A Nursing Home Pragmatic Clinical Trial of APPROACHES (Aligning Patient Preferences: a Role Offering Alzheimer's patient, Caregivers, and Healthcare providers Education and Support)

项目概要 大量阿尔茨海默病或相关痴呆症患者将得到护理护理 临近生命尽头的家园。不幸的是，许多这些患者经历了不必要的和负担重的 医疗治疗，例如可能可以避免的住院治疗，会对生活质量产生负面影响。 与患者和家庭护理人员进行预先护理计划 (ACP) 讨论对于探索以下目标非常重要： 危机的进展并支持明智的、基于价值观的决策。 ACP 流程有助于确保 关于住院等治疗的偏好是已知的、记录在案的并且受到尊重。研究 表明 ACP 可以减少繁琐的治疗并增加护理匹配的可能性 记录的偏好。目前法规要求疗养院向患者提供 ACP， 家庭。然而，对于疗养院工作人员没有培训要求，也没有实现这一目标的方法 监管和道德责任差异很大，导致 ACP 不一致。 “调整患者 偏好——为阿尔茨海默病患者、护理人员和医疗保健提供者提供的角色 教育和 支持（方法）”试验将测试 ACP 专家计划。现有疗养院工作人员将 接受培训，通过改进 ACP 来加强护理并减少不必要的、繁重的住院治疗 程序、标准化的 ACP 员工教育以及系统的 ACP 便利化。主要试验结果是 每 1000 人天活着的医院转院（入院和急诊科就诊）。符合 本着务实试验的精神，研究结果依赖于已经收集的数据，用于质量改进、临床或 计费目的。在为期 18 个月的 R21 试点阶段，目标是： 1) 建立试验的组织机构 结构和流程； 2) 在 4 个疗养院进行干预试点。在R33阶段，务实的 将与 3 家经营疗养院的公司合作进行整群随机临床试验 14 个州总共 206 个不同的城市和乡村设施。 42 个月的 R33 阶段的目标是 3) 评估 12 个月内痴呆症患者转院的主要结果 干预与对照疗养院； 4) 比较 ACP 文件、护理质量衡量标准 临终时，干预疗养院与对照疗养院之间的患者和家属满意度。如果 成功后，ACP 专家计划将准备好快速转化为疗养院实践，以 减少不必要的、繁重的住院治疗，提高痴呆症患者的护理质量。

PROJECT SUMMARY A significant number of patients Alzheimer's disease or related dementia diagnoses will be cared for in nursing homes near the end of life. Unfortunately, many of these patients experience unwanted and burdensome medical treatments, such as potentially avoidable hospitalizations, that negatively impact quality of life. Advance care planning (ACP) discussions with patients and family caregivers are important to explore goals in advance of a crisis and support informed, values-based decision-making. The ACP process helps ensure that preferences about treatments such as hospitalization are known, documented, and honored. Research indicates that ACP can reduce burdensome treatments and increase the likelihood that care will match documented preferences. Nursing homes are currently required by regulations to offer ACP to patients and families. However, there are no training requirements for nursing home staff and approaches to fulfilling this regulatory and ethical responsibility vary widely, resulting in inconsistent ACP. The “Aligning Patient Preferences – a Role Offering Alzheimer's patients, Caregivers, and Healthcare providers Education and Support (APPROACHES)” trial will test the ACP Specialist Program. Existing nursing home staff members will be trained to enhance care and reduce unwanted, burdensome hospitalizations through improved ACP procedures, standardized staff education on ACP, and systematic ACP facilitation. The primary trial outcome is hospital transfers (admissions and emergency department visits) per 1000 person-days alive. Consistent with the spirit of a pragmatic trial, study outcomes rely on data already collected for quality improvement, clinical or billing purposes. In the 18 month R21 pilot phase, the aims are to: 1) Establish the trial's organizational structure and processes; and 2) Pilot test the intervention in 4 nursing homes. In the R33 phase, a pragmatic cluster randomized clinical trial will be conducted in partnership with 3 nursing home corporations who operate a combined total of 206 diverse urban and rural facilities in 14 states. The aims of the 42 month R33 phase are to: 3) Evaluate the primary outcome of hospital transfers over 12 months among patients with dementia in intervention versus control nursing homes; and 4) Compare ACP documentation, measures of quality of care at the end of life, and patient and family satisfaction between the intervention versus control nursing homes. If successful, the ACP Specialist Program will be primed for rapid translation into nursing home practice to reduce unwanted, burdensome hospitalizations and improve quality of care for patients with dementia.