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：经历过社会需求的退伍军人，例如饥饿，无家可归，贫穷， 暴力或隔离 - 急性住院后死亡或再入院的危险比 那些没有的人。在弗吉尼亚州，社会工作者经过培训，可以通过案件评估和满足社会需求 管理，护理协调和社区支持。在最近的工作中，我已经证明了社会工作者 VA初级保健团队减少了计划外的医院和急诊护理。有关退伍军人社会风险的信息 可在VA健康记录中使用，但是社会工作者缺乏将其定位，将其拉起并显示的准备方式。 拥有一个工具来查找，组织和提供相关信息将使社会工作者能够 优先考虑他们为帮助他们最需要达到的退伍军人而努力。 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 急性后健康结果的风险。识别和解决退伍军人社会的新工具 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分期收费 住院和急诊科使用。拟议的项目和培训将帮助我推出 独立资助的研究计划调查如何满足退伍军人的社会需求 改善他们的医疗服务。 创新：我将以新颖的方式利用有关社会风险的VA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 输入阶段，以蜂蜜探索工具的有效性。 具体目的：目标1：确定退伍军人特定社会风险对计划外护理的影响 医院出院。目标2：为社会工作者设计一个案例调查工具，以优先考虑退伍军人 经历过社会风险的医院住院。目标3：试点测试案例调查工具，以评估其可行性， 可接受性和可用性。在进行研究时，我将追求四个培训目标：1） 了解社会工作和护理惯例，2）获得混合方法研究的培训，3） 在以人为本的设计方面发展专业知识，以及4）准备设计和领导务实的试验以评估 干预的有效性。 方法论：在AIM 1中，我将确定VA医院住院后计划外护理的关联（即 住院或急诊科的使用）通过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。我还将检查 社会工作者的随访中，VA的变化有社会风险的退伍军人。在AIM 2中，我会 设计一个案例调查工具，以显示AIM 1中确定的最关键的社会风险因素的信息。 将使用以人为本的设计方法来完善工具的内容，并具有迭代定义 - 预型 - 检验 周期。我将1）通过观察和对利益相关者的半结构化访谈来定义要求， 包括医院主义者，住院社会工作者，门诊社会工作者，公约提供者和老将 - 护理人员二元组； 2）将来自社会工作者的反馈纳入快速迭代原型修订中。目标 3，我的方法是在3 VA医疗中心试点站点实施该工具12个月。我会收集 定量数据（用法数据以及基于比例的问卷）和定性数据（半结构的数据 访谈）评估工具的可行性，可接受性和可用性。 下一步和实施：我将使用本研究的发现和案例调查工具 我们创建的是计划一项研究，以评估案件调查工具在改善退伍军人方面的有效性 结果。