Improving Transition Outcomes through Accessible Health IT and Caregiver Support

描述(由申请人提供)：背景：由于过渡支持不足，老年住院成年人经常经历可预防的短期重新住院。虽然积极主动的电话跟踪改善了过渡结果，但这些服务往往是不系统的和低强度的。非正式的照顾者对于确保成功的过渡是非常宝贵的，但许多患者独自生活，有一名家庭照顾者正在努力应对相互竞争的需求，或者住在离成年子女或其他潜在支持来源很远的地方。过渡支持需要新的模式，包括低成本技术和为患者的非正式护理网络提供更结构化的援助，同时为患者的临床团队提供避免健康危机所需的信息。目标：与NIA改善过渡结果的目标一致，我们将评估一种旨在通过三种行动机制提高对患有常见慢性病的老年人过渡支持的有效性的新型干预措施：(A)通过出院后定期自动呼叫与患者直接进行量身定制的沟通，(B)通过关于患者状况的结构化反馈和关于他们如何提供帮助的建议，支持居住在患者家庭之外的非正式护理人员，以及(C)支持主动护理管理，包括基于网络的疾病管理工具、关于潜在问题的自动警报，以及与患者及其护理人员进行异步沟通的能力。具体地说，这项试验将确定：1)CarePartner干预是否改善了患者的再入院风险和功能状态；2)干预对患者的自我护理行为和过渡过程的质量的影响；3)干预是否改善了照顾者的负担和压力水平。方法：760名患有复杂慢性病的老年人将在两个社区急性护理医疗服务机构入院时被确认。患者将被要求识别CarePartner(CP)，即愿意在过渡支持和组织更广泛的非正式照顾者网络中发挥积极作用的成年儿童或其他社交网络成员。患者将随机接受干预或常规护理。干预患者将收到自动评估和行为改变电话，他们的CP将在每次评估后收到结构化反馈和建议。患者的临床团队将可以通过网络访问患者的评估结果，将收到有关紧急健康问题的自动报告，并将能够使用安全网页和专门设计的语音信箱服务与患者和CP进行异步交流。患者将在基线、出院后30天和90天完成调查；利用率数据将从医院记录中获得。CPS、其他照顾者和临床医生将接受访谈，以评估干预对自我护理支持、照顾者压力和沟通过程的影响，以及干预措施更广泛实施的潜力。主要结果将是30天的再住院率；在30天和90天测量的次要结果包括功能状态、自我护理行为和死亡风险。

DESCRIPTION (provided by applicant): Background: Older hospitalized adults frequently experience preventable short-term readmissions due to inadequate transition support. Although proactive telephone follow-up improves transition outcomes, these services often are unsystematic and of low intensity. Informal caregivers are invaluable for ensuring successful transitions, but many patients live alone, have an in-home caregiver who is struggling with competing demands, or live at a distance from adult children or other potential sources of support. New models are needed for transition support that include low-cost technologies and more structured assistance for patients' informal caregiving network, while providing patients' clinical teams with the information they need to avert health crises. Objectives: Consistent with NIA's goals to improve transition outcomes, we will evaluate a novel intervention designed to improve the effectiveness of transition support for older adults with common chronic conditions via three mechanisms of action: (a) direct tailored communication to patients via regular automated calls post discharge, (b) support for informal caregivers living outside of the patient's household via structured feedback about the patient's status and advice about how they can help, and (c) support for proactive care management including a web-based disease management tool, automated alerts about potential problems, and the capacity for asynchronous communication with patients and their caregivers. Specifically, the trial will determine: 1) whether the CarePartner intervention improves patients' readmission risk and functional status; 2) the impact of the intervention on patients' self-care behaviors and the quality of the transition process; and 3) whether the intervention improves caregiver burden and stress levels. Methods: 760 older adults with complex chronic conditions will be identified upon admission to two community-based acute care medical services. Patients will be asked to identify a CarePartner (CP), i.e., an adult child or other social network member willing to play an active role in their transition support and organizing their broader network of informal caregivers. Patients will be randomized to the intervention or usual care. Intervention patients will receive automated assessment and behavior change calls, and their CPs will receive structured feedback and advice following each assessment. Patients' clinical team will have access to patients' assessment results via the web, will receive automated reports about urgent health problems, and will be able to communicate asynchronously with patients and CPs using a secure web page and a specially designed voicemail service. Patients will complete surveys at baseline, 30- and 90- days post discharge; utilization data will be obtained from hospital records. CPs, other caregivers, and clinicians will be interviewed to evaluate intervention effects on processes of self-care support, caregiver stress and communication, and the intervention's potential for broader implementation. The primary outcomes will be 30 day readmission rates; 2ndary outcomes measured at 30 and 90 days include functional status, self-care behaviors, and mortality risk.