Evaluating Sequential Strategies to Reduce Readmission in a Diverse Population

评估减少不同人群再入院的序贯策略

• 批准号: 8295101
• 负责人: Dennis Ross-Degnan
• 金额: $ 48.27万
• 依托单位: HARVARD PILGRIM HEALTH CARE, INC.
• 依托单位国家: 美国
• 财政年份: 2012
• 资助国家: 美国
• 起止时间: 2012-03-01 至 2015-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8295101
• 关键词: Evaluating; Sequential; Strategies; Reduce; Readmission

DESCRIPTION (provided by applicant): Hospital readmissions are common, costly, and potentially preventable. They are also potentially responsive to health system interventions. However, it is uncertain which components of care transition interventions are efficacious, for which populations, and at what cost. The proposed study will evaluate a three-tiered quality improvement (QI) intervention intended to reduce hospital readmissions within 30 days post-discharge from an urban safety net hospital that serves a racially and linguistically diverse population. Few studies have evaluated care transition interventions to reduce readmissions among low-income, diverse patient populations, and the accumulated evidence on the effects of these multi-faceted interventions on readmission rates has been inconclusive. This project will take advantage of a unique sequence of three QI innovations to reduce hospital readmissions implemented beginning in 2007 in an integrated safety net health care system. We propose to evaluate the additive impact of each intervention on reductions in readmissions and on post- discharge care. The "discharge-transfer" intervention tiers are as follows: 1) Tier 1 includes a comprehensive, individualized home care plan (HCP) reviewed by the medical service floor nurse with the patient prior to discharge; 2) Tier 2 adds the electronic transmission of the HCP to the patient's primary care medical home where, on the business day following discharge, a Registered Nurse makes an outreach telephone call to the discharged patient to confirm comprehension of the HCP and to address medical questions or needs; 3) Tier 3 further adds a community health worker, the Patient Navigator, to participate in bedside discussions to develop rapport and learn about patients' home situations, weekly outreach calls to assess patients' needs and to facilitate communication between the patient and the primary care team, and reminder calls to patients prior to all medical appointments to eliminate barriers to outpatient follow-up. Our project includes three research aims. First, in a retrospective time series analysis we will assess the incremental effect on readmissions and health care use of intervention tiers 1 and 2 relative to the prior standard of care. Second, we will evaluate the effects of an ongoing randomized natural experiment on readmissions, health care use, adherence to medication instructions, and preparedness for discharge. This natural experiment features random assignment to one of two QI interventions, Tier 2 or Tier 3, and exclusively targets patients at high risk for readmission, those with one or more of the following risk factors for readmission: discharge diagnosis of congestive heart failure, acute coronary syndrome, or pneumonia; length of stay > 3 days; weekend discharge; age > 60; or previous hospitalization within the past six months. For our third aim, we will analyze the costs and cost-effectiveness of the Patient Navigator intervention (Tier 3) relative to the Tier 2 intervention for high-risk patients. PUBLIC HEALTH RELEVANCE: The interventions to be studied seek to be cost-efficient, by leveraging existing infrastructure (IT systems) and personnel (outpatient nurses), and strategically testing the incremental benefit of adding low cost resources (community health workers) to shape sustainable approaches that are generalizable to other safety net hospitals and health care systems. Our results have the potential to identify specific, effective components of quality improvement interventions targeting care transitions designed to reduce hospital readmissions and the relative costs required to implement them for low-income, racially and linguistically diverse patients.

描述(由申请人提供)：再次住院很常见，费用很高，而且可能是可以预防的。他们还有可能对卫生系统的干预措施作出反应。然而，目前还不确定护理过渡干预措施的哪些组成部分对哪些人群有效，以及费用是多少。这项拟议的研究将评估一项旨在减少出院后30天内再次住院的三级质量改进(QI)干预措施，该医院服务于种族和语言多样化的人口。很少有研究评估护理过渡干预措施以减少低收入、不同患者群体的再入院，关于这些多方面干预措施对再入院率影响的累积证据尚不确定。该项目将利用独特的三个QI创新序列，以减少从2007年开始在综合安全网医疗保健系统中实施的再入院人数。我们建议评估每一种干预措施对减少再入院和出院后护理的附加影响。“出院-转院”干预层级如下：1)第1级包括全面的、个性化的家庭护理计划(HCP)，在出院前由医疗服务楼层护士与患者一起审查；2)第2级增加将HCP的电子传输到患者的初级保健疗养院，在那里，在出院后的第二个工作日，注册护士向出院患者拨打外展电话，以确认对HCP的理解并解决医疗问题或需求；3)第三层还增加了一名社区卫生工作者，患者导航员，参与床边讨论，以发展融洽和了解患者的家庭情况，每周外展电话，以评估患者的需求，并促进患者和初级保健团队之间的沟通，并在所有医疗预约之前提醒患者电话，以消除门诊跟进的障碍。我们的项目包括三个研究目标。首先，在回溯性的时间序列分析中，我们将评估与先前的护理标准相比，干预1级和2级对再入院和卫生保健使用的增量影响。其次，我们将评估正在进行的关于重新入院、医疗保健使用、遵守药物说明和出院准备的随机自然实验的效果。这项自然实验的特点是随机分配到两种QI干预措施中的一种，即Tier 2或Tier 3，并专门针对再次入院的高风险患者，即那些具有以下一种或多种再次入院风险因素的患者：出院诊断为充血性心力衰竭、急性冠脉综合征或肺炎；住院时间；3天；周末出院；60岁；或在过去6个月内曾住院。对于我们的第三个目标，我们将分析针对高危患者的患者导航器干预(Tier 3)相对于Tier 2干预的成本和成本效益。 公共卫生相关性：将研究的干预措施寻求具有成本效益，方法是利用现有的基础设施(IT系统)和人员(门诊护士)，并从战略上测试增加低成本资源(社区卫生工作者)的增量效益，以形成可推广到其他安全网医院和卫生保健系统的可持续方法。我们的结果有可能确定针对护理过渡的质量改进干预措施的具体、有效组成部分，旨在减少低收入、种族和语言多样化患者的再入院人数和实施这些措施所需的相对成本。