Care Coordination for High-Risk Patients with Multiple Chronic Conditions

背景护理碎片化对退伍军人来说是一个越来越大的挑战，他们中的许多人面临着多种慢性 需要从不同的提供者和诊所护理的条件。这一问题可能会因一项政策而加剧， 环境，越来越多地鼓励退伍军人的VA和社区护理的双重使用。当病人护理 分散在供应商，诊所和卫生系统中，它增加了信息丢失，药物治疗 相互作用和笨拙的治疗方案，导致健康恶化。健康状况不佳的退伍军人， 那些有功能限制或资源限制的人可能特别容易受到伤害，但人们对这些人知之甚少。 这些高危患者的碎片化模式和护理协调需求。 项目目标。本研究的目的是促进对护理碎片化和护理的理解 协调的潜力之间的高风险退伍军人与多种慢性疾病。 项目方法。为了实现研究目标，我们将首先描述护理碎片化的患病率， 国家高风险患者队列中的变异（目标1）。然后，我们将研究 护理碎片和结局，包括急性护理利用（目标2.1）和患者报告的护理 经验（目标3.1）。最后，我们将评估是否随机化到综合护理协调 减轻碎裂的影响（目标2.2和3.2）。 1.我们将使用2014 - 2015年VA，VA购买的护理（包括退伍军人访问，选择， 责任法案），以及来自全国高风险患者样本的医疗保险数据（护理评估 需要住院风险评分≥第90百分位数）。在目标1.1中，我们将描述初级保健、门诊 采用经验证和调整的护理分散程度衡量标准， 不连续性使用理论方法来比较措施，我们将选择一个主要的碎片 在每个领域内进行测量，以用于随后的目标。在目标1.2中，我们将使用这些选择的措施， 通过患者特征检查护理片段的变化（例如，年龄性别慢性病 住房不稳定，与VA的距离，以及护理协调计划的登记）。 第二章.使用目标1.1中确定的部分碎片化措施，我们将评估 高风险退伍军人的护理碎片化和急性护理利用率。在目标2.1中，我们将确定 护理碎片化是否与较高的急性护理利用率独立相关（包括 急诊科就诊和住院）。在目标2.2中，我们将利用正在进行的 初级保健办公室PACT-Intensive管理（PIM）示范的随机评价 测试综合护理协调是否影响 碎片化和急性护理结果。 第三章.在目标3中，我们将分析针对高风险人群进行的运营支持调查的结果 患者在PIM示范计划，以检查之间的关系照顾碎片和 患者体验护理。在目标3.1中，我们将评估更大的碎片化是否与 满意度低，感知护理协调差，以及患者报告的访问挑战， 沟通和自我管理。在目标3.2中，我们将研究全面护理 通过PIM提供的协调影响了碎片化和患者体验之间的关系。 研究结果将促进对高风险退伍军人护理碎片化，相关结果， 以及他们从重症监护协调中获得的潜在益处。该研究还将为项目开发提供信息 并为我们在弗吉尼亚州初级保健办公室的运营合作伙伴制定护理碎片化措施， 获得护理、社区护理、老年病和长期护理以及妇女保健服务。

Background. Care fragmentation is a mounting challenge for Veterans, many of whom face multiple chronic conditions requiring care from different providers and clinics. This issue is likely to intensify in light of a policy environment that increasingly encourages Veterans’ dual use of VA and community care. When patient care is dispersed across providers, clinics, and health systems, it increases risks of information loss, medication interactions, and unwieldy treatment regimens, leading to health deterioration. Veterans in poor health and those with functional limitations or resource constraints may be especially vulnerable, yet little is known about fragmentation patterns and care coordination needs in these high-risk patients. Project Objectives. The objective of this study is to advance understanding of care fragmentation and care coordination’s potential among high-risk Veterans with multiple chronic conditions. Project Methods. To achieve the study goals, we will first describe care fragmentation prevalence and variation in a national cohort of high-risk patients (Aim 1). We will then examine the relationships between care fragmentation and outcomes, including acute care utilization (Aim 2.1) and patient-reported care experience (Aim 3.1). Finally we will evaluate whether randomization to comprehensive care coordination mitigates the effects of fragmentation (Aims 2.2 and 3.2).  Aim 1. We will use 2014-2015 VA, VA purchased care (including Veterans Access, Choice, and Accountability Act), and Medicare data from a national sample of high-risk patients (Care Assessment Needs hospitalization risk score ≥ 90th percentile). In Aim 1.1, we will describe primary care, outpatient care, and health system fragmentation, using validated and adapted measures of care fragmentation and discontinuity. Using a theoretical approach to compare measures, we will select a primary fragmentation measure within each domain for use in subsequent aims. In Aim 1.2, we will use these select measures to examine variation in care fragmentation by patient characteristics (e.g., age, sex, chronic conditions, housing instability, distance from VA, and enrollment in care coordination programs).  Aim 2. Using select fragmentation measures identified in Aim 1.1, we will evaluate the relationship between care fragmentation and acute care utilization among high-risk Veterans. In Aim 2.1, we will determine whether care fragmentation is independently associated with higher rates of acute care utilization (including emergency department visits and hospitalizations). In Aim 2.2, we will take advantage of an ongoing randomized evaluation of an Office of Primary Care PACT-Intensive Management (PIM) Demonstration Program to test whether comprehensive care coordination influences the relationship between fragmentation and acute care outcomes.  Aim 3. In Aim 3, we will analyze findings from an operations-supported survey administered to high-risk patients in the PIM Demonstration Program to examine the relationship between care fragmentation and patient experiences with care. In Aim 3.1, we will assess whether greater fragmentation is associated with low satisfaction, poor perceived care coordination, and patient-reported challenges with access, communication, and self-management. In Aim 3.2, we will examine whether comprehensive care coordination offered through PIM influences the relationship between fragmentation and patient experience. Study findings will advance understanding of high-risk Veterans’ care fragmentation, associated outcomes, and their potential benefit from intensive care coordination. The study will also inform program development and generate care fragmentation measures for our operations partners in VA’s Offices of Primary Care, Access to Care, Community Care, Geriatrics and Extended Care, and Women’s Health Services.