Community-based Health Home in an Integrated Care Partnership for Adults with SMI

为 SMI 成人提供综合护理合作伙伴关系的社区健康之家

• 批准号: 8634875
• 负责人: Stephen J Bartels
• 金额: $ 32.72万
• 依托单位: DARTMOUTH COLLEGE
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-09-26 至 2015-10-25
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8634875
• 关键词: Acute; Address; Adult; Agreement; Applications Grants; Behavioral; Biometry; Caring; Chronic; Chronic Disease; Clinic; Communities; Comorbidity; Complex; Cost Savings; Data; Data Aggregation; Data Collection; Data Security; Disease Management; Environment; Evaluation; Foundations; Funding; Future; Goals; Grant; Health; Health Services; Healthcare; Home environment; Individual; Informatics; Information Systems; Institutional Review Boards; Leadership; Life; Life Expectancy; Longevity; Managed Care; Massachusetts; Measurement; Measures; Medicaid; Medical; Medicare/Medicaid; Mental Health; Modeling; Morbidity - disease rate; Nurses; Observational Study; Outcome; Outcome Measure; Outcome Study; Persons; Preparation; Primary Health Care; Principal Investigator; Procedures; Process; Protocols documentation; Provider; Reporting; Research Design; Research Infrastructure; Research Project Grants; Risk; Sample Size; Sampling; Security; Self Management; Services; Site; Staging; System; Testing; Training; base; behavioral health; beneficiary; capitate bone; computerized data processing; cost; data integration; data management; design; effectiveness measure; evidence base; experience; health care delivery; high risk; human subject; improved; innovation; meetings; novel; outreach; programs; public health relevance; relational database; severe mental illness; telehealth; virtual

DESCRIPTION (provided by applicant): The proposed one-year planning project will leverage an unprecedented opportunity afforded by a Center for Medicare and Medicaid Innovation (CMMI) grant implementing a novel pilot program of a Community Behavioral Health Home (CBHH) within an Integrated Care Partnership for dually eligible and high-cost Medicaid beneficiaries. This innovative service model consists of a "virtual health home" integrated into community-based outreach teams, an embedded medical nurse providing chronic disease management supported by telehealth, and a health outreach worker trained to provide integrated illness self-management support. The goal of this planning proposal is to build the data and research infrastructure to extend the current CMMI pilot (four outreach teams providing CBHH to 480 persons), to a full-scale empirical evaluation of the CBHH model in a newly formed Integrated Care Partnership including 20 outreach teams serving n=2400 dually eligible and high-cost Medicaid beneficiaries with SMI and medical comorbidity. Aim 1 will develop and pilot test an integrated data collection and management infrastructure including: a) establish an Outcomes and Data Informatics Workgroup; b) develop the relational database; c) prepare data use agreements and security protocols; d) create and pilot test automated data collection; e) organize protocols for de-identification and integration of claims data; and f) refine assignments to risk tiers. Aim 2 will engage in a planning process for a large-scale empirical study of the outcomes and costs in an implementation of the Community Behavioral Health Home (CBHH) model in a new Integrated Care Partnership for dually eligible and high-cost Medicaid beneficiaries with SMI and medical comorbidity, including: a) establish and operate the Research Design Planning Workgroup; b) refine the Community Behavioral Health Home (CBHH) model; c) identification of optimal research design for the future study; d) refinement of recruitment and human subject IRB procedures for the future study; e) preparation of an ROI research project grant application for a future large-scale study of the CBHH model implemented in 20 teams serving approximately 2,400 persons with SMI.

拟议的为期一年的规划项目将利用医疗保险和医疗补助创新中心（CMMI）赠款提供的前所未有的机会，在综合护理合作伙伴关系中为双重合格和高成本的医疗补助受益人实施社区行为健康之家（CBHH）的新试点计划。这一创新服务模式包括一个纳入社区外展小组的“虚拟保健之家”、一名在远程保健支持下提供慢性病管理的嵌入式护士，以及一名经过培训的保健外展工作者，以提供综合疾病自我管理支持。该规划提案的目标是建立数据和研究基础设施，以扩展当前的CMMI试点（四个外展团队为480人提供CBHH），在新成立的综合护理合作伙伴关系中对CBHH模型进行全面的实证评估，包括20个外展团队，为n=2400名双重合格和高成本的医疗补助受益人提供SMI和医疗补助。目标1将开发和试点测试一个综合数据收集和管理基础设施，包括：（a）建立一个成果和数据信息学工作组;（B）开发关系数据库;（c）编写数据使用协议和安全协议;（d）创建和试点测试自动数据收集;（e）组织索赔数据的去识别和整合协议;（f）完善风险等级分配。目标2将参与规划过程，以便对社区行为健康之家（CBHH）模式在新的综合护理伙伴关系中的实施结果和成本进行大规模实证研究，该伙伴关系适用于具有SMI和医疗保健的双重资格和高成本医疗补助受益人，包括：a）建立和运营研究设计规划工作组; B）完善社区行为健康之家（CBHH）模式; c）确定未来研究的最佳研究设计; d）完善未来研究的招募和人类受试者IRB程序; e）为CBHH模型的未来大规模研究准备ROI研究项目资助申请，该研究在20个团队中实施，为约2，400名SMI患者提供服务。