Improving care transitions for Veterans withsocial needs

改善有社会需求的退伍军人的护理过渡

• 批准号: 10638723
• 负责人: Portia Yvonne Cornell
• 金额: --
• 依托单位: PROVIDENCE VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-01 至 2028-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10638723
• 关键词: Accident and Emergency department; Acute; Address; Assessment tool; Caregivers; Caring; Case Management; Characteristics; Code; Communities; Community Healthcare; Data; Data Analyses; Diagnosis; Effectiveness; Effectiveness of Interventions; Emergency Care; Evaluation; Face; Feedback; Funding; Goals; Health; Home; Homelessness; Hospitalists; Hospitalization; Hospitals; Hunger; Inpatients; Intervention; Interview; Knowledge; Lead; Length of Stay; Medical; Medical center; Methodology; Methods; Neighborhoods; Outcome; Outpatients; Patients; Phase; Policies; Poverty; Program Evaluation; Provider; Qualitative Methods; Questionnaires; Research; Research Methodology; Research Personnel; Risk; Risk Factors; Site; Social Conditions; Social Work; Social Workers; Social isolation; Structure; Testing; Text; Training; Variant; Veterans; Violence; Work; acute care; care coordination; career; case finding; clinical practice; design; effectiveness evaluation; experience; follow-up; hazard; health record; high risk; hospital care; hospital readmission; housing instability; human centered design; improved; information display; insight; mortality; novel; outreach; pilot test; pragmatic trial; primary care team; programs; prototype; response; screening; skills; social; tool; usability

PROJECT SUMMARY BACKGROUND: Veterans who have experienced social needs—such as hunger, homelessness, poverty, violence, or isolation—face greater dangers of mortality or readmission after an acute hospitalization than those who have not. In the VA, social workers are trained to assess and address social needs through case management, care coordination, and community support. In recent work, I have shown that social workers in VA primary-care teams reduce unplanned hospital and emergency care. Information on Veterans’ social risks is available in the VA health record, but social workers lack a ready way to locate it, pull it up, and display it. Having a tool to find, organize, and present the relevant information would allow the social workers to prioritize their efforts toward helping the Veterans whom they most need to reach. SIGNIFICANCE/IMPACT: This research will provide new insight into how specific social risks can exacerbate the risk of adverse post-acute health outcomes. A new tool for identifying and addressing Veterans’ social risks will help social workers focus their efforts and may allow them to reduce unplanned post-discharge inpatient and emergency department use. The proposed project and training will help me to launch an independently funded research program investigating how addressing the social needs of Veterans can improve their medical care. INNOVATION: I will leverage VA data on social risks in a novel way that will enable social workers to deploy their efforts more effectively. The human-centered-design approach iterates between design and stakeholder- input phases in order to hone the effectiveness of a case-finding tool. SPECIFIC AIMS: Aim 1: Determine the effects of Veterans’ specific social risks on unplanned care after hospital discharge. Aim 2: Design a case-finding tool for social workers to prioritize Veterans with a recent hospital stay who have experienced social risks. Aim 3: Pilot-test the case-finding tool to assess its feasibility, acceptability, and usability. While carrying out the research, I will pursue four training goals: 1) to gain knowledge of social work and care-transition practices, 2) to obtain training in mixed-methods research, 3) to develop expertise in human-centered design, and 4) to prepare to design and lead a pragmatic trial to evaluate the effectiveness of the intervention. METHODOLOGY: In Aim 1, I will determine the association of unplanned care after a VA hospital stay (i.e., inpatient or emergency department use) with the social risks identified in a Veteran’s health record through screenings, diagnosis codes, social work assessments, and neighborhood characteristics. I will also examine variation across the VA in follow-up from social workers among Veterans with social risk. In Aim 2, I will design a case-finding tool to display information on the most critical social risk factors identified in Aim 1. I will refine the tool’s content using a human-centered design methodology with iterative define–prototype–test cycles. I will 1) define requirements through observation and semi-structured interviews with stakeholders, including hospitalists, inpatient social workers, outpatient social workers, PACT providers, and Veteran– caregiver dyads; and 2) incorporate feedback from social workers in rapid iterative prototype revision. In Aim 3, my approach will be to implement the tool at 3 VA medical center pilot sites for 12 months. I will collect quantitative data (usage data together with scale-based questionnaires) and qualitative data (semi-structured interviews) to assess the tool's feasibility, acceptability, and usability. NEXT STEPS & IMPLEMENTATION: I will use the findings from this research and the case-finding tool that we have created to plan a study to evaluate the effectiveness of the case-finding tool in improving Veterans’ outcomes.

项目摘要 背景：经历过饥饿、无家可归、贫困等社会需求的退伍军人， 暴力，或孤立，面临更大的危险，死亡或重新入院后，急性住院比 那些没有的人。在退伍军人事务部，社会工作者接受培训，通过个案评估和解决社会需求。 管理、护理协调和社区支持。在最近的工作中，我已经表明，社会工作者在 VA初级保健团队减少了计划外的医院和急诊护理。关于退伍军人社会风险的信息 在退伍军人管理局的健康记录中可以找到，但社会工作者缺乏一种现成的方法来定位它，把它拉出来，并显示它。 拥有一个工具来查找、组织和呈现相关信息，将使社会工作者能够 优先考虑他们的努力，帮助他们最需要接触的退伍军人。 意义/影响：这项研究将为特定的社会风险如何加剧提供新的见解 急性期后不良健康后果的风险。识别和解决退伍军人社会问题的新工具 风险将有助于社会工作者集中精力，并可能使他们减少计划外的出院后 住院和急诊使用。拟议的项目和培训将帮助我发起一个 独立资助的研究计划，调查如何解决退伍军人的社会需求， 改善他们的医疗服务。 创新：我将以一种新颖的方式利用VA关于社会风险的数据，使社会工作者能够部署 他们的努力更有效。以人为本的设计方法在设计和利益相关者之间迭代- 投入阶段，以磨练案件调查工具的有效性。 具体目标：目标1：确定退伍军人的具体社会风险对计划外护理的影响， 出院目标2：为社会工作者设计一个案例发现工具，以优先考虑最近有一个 有社会风险的住院病人。目标3：对病例调查工具进行试点测试，以评估其可行性， 可接受性和可用性。在研究过程中，我将追求四个培训目标：1）获得 社会工作和护理过渡实践的知识，2）获得混合方法研究的培训，3） 发展以人为本的设计专业知识，4）准备设计并领导一个务实的试验，以评估 干预的有效性。 方法学：在目标1中，我将确定VA住院后计划外护理的相关性（即， 住院或急诊科使用）与退伍军人健康记录中确定的社会风险， 筛查、诊断代码、社会工作评估和邻里特征。我也会检查 在VA的变化，从社会工作者之间的退伍军人社会风险的后续行动。在目标2中，我将 设计一个病例调查工具，以显示目标1中确定的最关键社会风险因素的信息。我 我将使用以人为中心的设计方法，通过迭代的定义-原型-测试来完善工具的内容 自行车.我将1）通过观察和与利益相关者的半结构化访谈来定义需求， 包括住院医生、住院社会工作者、门诊社会工作者、PACT提供者和退伍军人， 照顾者二人组; 2）在快速迭代原型修订中纳入社会工作者的反馈。在aim中 3，我的方法是在3个VA医疗中心试点实施该工具12个月。我会收集 定量数据（使用数据和基于量表的问卷）和定性数据（半结构化 面试），以评估该工具的可行性，可接受性和可用性。 下一步和实施：我将使用这项研究的结果和案例发现工具， 我们已经创建了一项研究计划，以评估病例发现工具在改善退伍军人 结果。