Implementing and Evaluating INTERACT in VA CLCs

描述(由申请人提供)： 从养老院(NHS)或社区生活中心(CLCs)转移到医院会使居民面临医源性事件、护理中断、定向障碍、压力和成本增加的风险。每年超过50万的医院出院来自社区NHS，对潜在可避免住院的估计从NH到医院转移的23%到67%不等。可避免的住院是退伍军人事务部老年医学和长期护理领导层已确定为研究和干预的高度优先领域的一个重要问题。减少急性护理转移干预(InterAct)是一项全面的、多层次的护理人员培训和质量改进计划，由Ouslander博士和他的同事设计，并已在由联邦医疗保险和医疗补助服务中心(CMS)和英联邦基金赞助的演示中进行测试，发现在参与的机构中减少了17%-24%的住院率。本研究的目标是在VHA CLCS中实施和评估InterAct。我们遵循基于证据的假设，即参与InterAct计划将更早地发现住院医生的临床问题，帮助评估并安全地启动对这些问题的管理，改善沟通和使用预先护理计划，并减少医院转院。InterAct计划、培训课程和工具将根据标准的CLC操作程序和VHA语言和政策进行改进，以适合在退伍军人管理局的环境中实施。基于合并的VIREC和Medicare住院和门诊数据以及CLC护士人员配置和其他组织数据，我们将根据住院率、距离VAMC医院的距离以及他们服务的短期和长期CLC退伍军人的组合来匹配CLC。总共将确定10对设施，并将从每对设施中随机选择一对，以便就实施InterAct计划进行接洽。我们预计，在6个月的培训期和另外12个月的积极干预和监测期内，至少有8个被接触的设施将接受、采用和实施该计划。如果被随机选择提供InterAct计划的CLC拒绝参与，那么这两个CLC匹配对的成员都将被从研究中删除。在6个月的培训期间和12个月的积极干预和监测期间，将收集广泛的流程措施，包括工作人员在在线培训中花费的时间以及中央支助委员会工作人员在支助电话会议上的时间，以用于执行分析和预算影响分析。此外，将审查工作人员在6个月培训和12个月干预监测期间应用的质量改进工具，以检查住院的特点和“可避免”性。不会有与配对和随机选择的CLC作为“对照”的接触，因为关于他们住院率的结果数据将完全来自现有的记录数据。将检查干预和对照CLC配对的病例组合和经季节性调整的住院率的变化，比较引入InterAct之前两年和之后两年的变化。此外，还将检查不适当住院率的变化。我们假设，在不增加CLC退伍军人不良事件的情况下，InterAct将使住院率至少降低20%。如果有效，GEC领导层随时准备将InterAct整合到正在进行的努力中，以改变CLC的文化，使他们更以退伍军人为中心，通过减少再次住院，从而增加回国的可能性。

DESCRIPTION (provided by applicant): Transfers from nursing homes (NHs) or community living centers (CLCs) to hospitals place residents at risk for iatrogenic events, disruptions in care, disorientation, stress and increase costs. Over half a million hospital discharges a year emanate from community NHs and estimates of potentially avoidable hospitalizations have ranged from 23% to 67% of NH to hospital transfers. Avoidable hospitalizations are a significant issue that VA Geriatrics and Extended Care leadership has identified as a high priority area for study and intervention. The Interventions to Reduce Acute Care Transfers (INTERACT), a comprehensive, multi-level nursing staff training and quality improvement program, was designed by Dr. Ouslander and his colleagues and has been tested in demonstrations sponsored by the Centers for Medicare & Medicaid Services (CMS) and The Commonwealth Fund, and found to reduce hospitalizations by 17%, 24% among engaged facilities. The goal of this study is to implement and evaluate INTERACT in VHA CLCs. We are guided by the evidence based hypothesis that engagement in the INTERACT program will identify residents' clinical problems earlier, help evaluate and safely initiate management for them, improve communication and use of advance care planning and result in fewer hospital transfers. The INTERACT program, training curriculum and tools will be refined to be appropriate for implementation in a VA setting both in relation to standard CLC operating procedures and VHA language and policies. Based upon merged VIREC and Medicare inpatient and outpatient data and CLC nurse staffing and other organizational data, we will match CLCs in terms of hospitalization rate, proximity to their VAMC hospital and the mix of short and long stay CLC Veterans they serve. A total of 10 pairs of facilities will be identifie and from each pair one will be randomly selected to be approached about implementing the INTERACT program. We expect at least 8 of the facilities approached will accept, adopt and implement the program over the 6 month training period and the additional 12 month active intervention and monitoring period. Both members of the CLC matched pairs will be dropped from the study if the CLC that is randomly selected to be offered the INTERACT program declines to participate. During the 6 month training period and the 12 month active intervention and monitoring period, extensive process measures, ranging from staff time spent in on-line training as well as CLC staff time on the support conference calls, will be gathered for use in both the implementation analyses as well as the Budget Impact Analyses (BIS). Additionally, quality improvement tools applied by staff to examine the characteristics and "avoidability" of hospitalizations during the 6 month training and 12 month intervention monitoring period will be reviewed. There will be no contact with CLCs matched and randomly selected as "controls" since outcome data on their hospitalization rates will come exclusively from existing record data. Changes in the case-mix and seasonally adjusted hospitalization rates of intervention and control CLC pairs will be examined, comparing changes over the two years prior to introducing INTERACT and the two years thereafter. In addition, changes in rates of inappropriate hospitalizations will be examined. We hypothesize that INTERACT will reduce the hospitalization rate by at least 20% without increases in adverse events among Veterans in CLC. If effective, GEC leadership stands ready to integrate INTERACT into ongoing efforts to transform the culture of CLCs to make them more Veteran centered and focused by reducing re-hospitalization thereby increasing the likelihood of returning home.