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

• 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
• 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

 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.

 描述（由申请人提供）： 对于退伍军人的健康和功能结果来说，也许没有比急性住院治疗后留在急性护理（PAC）设施（康复或专业护理设施）更关键的时间段了。经历这种过渡的退伍军人人口通常是老年人，体弱多病，残疾。因此，许多人被送回急诊室或重新入院。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，我们的初步数据表明，退伍军人出院到PAC被重新接纳或送往急诊科平均5次，在12个月后，他们的指数入院。从医院到PAC的转变越来越普遍，但不良结局可能是可以预防的。在我们的初步数据中，我们发现近一半的PAC设施再入院发生在出院后的前七天。大量的研究支持这样一种观点，即从医院到急性后护理设施的护理过渡执行不力是经历这种过渡的退伍军人的许多不良结果的基础。然而，很少有人知道退伍军人出院后急性护理的结果，也没有什么因素有助于这些结果。为了确定哪些因素可能影响这些护理过渡的结果，该提案使用了由被提名人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。在本提案中，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（PAC中高强度干预措施的医院计划），信息 转移（PAC访问医院EMR）、用药安全（药物核对和高风险药物监测）、提前护理计划（解决和传达代码状态）和患者监测（PAC医生初始评估的时间）。目的2：确定可修改的过渡性护理过程，有助于解释高性能医院PAC网站的积极偏差。目标3：在医院进行护士指导的过渡性护理干预的试点测试 PAC网站基于目标1和2中确定的ITC框架的关键领域。这项工作是至关重要的退伍军人和VA医疗保健系统在全国范围内，并有老年病和延长护理办公室的支持。三位有成就的调查员将作为独立调查员指导被提名人的项目工作和发展。Michael Ho博士是主要导师，在混合方法，多组分干预和实施科学方面具有专业知识。他是缺血性心脏病QUERI的联合主任，丹佛-西雅图COIN的联合主任，以及健康结果研究方面的广泛出版和资金充足的专家。Cari Levy博士是一位共同导师，具有与提案相关的重要内容专业知识，包括提案中使用的主要数据集的经验，作为老年病学家和以前的疗养院医疗主任，以及作为PAC环境中的资深研究员。Allan Prochazka博士是一名高级调查员，在丹佛西雅图COIN担任导师和职业发展主任，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的专业知识。这将通过与两名内容专家（定性专家杰奎琳·琼斯博士和统计专家安娜·巴伦博士）的指导、课程和研讨会来促进，这些课程和研讨会将利用丹佛-西雅图COIN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人作为独立调查员的发展，致力于改善整个VA系统出院后的护理过渡。