INtegrating Care After Exacerbation of COPD (InCasE)

描述（由申请人提供）： 慢性阻塞性肺疾病（COPD）加重在住院的退伍军人中很常见，导致健康相关生活质量下降，并且是医疗保健支出的重要驱动因素。COPD加重与慢性心力衰竭相媲美，是VA医疗服务出院的第二大原因。急性加重后的再入院率很高，多达一半的患者需要在6个月内再入院。与针对慢性心力衰竭再入院的举措相反，类似的努力并不适用于COPD。我们的研究表明，尽管最近的一些研究证明了成功的干预措施可以降低未来加重的风险，但VA可能会错过对COPD急性加重进行加强护理的机会。需要采取干预措施改善COPD护理，不仅要治疗COPD患者及其伴随的合并症，还要重新设计护理提供系统，例如在患者对齐护理团队（PACT）内治疗患者的专科。目前的制度反映了一种基于收费服务模式的程序，即专家等待病人转诊，而不对病人的健康承担责任。专家们在地理上也集中在主要的医疗中心，这些中心在文化和物理上与病人的医疗之家分开。确定如何使用以PACT-Veteran为中心的方法部署现有专科对于改善护理的可及性、及时性和质量非常重要。我们建议测试一种与VA操作目标一致的新型干预措施，并寻求提高COPD患者的护理质量，改善他们的生活质量，并降低他们的再次入院率和死亡率。我们的具体目标包括：在COPD急性加重出院的患者中：1。评价旨在改善COPD患者生活质量、降低再入院率和死亡率的多方面干预。该干预措施利用VA的综合医疗保健和信息系统，通过使用多学科团队纵向 支持出院和初级保健团队护理最近出院的COPD急性加重患者。该干预措施还旨在提供有关VA如何扩大专家责任的证据，以便在高风险时期更好地支持患者。我们假设干预将：1a.提高患者的生活质量; 1b.减少医院 COPD急性加重入院后的入院率和死亡率。次要目标1。评估干预是否改善了COPD特定的护理过程; 2.评估干预措施是否提高了退伍军人对护理的满意度; 3.评估初级保健临床医生对干预的可接受性和满意度。

DESCRIPTION (provided by applicant): Chronic obstructive pulmonary disease (COPD) exacerbations are common among Veterans admitted to hospital, lead to decrements in health-related quality of life, and are important drivers of health care expenditures. COPD exacerbation rivals chronic heart failure as the second leading cause of medical service discharges within VA. The readmission rate after exacerbations is high with as many as half of patients requiring readmission within 6 months. In contrast to initiatives targeting readmission for chronic heart failure, similar efforts do not exit for COPD. Our research suggests that VA potentially misses opportunities to augment care in response to COPD exacerbations despite a number of recent studies that demonstrate successful interventions to decrease future exacerbation risk. An intervention to improve COPD care is needed, not only to treat patients for COPD and their accompanying comorbidities, but also to redesign the care delivery system, such as specialties treating patients within Patient Aligned Care Teams (PACT). The current system reflects a process that is based on a fee-for-service model where specialists wait for patient referrals and do not assume responsibility for the health of a population of patients. Specialists are also geographically concentrated at major medical centers that are culturally and physically separated from the patient's medical home. Determining how to deploy existing specialties using a PACT-Veteran-centric approach is important to improve access, timeliness, and quality of care. We propose to test a novel intervention that is aligned with VA operational goals, and seeks to improve the quality of care among patients with COPD, improve their quality of life, and reduce their hospital re-admissions and mortality. Our specific aims include: Among patients who were discharged from hospital with an exacerbation of COPD: 1. Evaluate a multifaceted intervention that seeks to improve quality-of-life and decrease rate of hospital readmission and mortality among patients with COPD. The intervention leverages the VA's integrated healthcare and informatics system to facilitate the transition from hospital to home by using a multidisciplinary team to longitudinally support discharge and primary care teams in the care of patients recently discharged with a COPD exacerbation. The intervention is also designed to provide evidence about how VA may expand the responsibilities of specialists to better support patients during high risk periods. We hypothesize that the intervention will: 1a. Improve patient quality of life; 1b. Decrease hospital admission and mortality after hospital admission for COPD exacerbation. Secondary Aims 1. Assess whether the intervention improves COPD specific processes of care; 2. Assess whether the intervention improves Veterans' satisfaction with care; 3. Assess acceptability and satisfaction of the intervention to primary care clinicians.