Mobile Telecare for Underserved African-American Elders with Heart Failure

描述（由申请人提供）：同时符合医疗保险和医疗补助资格的老年人是这两个计划涵盖的最严重和最贫困的个人。尽管他们的慢性疾病（如心力衰竭）患病率明显高于所有其他医疗保险受益人，但只有2%的双重资格患者接受了病例管理或护理协调，可以防止因急性医疗问题住院和急诊就诊。非裔美国人尤其危险，与所有其他医疗保险受益人相比，他们与hf相关的住院率最高。在这个第一阶段的SBIR中，我们将进行一项试点临床试验，以测试一项护理协调计划，该计划是为从地区医院出院并由社区卫生保健提供者护理的非裔美国双重合格老年心衰患者设计的。拟议的移动心脏护理协调（MHCC）计划通过蓝牙设备和基于移动电话的通信技术集成远程监控，将医院心脏护理团队与社区提供者连接起来。该计划的目标是提供协调的出院后护理，以减少可能可以避免的住院和急诊室就诊。第一阶段SBIR将开发和测试MHCC干预的可行性和双重条件下非裔美国人HF的短期结果。在II期申请中，我们将对非裔美国双重条件老年HF患者进行随机临床试验，以确定与对照组（常规护理）相比，MHCC增强项目的参与者在出院后30天内再次入院的可能性（主要假设）和获得急诊室护理的可能性（次要假设）是否更低。I期申请将提供必要的数据，以确定II期更大的足够动力的随机对照试验所需的样本量。随后的II期应用将产生一种创新的、具有成本效益的、全国可复制的护理协调模式，旨在减少潜在可避免的住院和急诊室就诊，并提高所有非裔美国人双重资格心衰患者的护理质量。

DESCRIPTION (provided by applicant): Older adults who are dually eligible for Medicare and Medicaid are among the sickest and poorest individuals covered in either program. Although they have a significantly higher prevalence of chronic conditions, such as heart failure (HF) than all other Medicare beneficiaries, as few as 2% of dual eligible patients receive the type of case management or care coordination that can prevent hospitalizations and emergency department visits for acute medical problems. African-Americans are particularly at risk, having the highest rates of HF-related hospitalizations compared to all other Medicare beneficiaries. In this Phase I SBIR, we will conduct a pilot clinical trial to test a care coordination program designed for African-American dual eligible older adults with HF who have been discharged from a regional hospital and who are being cared for by community-based health care providers. The proposed Mobile Heart Care Coordination (MHCC) program integrates telemonitoring through a Bluetooth-enabled device and mobile phone-based communication technologies that connect hospital-based cardiac care teams with community-based providers. The goal of the program is to provide coordinated post-discharge care in order to reduce potentially-avoidable hospitalizations and emergency room visits. This Phase I SBIR will develop and test the MHCC intervention's feasibility and short-term outcomes for dual eligible African-Americans with HF. In a Phase II application, we will conduct a randomized clinical trial with African-American dual-eligible older adults with HF to determine whether participants in the MHCC- enhanced program are less likely to be readmitted within 30 days of hospital discharge (primary hypothesis) and less likely to access emergency room care (secondary hypothesis) compared to the comparison group (usual care). The Phase I application will provide the necessary data to determine the sample size required for the larger adequately powered randomized controlled trial in Phase II. The subsequent Phase II application will result in an innovative, cost-effective, and nationally replicable care coordination model aimed at reducing potentially-avoidable hospitalizations and emergency room visits, and improving quality of care for all African- American dual eligible patients with HF.