacqueline Jones, a qualitative expert, and Dr. Anna Baron, a statistical expert), coursework, and seminars taking advantage of the rich resources of the Denver-Seattle COIN and University of Colorado. The mentorship, training, and protected time afforded by this award will ensure the nominee's development as an independent investigator dedicated to improving transitions of care after hospital discharge throughout the VA system.