Technology Application to Enhance Discharge Referral Decision Support

描述(申请人提供)：医院出院计划是一个经常发生和昂贵的医院护理过程，每年为1300多万联邦医疗保险受益人进行。这一过程有多个步骤，需要仔细、全面的评估，以充分确定患者目前的需求，预测未来的需求，做出适当的转诊决定，并协调后续服务。尽管住院老年人的决策量很大，但还没有国家认可的经验性决策 支持正在使用的工具，以帮助排放规划者和其他人做出这些重要决策。完成的国家护理研究所研究(RO1-NR07674)，以及进一步的开发和测试，导致了正在申请专利的发明，称为出院决策支持系统(D2S2)2，3本发明准备由我们的公司，RightCare Solutions商业化。基于患者症状和其他特征的预测模型以及专家作出的转诊决策，D2S2是一种有效和可靠的决策工具，可确定哪些住院患者应被考虑转诊到急诊后护理(PAC)，如家庭护理或熟练护理设施。3这些决策的质量决定了老年人是否接受他们所需的PAC服务，是否返回并成功地留在家里。建议的研究目的是通过自动化提高决策支持的交付速度、复杂性和传播，从而增加D2S2的商业应用。第二个目标将评估执行情况和对重新接纳的影响。这项研究涉及到技术开发，以帮助临床医生及时使用和提供D2S2建议。这些改进将指导临床医生更快、更准确地预测和更好地匹配服务以满足患者的需求。这些目标的实现将导致成功地生产出一种适销对路、技术创新和高效的决策支持工具，指导患者获得“正确的护理”。

DESCRIPTION (provided by applicant): Hospital discharge planning is a frequently occurring and expensive hospital care process done annually for more than 13 million Medicare beneficiaries. The process has multiple steps that require careful, comprehensive assessment to adequately determine patients' present needs, anticipate future needs, make appropriate referral decisions, and coordinate follow-up services. Although the volume of decisions for hospitalized older adults is high, there are no nationally recognized, empirically derived decision support tools in use to assist discharge planners and others in making these important decisions. The completed National Institute of Nursing Research study (RO1- NR07674), and further development and testing, resulted in the patent pending invention called the Discharge Decision Support System (D2S2) 2,3 This invention is poised for commercialization by our company, RightCare Solutions. Based on a prediction model of patient symptoms and other characteristics, and referral decisions made by experts, the D2S2 is a valid and reliable decision tool that identifies which hospitalized patients should be considered for referral for post-acute care (PAC) such as home care or skilled nursing facility.3 The quality of these decisions determines whether older adults receive the PAC services they need, to return, and remain successfully in their homes. The proposed study purpose is to increase the commercial application of the D2S2 by increasing the speed of delivery, sophistication, and dissemination of the decision support through automation. A second aim will evaluate the implementation and impact on readmissions. The study involves technology development to assist clinicians in timely use and delivery of the D2S2 advice. These enhancements will guide clinicians to anticipate and better match services to patients' needs more quickly and accurately. Completion of these aims will result in successful production of a marketable, technologically innovative, and highly effective decision support tool that directs patients to the "right care".