Restructuring Epilepsy Care: Organizational Dynamics and Quality

重组癫痫护理：组织动态和质量

• 批准号: 8277469
• 负责人: Mary Jo Pugh
• 金额: --
• 依托单位: SOUTH TEXAS VETERANS HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2012
• 资助国家: 美国
• 起止时间: 2012-05-01 至 2016-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8277469
• 关键词: Address; Adopted; Affect; Anthropology; Behavior; Caring; Case Study; Chronic Disease; Clinical; Clinical Protocols; Communication; Consult; Data; Disease; Effectiveness; Elderly; Electronics; Epilepsy; Evaluation; Foundations; Funding; Glean; Goals; Health Services Accessibility; Healthcare; Improve Access; Individual; Inpatients; Intervention; Interview; Knowledge; Lead; Link; Location; Mails; Managed Care; Measures; Medical; Mental Health; Methods; Modeling; Outcome; Outpatients; Participant; Patients; Performance; Pharmacy facility; Physicians; Population; Positioning Attribute; Process; Provider; Quality Indicator; Quality of Care; Recurrence; Research; Research Personnel; Role; Sampling; Science; Seizures; Structure; Surveys; System; Teleconferences; Time; Traumatic Brain Injury; Variant; Veterans; base; care delivery; care systems; comparative; high risk; implementation science; improved; innovation; insight; medical specialties; member; multidisciplinary; nervous system disorder; novel; response; successful intervention; symposium; therapy development

DESCRIPTION (provided by applicant): Background: Epilepsy (a neurological disorder characterized by recurrent seizures) is a growing concern for the VA as it serves two growing populations at high risk for the disorder: individuals with traumatic brain injury (TBI) and the elderly. The growing number of Veterans with epilepsy and the resultant need to improve access while more effectively managing care led to the creation of four geographic Epilepsy Centers of Excellence (ECOEs) in FY09. The COE approach arose out of the need to improve delivery care but has yet to be studied for its effectiveness as a model of care. We seek to examine the impact of the ECOE model using the relational coordination (RC) framework as way to understand the impact of the ECOE structure on the interdependencies between VA providers. Research using the RC framework has demonstrated that in situations where patients and providers deal with an unpredictable chronic illness and have to coordinate care across multiple facilities and providers under time-constrained conditions such as in epilepsy, the quality of communication and relationships among participants affects both the timeliness and quality of care. This study seeks to examine how changes in the structure of epilepsy care are associated with RC and with quality of and access to epilepsy care. Objective 1: Describe changes in quality of and access to epilepsy care before and after ECOE initiative implementation. Objective 2: Describe the associations between changes in the structure/ processes of care implemented by the four geographic ECOEs and RC among epilepsy care team members in each ECOE. Objective 3: Determine whether variations in access to and quality of VA epilepsy care among geographic ECOEs are associated with RC. Methods: This four-year comparative case study will use VA inpatient, outpatient, and pharmacy data to identify Veterans with epilepsy, and medical chart abstraction data from a random sample stratified within ECOE by epilepsy chronicity and seizure control to identify changes in quality of and access to care in the VA throughout ECOE implementation (FY08-FY14). In order to examine the associations between RC and structural change we will first administer RC surveys to staff from each hub, and from 4 spokes who refer to each hub; the spokes will be selected based on high and low referrals within each hub. We will then use survey results to select individuals from each location surveyed for semi-structured interviews to obtain richer details regarding the organization of care and specific innovative approaches used by epilepsy care teams in each ECOE to improve the quality of and access to care. Finally, we will link RC among providers, and epilepsy clinical outcomes to determine the extent to which RC is associated with improvements in quality of and access to epilepsy care using multivariable models. Impact: This study will provide valuable information for VA stakeholders through demonstrating the impact of the ECOE model of care on clinical outcomes. Our findings will lay the foundation for assessing the value of the COE model for care of other diseases and hub-and-spoke models of subspecialty care. Identification of quality gaps provides specific targets for interventions that will have the greatest impact on patient outcomes and system utilization. While this study focuses on VA epilepsy care, no similar studies of a COE model exist outside the VA. Thus findings from this study may provide insights regarding care models for both VA care of other diseases for which a COE model may be considered, and for non-VA epilepsy care. Finally, our inclusion of the RC framework contributes to implementation science by providing an understanding of the impact of the COE structure on interdependencies among VA providers, and suggesting specific types of interventions that may be used to improve RC and specific aspects of epilepsy care simultaneously.

描述（由申请人提供）： 背景资料：癫痫（一种以反复发作为特征的神经系统疾病）是VA日益关注的问题，因为它为两个不断增长的高风险人群提供服务：创伤性脑损伤（TBI）和老年人。越来越多的退伍军人患有癫痫，因此需要改善访问，同时更有效地管理护理，导致在2009财年创建了四个地理癫痫卓越中心（ECOE）。特遣队所属装备办法的产生是出于改善分娩护理的需要，但其作为护理模式的有效性尚待研究。我们试图研究的影响ECOE模型使用的关系协调（RC）框架的方式来理解的影响ECOE结构的VA供应商之间的相互依赖关系。使用RC框架的研究表明，在患者和提供者处理不可预测的慢性疾病的情况下，必须在时间有限的条件下（如癫痫）协调多个设施和提供者的护理，参与者之间的沟通和关系质量影响护理的及时性和质量。本研究旨在探讨癫痫护理结构的变化如何与RC和癫痫护理的质量和获得。目标1：描述ECOE倡议实施前后癫痫护理质量和可及性的变化。目标二：描述由四个地理ECOE和RC在每个ECOE的癫痫护理团队成员中实施的护理结构/流程变化之间的关联。目的3：确定地理ECOE之间VA癫痫护理的可及性和质量的差异是否与RC相关。研究方法：这项为期四年的比较病例研究将使用VA住院患者、门诊患者和药房数据来识别患有癫痫的退伍军人，并使用来自ECOE内按癫痫慢性化和癫痫控制分层的随机样本的病历摘要数据来识别整个ECOE实施期间（FY 08-FY 14）VA中护理质量和可及性的变化。为了研究驻地协调员与结构改革之间的关系，我们将首先对每个中心的工作人员以及向每个中心推荐的4个辐条的工作人员进行驻地协调员调查;辐条将根据每个中心内推荐的高和低情况进行选择。然后，我们将使用调查结果从每个调查地点选择个人进行半结构化访谈，以获得有关每个ECOE癫痫护理团队为提高护理质量和获得护理而使用的护理组织和具体创新方法的更丰富细节。最后，我们将RC供应商之间的联系，癫痫的临床结果，以确定在何种程度上RC与改善质量和获得癫痫护理使用多变量模型。影响：本研究将通过证明ECOE护理模式对临床结局的影响，为VA利益相关者提供有价值的信息。我们的研究结果将为评估COE模式对其他疾病的护理价值和亚专科护理的中心辐射模式奠定基础。质量差距的识别为干预措施提供了具体目标，这些干预措施将对患者结局和系统利用率产生最大影响。虽然这项研究的重点是VA癫痫护理，没有类似的研究，一个COE模型存在以外的VA。因此，这项研究的结果可以提供有关护理模式的见解VA护理的其他疾病，其中COE模型可以考虑，和非VA癫痫护理。最后，我们的RC框架的列入有助于实施科学提供了一个理解的COE结构之间的相互依赖VA供应商的影响，并建议特定类型的干预措施，可用于改善RC和癫痫治疗的具体方面同时。