ED-LEAD: Emergency Departments LEading the transformation of Alzheimer's and Dementia care

项目摘要 在痴呆症（PLWD）患者中，急诊（艾德）就诊是一个关键事件， 有机会解决访问之前未满足的需求。我们的多PI（mPI）团队共同 在>50例ED以及多个临终关怀和家庭健康中进行了随机分组、多中心试验 机构，并独特地准备解决以前的缺点，在发展可扩展的模式， 照顾PLWD。通过这项工作，以及我们的合作研究者，我们已经开发和测试了三种 与PLWD及其到艾德就诊的护理伙伴相关的干预措施：1）重新设计急诊护理 （UH 3AT 009844）通过数字警报加强紧急服务提供者的新的和有意的工作流程， 研究中心之间的结构化协作，已经证明可以增加对预先护理计划的识别， 招募多学科的支持; 2）护士主导的电话护理计划（PCARI），增加了先进的 护理规划并将患者与临终关怀中心联系起来;以及3）社区护理人员主导的结构化辅导 干预（R 01 AG 050504）使30天内艾德再访的几率降低了75%。在此基础上 证据，ED领导阿尔茨海默氏症和痴呆症护理转型（艾德- LEAD）的目的是将艾德就诊从危机转变为改善艾滋病患者福祉和护理的机会 伙伴ED-LEAD将被嵌入到14个卫生系统的不同群体中，包括80个ED， 大量的人种和种族多样性，以艾德为随机化单位。行政核心将 监督所有行政里程碑的完成，包括整合两个NIA的专业知识和指导， 资助的网络和外部咨询委员会。实施核心将：1）协调核心职能 2）优化临床决策支持; 3）在三个方面实现干预保真度 干预措施。最后，统计分析核心将提供生物统计和数据管理支持。我们 具体目标是：1）优化同时运行的紧急护理重新设计，护士领导的电话护理， 社区护理人员主导的过渡干预PLWD的可行性，保真度和可用性在两个ED; 2） 研究这三种干预措施单独和联合对患有严重疾病的PLWD的有效性， 一项在80个ED内进行的随机分组多因素试验，涉及：艾德复诊、住院和健康 首次艾德访视后在家的天数;以及3）确定研究中心、提供者、患者和护理合作伙伴级别 不同人群的特征与每项干预措施的实施差异相关。艾德- LEAD将解决国家科学院、工程院和医学院指出的缺点 通过提供高质量的真实世界证据来报告PLWD，这些证据可能会改善生活并减少痛苦 和他们的伴侣。它将解决NIA和国家阿尔茨海默病计划的关键战略目标， “实施和评估新的护理模式，以支持有效的护理过渡”，并提供卫生系统 有必要的证据来扩大对这一弱势群体的干预。

PROJECT SUMMARY In persons living with dementia (PLWD), an Emergency Department (ED) visit is a critical event and an opportunity to address the unmet needs that preceded the visit. Our multiple PI (mPI) team have together conducted cluster-randomized, multi-site trials in >50 EDs as well as multiple hospice and home health agencies, and are uniquely poised to address previous shortcomings in the development of scalable models of care for PLWD. Through this work, and that of our co-investigators, we have developed and tested three interventions relevant to PLWD and their care partners who visit the ED: 1) emergency care redesign (UH3AT009844) of new and intentional workflows for emergency providers reinforced by digital alerts and structured collaboration between sites, already shown to increase identification of advance care plans and enlisted multidisciplinary support; 2) a nurse-led telephonic care program (PCORI) that increased advance care planning and connected patients to hospice; and 3) a community paramedic-led structured coaching intervention (R01AG050504) that reduced the odds of an ED revisit within 30 days by 75%. Building on this evidence, the overarching goal of EDs LEading the Transformation of Alzheimer’s and Dementia Care (ED- LEAD) is to turn an ED visit from a crisis into an opportunity to improve the well-being of PLWD and their care partners. ED-LEAD will be embedded in a diverse group of 14 health systems, including 80 EDs with substantial racial and ethnic diversity, with the ED as the unit of randomization. An Administrative Core will oversee completion of all administrative milestones including integrating expertise and guidance from two NIA- funded networks and an External Advisory Board. An Implementation Core will: 1) harmonize core functions and processes; 2) optimize clinical decision support; and 3) and enable intervention fidelity across the three interventions. Finally, a Statistical Analysis Core will provide biostatistical and data management support. Our specific aims are to: 1) optimize a concurrently run emergency care redesign, nurse-led telephonic care, and community paramedic-led transitions intervention in PLWD for feasibility, fidelity and usability in two EDs; 2) study the effectiveness of these three interventions, alone and in combination, for PLWD with serious illness in a cluster-randomized multifactorial trial embedded within 80 EDs on: ED revisits, hospitalizations, and healthy days at home following the index ED visit; and 3) determine site, provider, patient, and care partner-level characteristics within a diverse population associated with variation in implementation of each intervention. ED- LEAD will address shortcomings noted in the National Academies of Sciences, Engineering, and Medicine report on PLWD by providing high-quality, real-world evidence that may improve the lives and reduce suffering of PLWD and their care partners. It will address key strategic goals of NIA and the National Alzheimer’s Plan to “implement and evaluate new care models to support effective care transitions”, and provide health systems with the necessary evidence to scale interventions for this vulnerable population.