Improving Transitional Care for Veterans Discharged to Post-acute Care Facilities

 描述(由申请人提供)： 对于退伍军人的健康和功能结果来说，可能没有比急性住院然后在急性后护理(PAC)设施(康复或熟练护理设施)停留更关键的时间了。经历这一转变的退伍军人群体通常是老、弱、病和残。结果，许多人被送回急诊科或重新入院。这通常是反复入院、功能状态恶化导致长期护理安置和早期死亡的螺旋式下降的开始。例如，我们的初步数据显示，在退伍军人指数入院后的12个月里，他们平均重新入院或被送往急诊部5次。从医院过渡到PAC正变得越来越普遍，但不良结果可能是可以预防的。在我们的初步数据中，我们发现近一半的PAC设施的再入院发生在出院后的头七天。大量研究支持这一观点，即从医院到急性后护理机构的护理执行不佳是经历这种过渡的退伍军人许多糟糕结果的基础。然而，人们对退伍军人接受急性后护理的结果知之甚少，也不知道是什么因素导致了这些结果。为了确定哪些因素可能会影响这些护理过渡的结果，该提案使用了由被提名者开发的理想护理过渡框架，以确定可能影响过渡护理结果的关键领域。在这项提案中，我们的目标包括：目标1：评估ITC框架的五个关键领域对7天医院利用率和死亡率的影响。领域和实例包括：出院计划(在PAC中提供高强度干预的医院计划)、信息 PAC在以下方面发挥了重要作用：转移(PAC获得医院电子病历)、用药安全(药物对账和监测高风险药物)、高级护理计划(处理和传达代码状态)以及患者监控(PAC医生进行初始评估的时间)。目的2：确定可修改的过渡性护理流程，以帮助解释高绩效医院-PAC站点的积极偏差。目标3：在医院试行护士指导的过渡性护理干预 基于AIMS 1和2中确定的ITC框架的关键领域的PAC站点。这项工作对退伍军人和退伍军人医疗保健系统至关重要，并得到老年医学和长期护理办公室的支持。三名有成就的调查员将作为独立调查员指导被提名者的项目工作和发展。何敏嘉博士是主要导师，在混合方法、多成分干预和实施科学方面拥有专业知识。他是缺血性心脏病QUERI的联席主任，丹佛-西雅图硬币的联席主任，以及一位出版广泛、资金充足的健康结果研究专家。Cari Levy博士是一位共同导师，拥有与该提案相关的重要内容专业知识，包括在该提案中使用的主要数据集的经验，作为一名老年病学家和以前的疗养院医务主任，以及作为PAC环境中的一名有成就的研究人员。艾伦·普罗查兹卡博士是一名资深研究员，在丹佛-西雅图硬币公司担任导师和职业发展总监，拥有丰富的职业发展奖导师经验。职业发展活动包括获得纵向和集群数据分析、定性数据方法和实施科学方面的专业知识。这将通过两位内容专家(定性专家Jacqueline Jones博士和统计学专家Anna Baron博士)的指导、课程作业和研讨会来促进，利用丹佛-西雅图硬币和科罗拉多大学的丰富资源。该奖项提供的指导、培训和受保护的时间将确保被提名者发展为一名独立调查员，致力于改善整个退伍军人管理局系统出院后的护理过渡。

 DESCRIPTION (provided by applicant): There is perhaps no more crucial time period for the health and functional outcomes of Veterans than an acute hospitalization followed by a stay in a post-acute care (PAC) facility (rehabilitatio or skilled nursing facility). The population of Veterans who undergo this transition are generally elderly, frail, ill, and disabled. As a result, many are sent back to the Emergency Department or readmitted to the hospital. This is often the start of a downward spiral of recurrent admissions, worsening functional status resulting in long-term care placement, and early mortality. For example, our preliminary data indicates Veterans discharged to PAC were readmitted or sent to the Emergency Department 5 times on average in the 12 months following their index admission. Transitions from the hospital to PAC are becoming more and more common, but poor outcomes may be preventable. In our preliminary data, we found nearly half of all readmissions from PAC facilities occurred in the first seven days after hospital discharge. Substantial research supports the idea that poorly-executed transitions of care from the hospital to the post-acute care facility underlie many poor outcomes of Veterans who undergo this transition. However, little is known about the outcomes of Veterans discharged to post-acute care, nor what factors contribute to these outcomes. To identify which factors might affect outcomes in these transitions of care, the proposal uses the Ideal Transitions of Care framework, developed by the nominee, to identify key domains that may affect transitional care outcomes. In this proposal, our Aims include: Aim 1: Assess the impact of five key domains of the ITC framework on 7-day hospital utilization and mortality. Domains and examples include: discharge planning (hospital plan for delivery of high-intensity interventions in PAC), information transfer (PAC access to hospital EMR), medication safety (medication reconciliation and monitoring of high-risk medications), advance care planning (addressing and communicating code status), and patient monitoring (time to initial PAC physician evaluation). Aim 2: Determine modifiable transitional care processes that help explain positive deviance in high-performing hospital-PAC sites. Aim 3: Pilot test a nurse-directed transitional care intervention in a hospital PAC site based on key domains of the ITC framework identified in Aims 1 and 2. This work is of crucial importance to Veterans and the VA healthcare system nationally and has the support of the Office of Geriatrics and Extended Care. Three accomplished investigators will guide the nominee's project work and development as an independent investigator. Dr. Michael Ho is the primary mentor with expertise in mixed methods, multicomponent interventions, and implementation science. He is the Co-Director of the Ischemic Heart Disease QUERI, Co-Director of the Denver-Seattle COIN, and a widely-published and well- funded expert in health outcomes research. Dr. Cari Levy is a co-mentor with significant content expertise relevant to the proposal, including experience with the main dataset used in the proposal, as a geriatrician and prior nursing home medical director, and as an accomplished researcher in the PAC setting. Dr. Allan Prochazka is a senior investigator with substantial Career Development Award mentorship experience as Director of Mentorship and Career Development at the Denver-Seattle COIN. Career development activities include gaining expertise in longitudinal and clustered data analysis, qualitative data methods, and implementation science. This will be facilitated by mentorship with two content experts (Dr. Jacqueline Jones, a qualitative expert, and Dr. Anna Baron, a statistical expert), coursework, and seminars taking advantage of the rich resources of the Denver-Seattle COIN and University of Colorado. The mentorship, training, and protected time afforded by this award will ensure the nominee's development as an independent investigator dedicated to improving transitions of care after hospital discharge throughout the VA system.