Identifying and Delivering Point-of-care Information to Improve Care Coordination

描述（由申请人提供）： 多学科护理团队，如退伍军人管理局（VA）的患者对齐护理团队（PACTs），已被提出作为改善护理协调的多种策略之一。为了使这一战略取得成功，PACT成员必须擅长协调，即，共同致力于相互依存的任务，以提供单一提供者无法有效完成的循证护理。然而，监测团队协调的能力仍处于起步阶段;目前的护理协调措施主要集中在利用率结果，如住院或急诊室利用率。一位PI先前的研究确定了及时，个性化和可定制的反馈和跟踪工具，作为成功的转诊团队协调和提高护理质量的重要促进因素。此外，在该应用的规划会议上，我们的VISN 12合作伙伴确定了需要辅助工具来帮助更好地协调患者护理，并指出目前的PACT指南针协调措施在遇到2-3个月后到达。因此，护理点协调辅助工具是患者跟踪、反馈和随访的关键需求。 我们的目标是确定PACT成员的护理点信息需求，以成功协调护理，并确定在护理点提供信息的最佳机制。使用PACT设置中的护理协调作为测试案例，用于三种高风险患者护理场景：患有不受控制的糖尿病的患者，具有延迟癌症诊断风险的患者，以及在最近出院后具有次优药物剂量的CHF患者，我们将实现以下目标：1.制定PACT有效协调的可衡量标准，根据对整体护理质量的贡献进行优先排序和加权。 2.使用目标1中制定的可衡量标准，确定护理点所需的具体信息，以改善协调，并开发护理点辅助工具，以提供所需信息。 3.评估采用上述协调标准和床旁辅助工具对PACT临床医生协调行为的影响。 项目方法本次实施规划预审采用混合方法设计;我们将调整生产力衡量和提高系统，（ProMES，一种用于制定业绩计量和评估生产力的结构化方法），以制定有效协调的计量（目标1），确定基于PACT实践的协调信息需求，并为改善协调开发护理点辅助工具（目标2），并评估其在采用/实施前和实施后期间（目标3）在初级保健诊所协调的有效性。研究将包括3个组：（1）并行对照组（2个VISN 16研究中心），仅被动监测;（2）测量和反馈臂（2个VISN 12站点），将参与制定协调措施，并定期收到关于其协调业绩的反馈;和（3）一个完整的干预组（2个VISN 12个站点），除了测量和反馈组中包含的所有内容外，还将设计和使用旨在改善协调的即时护理辅助工具。我们将在基线结束后监测协调长达一年（即，从完成护理协调措施制定到首次部署护理点艾滋病之间的时期）。将使用描述性统计和纵向分析（如多水平模型）评估各研究中心之间以及床旁辅助工具部署前后的协调差异。

DESCRIPTION (provided by applicant): Multidisciplinary care teams, such as the Veterans Administration's (VA) Patient Aligned Care Teams (PACTs), have been proposed as one of multiple strategies to improve care coordination. For such a strategy to succeed, PACT members must excel at the act of coordinating, i.e., working collectively on interdependent tasks to deliver evidence-based care that could not be accomplished as effectively by a single provider. However, the ability to monitor team coordination is still in its infancy; current measures of care coordination focus primarily on utilization outcomes such as hospitalization or Emergency Department utilization. Previous research by one of the PIs identified timely, individualized, and customizable feedback and tracking tools as essential facilitators of successful referral team coordination and improved quality of care. Additionally, in a planning meeting for this application our VISN 12 partners identified a need for aids to help better coordinate patient care, noting that current PACT Compass coordination measures arrive 2-3 months after an encounter. Thus, point-of-care coordination aids are a critical need for patient tracking, feedback, and follow-up. PROJECT OBJECTIVES Our objective is to determine the point-of-care information needs of PACT members to successfully coordinate care and to identify the optimal mechanisms of delivering that information at the point of care. Using as test cases care coordination in PACT settings for three high-risk patient care scenarios: patients with uncontrolled diabetes mellitus, patients at risk for delayed cancer diagnosis, and CHF patients with sub-optimal medication dosage after a recent hospital discharge, we will accomplish the following objectives: 1. Develop measurable criteria for effective coordination in PACTs, prioritized and weighted by contribution to overall quality of care. 2. Using the measurable criteria developed in Aim 1, determine the specific information needed at the point of care to improve coordination and develop point-of-care aids for delivering the needed information. 3. Assess the effect of adopting the aforementioned coordination criteria and point-of-care aids on PACT clinicians' coordination behaviors. PROJECT METHODS This implementation planning pre-trial employs a mixed methods design; we will adapt the Productivity Measurement and Enhancement System (ProMES, a structured methodology for developing performance measures and assessing productivity) to develop measures of effective coordination (Aim 1), identify PACT practice-based coordination information needs and develop point-of-care aids for improving coordination (Aim 2), and assess the effectiveness of their coordination in pre- and post-adoption/implementation periods (Aim 3) in primary care clinics. The study will comprise 3 arms: (1) a concurrent control arm (2 VISN 16 sites), which will only be monitored passively; (2) a measurement and feedback arm (2 VISN 12 sites), which will be involved in designing the coordination measures and receive periodic feedback on their coordination performance; and (3) a full intervention arm (2 VISN 12 sites) which, in addition to everything included in the measurement and feedback arm, will design and use point-of-care aids aimed at improving coordination. We will monitor coordination for up to one year after end of baseline (i.e., the period between the completion of care coordination measure development and the first deployment of point-of-care aids). Differences in coordination both across sites and pre- vs. post- deployment of point-of-care aids will be assessed using descriptive statistics and longitudinal analyses such as multilevel modeling.