Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination

年龄≥65岁且有心血管事件发生或复发风险的Medicare受益人， 影响多个器官系统的生理问题，这可能导致接受门诊护理， 不同专业的供应商。虽然从多个提供者那里接受护理在临床上可能是合适的， 医疗服务提供者之间的沟通差距很常见，这可能对患者造成危害。责任医疗 组织（ACO）经常雇用“护理协调员”（通常具有护理或社会工作背景） 他们促进了参与病人护理的个人之间的沟通。然而，ACO通常具有 成千上万的病人，只有少数护理协调员。如何最佳地分配护理协调员不是 知道的通常的做法是在出院后为患者指派护理协调员。而 这是合理的，它假设所有出院患者都需要护理协调（他们可能不需要）， 其缺点是要等到住院治疗之后。与此同时，患者往往意识到， 当他们的护理没有得到很好的协调，但没有现有的干预措施利用这些意见。 一项初步随机对照试验将确定两种方法分配的比较有效性。 护理协调员的病人：（a）一种新的以病人为中心的方法，分配护理协调员， 感知护理协调问题与（B）常规护理（即，出院后）。研究 目的是：（1）确定这两种方法对综合结果的比较有效性 随访12个月以上的急诊科就诊或住院率，以及（2）措施实施情况 结果（可接受性、适当性、保真度和有效性），以告知未来的多中心随机 对照试验试点试验将包括≥65岁的Medicare受益人（总共N = 400人，或每次试验200人 组）归因于ACO，患有心血管疾病或≥1种心血管风险因素， 在过去一年中，流动护理高度分散（作为沟通差距的风险因素）。 丽莎克恩，医学博士，公共卫生硕士（PI）是医学和卫生服务研究员的副教授， 迄今为止，世卫组织一直致力于对其他机构的 她自己的干预和观察研究。K18 AHRQ辅导职业提升奖 在以患者为中心的结局研究中建立的研究者将允许克恩博士过渡到一个 职业生涯的设计，实施和评估自己的干预措施，通过学习务实的临床 试验（培训目标1）和实施科学（培训目标2）。克恩博士的指导团队具有以下方面的专业知识： 实用的临床试验，实施科学，护理协调，心血管疾病和生物统计学。 拟议的工作有可能改善门诊护理和改善病人的结果。

Medicare beneficiaries ≥65 years old who are at risk for incident or recurrent cardiovascular events often have physiologic problems affecting multiple organ systems, which can lead to receiving ambulatory care from providers in different specialties. Although receiving care from multiple providers may be clinically appropriate, gaps in communication among providers are common, which can be hazardous for patients. Accountable care organizations (ACOs) often employ “care coordinators” (typically with backgrounds in nursing or social work) who facilitate communication among the individuals involved in a patient’s care. However, ACOs typically have thousands of patients and only a few care coordinators. How to optimally allocate care coordinators is not known. The usual approach has been to assign care coordinators to patients after a hospital discharge. While this is reasonable, it assumes that all discharged patients need care coordination (which they may not), and it has the disadvantage of waiting until after a hospitalization has occurred. Meanwhile, patients are often aware of when their care is not being well coordinated, yet no existing intervention leverages these observations. A pilot randomized controlled trial will determine the comparative effectiveness of two approaches for assigning care coordinators to patients: (a) a novel patient-centered approach that assigns care coordinators to those who perceive a problem with care coordination vs. (b) usual care (i.e., after hospital discharge). The Research Aims are to: (1) determine the comparative effectiveness of these two approaches on the combined outcome of emergency department visit or hospitalization over 12 months of follow-up, and (2) measure implementation outcomes (acceptability, appropriateness, fidelity, and efficiency) to inform a future multi-center randomized controlled trial. The pilot trial will include Medicare beneficiaries ≥65 years old (N = 400 total, or 200 per trial arm) who are attributed to an ACO, have cardiovascular disease or ≥1 cardiovascular risk factors, and had highly fragmented ambulatory care in the past year (as a risk factor for gaps in communication). Lisa Kern, MD, MPH (PI) is an Associate Professor of Medicine and health services researcher who is expert in ambulatory care quality and who has spent her career to date conducting independent evaluations of others’ interventions and observational studies of her own. This K18 AHRQ Mentored Career Enhancement Award for Established Investigators in Patient-Centered Outcomes Research would allow Dr. Kern to transition to a career of designing, implementing, and evaluating her own interventions, through learning pragmatic clinical trials (Training Aim 1) and implementation science (Training Aim 2). Dr. Kern’s mentoring team has expertise in pragmatic clinical trials, implementation science, care coordination, cardiovascular disease, and biostatistics. The proposed work has the potential to improve ambulatory care and improve patient outcomes.