权益分类	功能权益	普通用户	{{item.name}}会员
{{category.name}}	{{benefitItem.name}}

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

改善出院到急性后护理机构的退伍军人的过渡护理

基本信息

批准号：
9981432
负责人：
Robert Edward Burke
金额：
--
依托单位：
VA EASTERN COLORADO HEALTH CARE SYSTEM
依托单位国家：
美国
项目类别：
财政年份：
2015
资助国家：
美国
起止时间：
2015-10-01 至 2020-09-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9981432
关键词：
Accident and Emergency department Activities of Daily Living Acute Address Admission activity Advance Care Planning Affect Award Back Caring Cessation of life Chronic Clinical Code Colorado Communities Contracts Data Data Analyses Data Set Development Disabled Persons Discharge Plannings Elderly Emergency department visit Ensure Evaluation Funding Geriatrics Guidelines Health Health Services Accessibility Health care facility Healthcare Systems Home environment Hospital Mortality Hospital Planning Hospitalists Hospitalization Hospitals Independent Living Intervention Interview K-Series Research Career Programs Lead Length of Stay Link Literature Long-Term Care Measures Medicare Mentors Mentorship Methods Mission Monitor Myocardial Ischemia Nurses Nursing Homes Outcome Outcomes Research Patient Monitoring Patient Monitoring System Patient risk Patients Personal Satisfaction Pharmaceutical Preparations Physician Executives Physicians Population Process Process Measure Publishing Qualitative Methods Recording of previous events Recurrence Rehabilitation therapy Research Research Personnel Research Support Resources Risk Adjustment Site Skilled Nursing Facilities Structure System Testing Time Training Universities Veterans Work acute care base care outcomes care providers career career development community living cost cost effective design deviant disability experience functional loss functional outcomes functional status high risk hospital readmission hospital utilization implementation science improved improved outcome indexing innovation medication safety mortality multi-component intervention novel premature primary outcome public health relevance readmission rates secondary outcome

项目摘要

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.