Improving patient-centered care coordination for high-risk Veterans in PACT

在 PACT 中改善高危退伍军人以患者为中心的护理协调

• 批准号: 9075372
• 负责人: Kristina Marie Cordasco
• 金额: --
• 依托单位: VA GREATER LOS ANGELES HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-10-01 至 2020-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9075372
• 关键词: Accident and Emergency department; Accident and Emergency department; Accounting; Acute; Acute; Address; Address; Algorithms; Algorithms; Area; Area; Care given by nurses; Caring; Caring; Case Manager; Case Manager; Cessation of life; Chronic; Chronic; Chronic Disease; Chronic Disease; Collaborations; Collaborations; Communication; Communication; Communities; Communities; Community Hospitals; Complex; Complex; Computerized Patient Records; Computerized Patient Records; Consultations; Consultations; Deterioration; Deterioration; Disease; Disease; Effectiveness; Electronics; Emergency Department patient; Emergency Department patient; Emergency department visit; Emergency department visit; Evaluation; Evaluation; Evidence based treatment; Evidence based treatment; Expenditure; Expenditure; Goals; Goals; Growth; Growth; Health; Health; Health Expenditures; Health Expenditures; Health Professional; Health Professional; Healthcare; Healthcare; Healthcare Systems; Healthcare Systems; Home environment; Home environment; Hospital Departments; Hospitalization; Hospitalization; Hospitals; Hospitals; Inpatients; Inpatients; Intervention; Intervention; Lead; Lead; Length of Stay; Length of Stay; Link; Link; Literature; Literature; Long-Term Care; Long-Term Care; Los Angeles; Los Angeles; Medical; Medical; Methods; Methods; Minority; Minority; Modeling; Modeling; Names; Names; Needs Assessment; Needs Assessment; Neighborhoods; Neighborhoods; Outcome; Outcome; Outpatients; Outpatients; Patient Care; Patient Care; Patient-Centered Care; Patient-Centered Care; Patient-Focused Outcomes; Patients; Patients; Performance; Performance; Population; Primary Health Care; Primary Health Care; Process; Process; Production; Production; Program Evaluation; Program Evaluation; Provider; Provider; Randomized; Randomized; Readiness; Readiness; Reporting; Reporting; Research; Research; Resources; Resources; Safety; Safety; Services; Services; Site; Site; Social Functioning; Social Functioning; Source; Source; Specialist; Specialist; Structure; Structure; System; System; Team Nursing; Team Nursing; Testing; Testing; Translating; Translating; Triage; Triage; Veterans; Veterans; Visit; Visit; Work; Work; acute care; base; base; care coordination; care systems; clinical practice; clinical practice; community partnership; compare effectiveness; compare effectiveness; contextual factors; contextual factors; cost; cost; design; design; effectiveness testing; electronic data; electronic data; experience; experience; follow-up; follow-up; health administration; health administration; high risk; high risk; high risk population; implementation strategy; improved; improved; insight; insight; mortality risk; payment; payment; programs; programs; psychologic; psychologic; randomized trial; randomized trial; tool; tool; treatment as usual; treatment as usual

 DESCRIPTION (provided by applicant): Project Background: Across a variety of different health care payment systems, a minority of patients account for the majority of costs. Within VHA, the one-third of patients who have three or more chronic conditions account for two-thirds of costs. An even smaller group of patients is at near-term high risk of acute care, the single greatest driver of costs. Veterans cared for by primary care as part of VHA's Patient Aligned Care Teams (PACT) can be identified as at high risk of death or need for hospitalization using the Care Assessment Need (CAN) score. When these vulnerable patients experience gaps in care coordination, they are highly likely to experience negative outcomes. Although a variety of models of care to manage high-risk patients have been tested outside VHA, results have been variable. Within VHA, the Intensive Management Patient-Aligned Care Team (ImPACT) pilot and the five-site PACT Intensive Management (PIM) demonstration are providing insights into how PACT teams more generally can successfully care for high-risk patients. There remains an urgent need to develop better ways to implement coordinated care for these high-risk Veterans. Project Objectives: The proposed program aims to achieve the following impact goal: to improve care coordination and experience of care across settings for high-risk Veterans in PACT. This goal is aligned with Blueprint for Excellence transformational actions 1a (Coordination of Care in PACT for Complex Veterans), 2a ("Triple Aim": Better Health, Care, and Value), 6e (Leverage Community Resources), and 8d (Collaborate with Community-based Organizations), and with MyVA focus areas 1: improving Veteran experience; 3: establishing a culture of continuous performance improvement, and 4: enhancing strategic VA- community partnerships. Within this program, Implementation Project 1 aims to disseminate strategies for coordination of care for high-risk Veterans via a distance-coaching strategy combined with an online toolkit. The quality improvement project aims to improve coordination between the Emergency Department (ED) and PACT by adapting and spreading a pilot-tested Computerized Patient Record System (CPRS)-based care coordination system for ED-PACT handoffs across all PACT sites in the VA Greater Los Angeles Healthcare System (VAGLAHS). Implementation Project 2 aims to improve coordination between high-risk Veterans and their home communities at hospital discharge by adapting an existing "community alignment" intervention. The implementation core focuses on assessing and improving organizational readiness for care coordination between PACT and other care settings; 2) core evaluation metrics reflecting patient-reported care experiences as well as electronic data; and 3) production of a combined care coordination toolkit across projects. Project Methods: The VA Offices of Patient Care Services, and Quality, Safety and Value will partner with QUERI to accomplish the proposed work. Implementation Project 1 involves 1) developing an online toolkit for care coordination in PACT, 2) piloting a distance coaching intervention at PACT sites, and 3) comparing the effectiveness of the online toolkit alone to the combination of the toolkit plus coaching. The quality improvement project will improve communication between the ED and the PACT team by a structured message being sent from the ED provider to the PACT nurse care manager, who then takes lead in triaging and arranging for appropriate care. Implementation Project 2 will involve 1) adapting a previously-tested "community alignment" intervention to the needs of VAGLAHS and Los Angeles community agencies for high- risk Veterans; 2) piloting the adapted intervention at VAGLAHS over a six-month period; 3) evaluating the full intervention at hospital discharge with 450 patients, half randomly assigned to the intervention and half to usual care. The implementation core will interface with each of the projects and build on existing literature to develop tools for assessing and improving organizational readiness for care coordination.

 描述（由申请人提供）： 项目背景：在各种不同的医疗保健支付系统中，少数患者承担了大部分费用。在 VHA 中，三分之一患有三种或以上慢性病的患者占三分之二的费用。一小部分患者近期面临急症护理的高风险，这是成本的最大驱动因素。使用护理评估需求 (CAN) 评分，可以将作为 VHA 患者协调护理团队 (PACT) 一部分的初级护理护理的退伍军人确定为死亡或需要住院的高风险。当这些弱势患者在护理协调方面遇到差距时，他们很可能会遇到负面结果。尽管在 VHA 之外测试了多种管理高危患者的护理模式，但结果却各不相同。在 VHA 内，强化管理患者协调护理团队 (ImPACT) 试点和五个地点的 PACT 强化管理 (PIM) 演示为 PACT 团队如何更广泛地成功护理高风险患者提供了见解。仍然迫切需要开发更好的方法来对这些高风险退伍军人实施协调护理。项目目标：拟议计划旨在实现以下影响目标：改善 PACT 中高风险退伍军人跨环境的护理协调和护理体验。这一目标与卓越蓝图转型行动 1a（在 PACT 中协调复杂退伍军人的护理）、2a（“三重目标”：更好的健康、护理和价值）、6e（利用社区资源）和 8d（与社区组织合作）以及 MyVA 重点领域 1：改善退伍军人体验相一致； 3：建立持续改进绩效的文化，以及 4：加强 VA 与社区的战略伙伴关系。在该计划中，实施项目 1 旨在通过远程辅导策略与在线工具包相结合，传播协调高危退伍军人护理的策略。该质量改进项目旨在通过调整和推广经过试点测试的基于计算机化患者记录系统 (CPRS) 的护理协调系统，在 VA 大洛杉矶医疗系统 (VAGLAHS) 的所有 PACT 站点之间进行 ED-PACT 交接，从而改善急诊科 (ED) 和 PACT 之间的协调。实施项目 2 旨在通过调整现有的“社区协调”干预措施，改善高风险退伍军人出院时与其家乡社区之间的协调。实施核心侧重于评估和改善 PACT 与其他护理机构之间护理协调的组织准备情况； 2）反映患者报告的护理经历以及电子数据的核心评估指标； 3) 制作跨项目的综合护理协调工具包。项目方法：退伍军人管理局患者护理服务、质量、安全和价值办公室将与 QUERI 合作完成拟议的工作。实施项目 1 涉及 1) 开发用于 PACT 护理协调的在线工具包，2) 在 PACT 站点试点远程辅导干预，以及 3) 比较单独在线工具包与工具包加辅导组合的有效性。质量改进项目将通过从 ED 提供者向 PACT 护士护理经理发送结构化消息来改善 ED 和 PACT 团队之间的沟通，然后由后者负责分类和安排适当的护理。实施项目 2 将涉及 1) 调整先前测试过的“社区协调”干预措施，以满足 VAGLAHS 和洛杉矶社区机构对高风险退伍军人的需求； 2) 在 VAGLAHS 试行为期六个月的适应性干预措施； 3) 对 450 名患者出院时的全面干预进行评估，其中一半随机分配至干预组，另一半接受常规护理。实施核心将与每个项目对接，并以现有文献为基础开发工具 评估和改善组织对护理协调的准备情况。