Putting the puzzle together: Leveraging dual use to improve care for Veterans living with dementia

解决难题：利用双重用途改善对患有痴呆症的退伍军人的护理

• 批准号: 10414417
• 负责人: Sarah Krein
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-04-01 至 2026-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10414417
• 关键词: Aging; Ambulatory Care; Attention; Caregivers; Caring; Case Manager; Collaborations; Communities; Complex; Continuity of Patient Care; Data; Dementia; Dementia caregivers; Drug Prescriptions; Elderly; Enrollment; Family; Goals; Guidelines; Health; Health Services Accessibility; Home; Hospital Costs; Individual; Intervention Trial; Interview; Knowledge; Learning; Left; Light; Link; Long-Term Care; Medical center; Medicare; Medicare claim; Methodology; Methods; Opioid; Outcome; Outpatients; Patient-Focused Outcomes; Patients; Performance; Pharmaceutical Preparations; Policies; Primary Health Care; Provider; Publishing; Quality of Care; Recording of previous events; Research Personnel; Research Priority; Services; Source; Structure; System; Systems Development; Time; Variant; Veterans; Visit; Voice; Work; care coordination; care delivery; care outcomes; care seeking; care systems; caregiving; dementia care; design; expectation; experience; high risk; improved; indexing; innovation; insight; interest; member; military veteran; opioid overdose; person centered; preference; primary outcome; programs; psychosocial; research and development; skills; tool

Background: The number of Veterans living with dementia (VLWD) will increase by 2030 to nearly 340,000; these VLWD and their caregivers often have complex psychosocial and health needs. Coordinating this care is complicated by the fact that most VLWD are Medicare-eligible and therefore use care both through the VA and Medicare. Unfortunately, dual use is often associated with duplication of services and potentially inappropriate care. In light of these complexities, VHA Directive 1140.12 from October 2019 mandated that VA facilities establish a Dementia System of Care to provide person-centered services for these VLWD. Because the design of dementia care services is left to individual VA facilities, national variation affords a unique opportunity to learn from particularly successful facilities. Significance: The proposed study will provide important new knowledge to advance the HSR&D priorities of long-term care/aging, access to care, and primary care practice. This knowledge will be achieved by linking patient-level VA data, Medicare claims, and the GECDAC Residential History File, enacting the VA Office of Research and Development’s Research Priority of putting VA data to work for Veterans. Innovation and Impact: This will be the first: (1) comprehensive analysis of non-VA care used by VLWD, including both Medicare- and VA-reimbursed community care; (2) analysis of dual use at the VA facility level, which is critical data for operational purposes; and (3) analysis of dementia care since the VHA Dementia System of Care directive. Finally, we will include the voice of VLWD and caregivers in both facility interviews and as Stakeholder Panel members. Specific Aims: (1) Characterize the associations of dual use and continuity of care with the Veteran-centered outcome of home time and how home time varies across VA facilities. (2) Assess facility-level strategies that promote home time and the acceptability of these strategies to Veterans and caregivers. (3) Develop a toolkit of dementia care strategies that facilities can use to enhance VLWD care delivery. Methodology: In this explanatory sequential mixed methods study, we will first identify community-dwelling VLWD and link their VA data and Medicare claims with the GECDAC Residential History File. Then, we will examine the association of dual use of outpatient and prescription medications with home time, and whether this is moderated by continuity of care. We will collapse these findings to examine dual use, continuity of care, and home time at the facility level. With input from a Stakeholder & Expert Panel, we will identify four high- and four low-performing VA facilities and conduct semi-structured interviews focused on local dementia care strategies with VA providers, VLWD-caregiver dyads, and a non-VA community care coordinator (n=9 interviews per facility). Finally, we will integrate our Aims 1 and 2 findings and, with Stakeholder & Expert Panel input, develop a dementia care toolkit consisting of strategies and tools that VA facilities can use to help implement their local Dementia System of Care. Next Steps/Implementation: The 2019 VHA Directive directing VA facilities to establish a local Dementia System of Care was not optional, but some facilities may have launched their systems more successfully than others. The toolkit developed during Aim 3 will provide additional guidance for challenging work facilities are already doing to improve the quality of care provided to VLWD.

背景：到2030年，退伍军人痴呆症(VLWD)人数将增加到 近34万人；这些极低出生体重病患者和他们的照顾者通常有复杂的心理和健康状况 需要。协调这种护理是复杂的，因为大多数VLWD都符合联邦医疗保险的条件 因此，通过退伍军人管理局和联邦医疗保险使用医疗保健。不幸的是，双重用途通常是 与服务重复和潜在的不适当护理有关。鉴于这些， 复杂性，2019年10月的VHA指令1140.12要求退伍军人管理局的设施建立一个 痴呆症护理系统为这些VLWD患者提供以人为中心的服务。因为 痴呆症护理服务的设计留给各个退伍军人管理局，国家差异提供了 向特别成功的设施学习的独特机会。 意义：拟议的研究将提供重要的新知识来推动 长期护理/老龄化、获得护理的机会和初级保健实践的HSR&D优先事项。这 知识将通过将患者级别的退伍军人数据、联邦医疗保险索赔和GECDAC联系起来实现 住宅史档案，制定退伍军人事务部研发部 优先为退伍军人提供退伍军人数据。 创新和影响：这将是第一次：(1)对使用的非退伍军人护理进行全面分析 VLWD，包括医疗保险和退伍军人管理局报销的社区护理；(2)DUAL分析 在退伍军人管理局设施一级使用，这是业务目的的关键数据；以及(3)分析 自《VHA痴呆症护理系统指令》以来的痴呆症护理。最后，我们将包括 在设施访谈和利益相关者小组成员中发出VLWD和照顾者的声音。 具体目标：(1)说明双重用途和连续性护理与 以退伍军人为中心的家庭时间结果以及不同退伍军人设施的家庭时间差异。(2) 评估促进家庭时间的设施级别的策略以及这些策略的可接受性 献给退伍军人和护理员。(3)开发痴呆症护理策略工具包，设施可以 用于加强极低出生体重病护理的提供。 方法：在这项解释性的顺序混合方法研究中，我们将首先确定 社区居住的VLWD并将他们的退伍军人数据和医疗保险索赔与GeCDAC联系起来 住宅历史档案。然后，我们将考察门诊和门诊两用之间的联系 在家中服用处方药，以及这种情况是否受到持续护理的影响。 我们将分析这些发现，以检查双重用途、护理的连续性和家庭时间 设施级别。根据利益相关者和专家小组的意见，我们将确定四个高度-和四个 表现不佳的退伍军人管理局，并进行侧重于局部痴呆症的半结构化访谈 与退伍军人管理局提供者、VLWD照顾者二人组和非退伍军人社区护理机构的护理战略 协调员(每个机构n=9次面谈)。最后，我们将整合我们的目标1和目标2的调查结果， 利用利益相关者和专家小组的意见，开发包含策略的痴呆症护理工具包 和工具，退伍军人管理局可以用来帮助实施他们当地的痴呆症护理系统。 下一步/实施：2019年VHA指令指示退伍军人管理局设施建立本地 痴呆症护理系统不是可选的，但一些设施可能已经推出了他们的 系统比其他系统更成功。在AIM 3期间开发的工具包将提供 对具有挑战性的工作设施的额外指导已经在做，以提高质量 为VLWD提供的护理。