Emergency Care Redesign (ECR)

项目总结 痴呆症患者(PLWD)和他们的护理伙伴更多地去急诊科(ED)就诊 经常比那些未受影响的人，并面临与管理相关的独特和复杂的挑战 阿尔茨海默病和阿尔茨海默病相关痴呆(AD/ADRD)和出现症状。 基于团队的痴呆症护理对PLWD很有效，紧急护理重新设计了干预措施 (UH3AT009844)通过数字警报加强了紧急服务提供者的新的和有意的工作流程 增加了预先护理计划，并争取到了多学科支持。心理社会挑战和 AD/ADRD护理的固有复杂性迫切需要一种方法来简化可行的评估并确保采用 以急救团队为基础的战略。简化方法，以反映更少的时间密集型和更多的 务实的干预，同时关注所需的知识、敏感性和实现最佳护理的结构 对于PLWD和他们的护理伙伴(DADS)来说，需要三个核心组成部分：1)识别问题；2) 确定问题的轻重缓急(包括护理目标)；以及3)建立可行的、心理敏感的 干预措施。虽然这些组件对于减少ED复诊和其他严重的 对于二元组的重要性，如果没有嵌入式结构和信息支持，这样的结果是不可能的 强调和鼓励护理流程与高质量的紧急护理相一致的工作流程。这个 拟议的干预措施，紧急护理重新设计，将提供试验测试的痴呆症护理的核心组成部分 嵌入急救护理提供者(护士、 医生、执业护士、医生助理和社会工作者)、临床决策支持 用于加强的通知、提醒和教学简短视频，以及 电子健康记录，用于急需的评估和数据获取、审计和反馈支持 两周一次的个案审查咨询，以及访问后的社会工作电话，以加强社区转介 所有前往急症室就诊的长期残疾人士。我们将在一个ED内优化这种以痴呆症为信息的重新设计的急性护理 (重新设计急救服务)，然后在14个医疗系统的80个急救中心中的40个实施该计划 在整个美国。我们将测试紧急护理重新设计-知情程序的有效性 为PLWD和护理伙伴提供单一干预或与护士指导相结合的护理 电话护理和/或社区辅助医疗人员领导的集群中的过渡干预-随机的， 关于以下结果的多因素试验(在这40个设施中)：ED在以下情况下30天内复诊 勃起功能障碍出院后6个月内的指标访问、住院和在家健康天数。我们将确定地点， 与实施和变化的保真度相关的提供商、患者和护理合作伙伴级别的特征 在ED痴呆症的影响下--知情护理。这一干预措施承诺减少ED的复诊，同时提供 以证据为基础的真实世界护理，以改善患有严重疾病的PLWD及其护理合作伙伴的生活。

PROJECT SUMMARY Persons living with dementia (PLWD) and their care partners visit the emergency department (ED) more frequently than those who are unaffected, and face unique and complex challenges associated with managing Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD) and presenting symptoms. Team-based dementia care has worked well for PLWD, and an emergency care redesign intervention (UH3AT009844) of new and intentional workflows for emergency providers reinforced by digital alerts has increased advance care plans and enlisted multidisciplinary support. The psychosocial challenges and the inherent complexity of AD/ADRD care beg for a way to simplify a feasible assessment and ensure adoption of an emergency care team-based strategy. Simplifying an approach to reflect a less time-intensive and more pragmatic intervention while attending to needed knowledge, sensitivities, and a structure to achieve best care for PLWD and their care partners (dyads) requires three core components: 1) identifying problems; 2) prioritizing problems (inclusive of goals of care); and 3) establishing feasible, psychosocially sensitive interventions. While these components are essential to reduce ED revisits and other outcomes of critical importance to dyads, such results are unlikely without an embedded structure and an informatic-supported workflow that emphasizes and encourages care processes congruent with high-quality emergency care. The proposed intervention, Emergency Care Redesign, will provide core components of trial-tested dementia care management programs, embedded within an educational structure for emergency care providers (nurses, physicians, nurse practitioners, physician assistants, and social workers), clinical decision supports for PLWD notification, reminders and instructional brief videos for reinforcement, a shared structured worksheet in the electronic health record for critically needed assessments and data acquisition, audit and feedback supporting a biweekly case-review consultation, and a post visit social work phone call to reinforce community referrals for all PLWD who visit the ED. We will optimize, within one ED, this dementia-informed redesigned acute care (Emergency Care Redesign) and then implement this program in 40 out of 80 EDs within 14 health systems throughout the United States. We will test the effectiveness of emergency care redesign-informed procedures for the care of PLWD and care partners either as a single intervention or in combination with nurse-led telephonic care and/or a community paramedic-led transitions intervention in a cluster-randomized, multifactorial trial (in these 40 facilities) on the following outcomes: ED revisits within 30 days following the index visit, hospitalizations, and healthy days at home within 6 months of ED discharge. We will determine site, provider, patient, and care partner-level characteristics associated with fidelity of implementation and variation in impact of ED dementia-informed care. This intervention promises to reduce ED revisits while providing evidence-based, real-world care to improve the lives of PLWD with serious illness and their care partners.