Comparative effectiveness of home care environments for diverse elders' outcomes

描述（由申请人提供）：候选人是一名社区/公共卫生护士和老年卫生服务研究员，致力于家庭卫生服务系统的比较有效性研究。她的短期培训目标是：(1)发展比较有效的研究方法专业知识；(2)针对家庭卫生保健数据集和研究设计问题的数据管理和分析方法。长期研究目标是为快速老龄化和日益多样化的人口改善家庭保健护理结果的设计和交付。除了重点研究外，职业发展计划还包括与她的指导/研究团队的同事互动，将在比较有效性研究方法方面进行正式课程学习。宾夕法尼亚大学将为她的职业发展提供一个良好的环境。资源包括通过护理、医学、社会学、统计学和商业学院的卫生服务研究、老龄化和比较有效性研究的重点研究中心与杰出的跨学科教师合作。在优秀导师的指导下，在一流的培训环境中，通过访问丰富的数据集和强大的初步数据，该提案实现了三个具体目标：1)比较护理服务系统策略（更多受过学士学位教育的护士，“提前”护理访问和支持性机构工作环境）改善家庭健康患者结果的有效性~ 2)确定护理对家庭健康结果的影响是否以及在什么条件下取决于非正式护理人员的帮助~ 3)确定家庭健康结果的种族/民族差异程度。并确定哪种护理系统交付策略最有可能与种族/少数民族患者和临床复杂的老年人的改善结果相关。本培训与研究将利用比较效能研究方法的最新进展，发现家庭健康结果的种族/民族差异，了解影响因素（个人、家庭、社区和卫生系统），并评估护理服务系统策略在不同个体和社会环境下改善家庭健康患者结果的比较效能。这一创新项目将利用一个独特的数据集，该数据集由护士调查组成，提供了近250家家庭保健机构的护理和工作环境的详细信息，这些机构为生活在不同社区的老年人提供服务。护士调查结果与独立的家庭保健病人评估和结果数据相结合，为了解每个病人的独特情况提供了一个窗口，包括他们的健康状况和护理需求的复杂性和严重性，以及他们的生活环境和非正式照顾者的信息。与其他行政和公共数据集的联系将提供关于家庭保健机构服务模式和社区措施的更多关键变量，包括犯罪、隔离、社会经济地位和保健提供者的供应/短缺。提出的研究是重要的，因为它将强调不同的家庭保健护理交付策略的价值，以改善弱势群体的患者结果可能实现。如何最好地为不同的患者提供安全、有效和负担得起的家庭健康护理，这一挑战正在被解决，它影响着从家庭到医疗之家和医院的连续护理中患者的结果。有限的证据可用于指导家庭卫生保健系统的管理者做出关于家庭卫生护理提供系统策略的利弊决策。根据是否有非正式的家庭照顾者和社区支持，家庭保健护理提供策略的最佳组合可能会有明显的不同。专业的家庭健康护理和非正式的（非专业）或社区护理可以相互作用，例如，通过减少所需服务的强度来提高系统级干预的有效性。提出的比较有效性研究将形成一个关键的证据体，将有效的护理服务系统战略转化为提供者、支付方、购买者、政策制定者、其他主要调查人员和公众可以信任的循证实践建议。

DESCRIPTION (provided by applicant): The candidate is a community/public health nurse and gerontological health services researcher committed to comparative effectiveness research on home health delivery systems. Her short-term training objectives are (1) to develop comparative effectiveness research methods expertise and (2) data management and analytic methods specific to home health care datasets and research design issues. Long term research goals are to improve the design and deliver of home health nursing care outcomes for a rapidly aging and increasingly diverse population. In addition to focused research, career development plans include interaction with colleagues on her mentoring/research team, formal course work will be taken in comparative effectiveness research methods. The University of Pennsylvania will provide an outstanding environment for her career development. Resources include access to eminent interdisciplinary faculty who collaborate through focused Research Centers in Health Services Research, Aging and Comparative Effectiveness Research, across the Schools of Nursing, Medicine, Sociology, Statistics, and Business. Guided by excellent mentors, in a superb training environment, with access to rich datasets and strong preliminary data, this proposal addresses three specific aims: 1) Compare the effectiveness of nursing delivery system strategies (more nurses educated at the baccalaureate level, "front-loading" of nursing visits, and supportive agency work environments) to improve home health patient outcomes~ 2) Determine if and under what conditions the impact of nursing on home health outcomes is contingent upon informal caregiver assistance~ and 3) Determine the extent of racial/ethnic disparities in home health outcomes, and determine which nursing system delivery strategies are most likely to be associated with improved outcomes for racial/ethnic minority patients and clinically complex older adults. The proposed training and research will utilize the latest advances in comparative effectiveness research methods to detect racial/ethnic disparities in home health outcomes, understand the contributing factors (individual, family, community and health systems), and evaluate the comparative effectiveness of nursing delivery system strategies on improving outcomes for home health patients under different individual and socio-environmental circumstances. This innovative project will capitalize on a unique data set, comprised of nurse surveys providing detailed information about nursing care and work environment within home health agencies in nearly 250 home health agencies that serve older adults living in diverse communities. The nurse survey results combined with independent home health care patient assessment and outcomes data provides a window into each patient's unique circumstances, including the complexity and severity of their health status and care needs, as well as information about their living environment and informal caregivers. Linkages with additional administrative and public datasets will provide additional key variables regarding home health agency service patterns and community measures of crime, segregation, socio-economic status and health care provider availability/shortages. The proposed research is significant because it will highlight the value of different home health nursing delivery strategie for improving patient outcomes among vulnerable populations may be achieved. The challenge being addressed--how to best provide safe, effective, and affordable home health nursing care to diverse patients--affects patient outcomes across the continuum of care from home to medical home and hospital. Limited evidence is available to guide home health care systems administrators in making decisions about the pros and cons of home health nursing delivery system strategies. The best combination of home health nursing care delivery strategies may be categorically different depending on the presence of informal family caregivers and community supports. Professional home health nursing care and informal (lay) or community care may interact synergistically to increase the effectiveness of systems level intervention, for example, by reducing the intensity of services needed. The comparative effectiveness study proposed will form a critical body of evidence needed to translate effective nursing delivery system strategies into evidence-based practice recommendations that providers, payers, purchasers, policy makers, other principle investigators, and the public can trust.