Integration of Geriatric Care into Dialysis Clinics

项目摘要/摘要 老年透析患者通常有老年综合征，这有助于提高医疗保健利用率 以及糟糕的生活质量。目前，老年综合征的识别和管理不包括在 透析护理。在透析患者的常规护理中增加老年综合征管理可能会导致 显著提高生活质量和医疗保健利用率。整合老年医学评价的障碍 以及对透析诊所的管理(例如，时间、人员、成本)可以通过开发最小化 创新的老年护理模式，利用现有的透析单位、跨专业团队和工作流程。 我们将试行一种新的透析护理模式，其中包括一个集中的老年团队，该团队使用来自 老年透析患者的老年筛查(GOLD)为老年患者制定个性化建议 根据患者的优先顺序进行证候管理。黄金是一个自我管理的筛查电池 用于筛查一系列老年综合征(认知障碍、抑郁症、跌倒、 行动不便、社会支助需求和营养不良)。多学科透析组将整合 在集中老年医疗团队的支持下，将建议纳入他们的护理计划。最终，这位老人 护理模式可以无缝集成到透析诊所结构中。此应用程序的目标是 利用关键利益相关者的输入优化护理模式，并进行试点随机对照试验(RCT)，以 获取关键证据，以便为最终的随机对照试验提供信息。我们提出了三个目标：1)迭代精炼黄金以实现 与老年医生评估的可接受一致性，2)反复改进老年护理模式，以确保 主要利益相关者的可接受性和可行性，以及3)开展一项试点随机对照试验(n=100)以评估老年护理 模型对老年综合征管理的影响，并为更大规模随机对照试验的设计提供信息。对于目标1，我们将有 参与者完成金牌并接受老年评估。我们将评估每一枚黄金的协议 工具与其相应的老年评估，如果没有达到目标一致，我们将迭代 对黄金仪器进行改装和重新测试。对于目标2，我们将使用基于经验的联合 通过利益相关者咨询委员会和研究参与者的多个阶段的反馈进行设计。在患者之后 完成护理模式后，这些患者和他们的透析临床医生将评估 通过调查和访谈了解护理模式。护理模型将反复改进，直到特定指标 取得了成功。对于目标3，患者将随机接受老年护理模式或常规护理； 3个月后，比较患者报告和图表摘要对老年综合征管理的影响。 我们还将评估患者报告的结果、身体功能和医疗保健利用情况，最长可达12 需要几个月的时间来评估其是否足以作为结果纳入随后的最终随机对照研究。完成后， 我们将拥有一项大型随机对照试验的关键初步数据，以测试一种新的透析老年护理模式。总体而言，这 应用将解决老年透析人群中的老年综合征这一重大问题。

PROJECT SUMMARY/ABSTRACT Older dialysis patients commonly have geriatric syndromes which contribute to increased healthcare utilization and poor quality of life. Currently, identification and management of geriatric syndromes are not included in dialysis care. Adding geriatric syndrome management into routine care for dialysis patients could result in significant improvements in quality of life and healthcare utilization. Barriers to integration of geriatric evaluation and management into dialysis clinics (e.g., time, personnel, costs) can be minimized through the development of innovative geriatric care models that leverage the existing dialysis unit interprofessional team and workflow. We will pilot a new dialysis care model that includes a centralized geriatric team that uses information from the Geriatric screen for OLder Dialysis patients (GOLD) to develop individualized recommendations for geriatric syndrome management based on the patient’s priorities. The GOLD is a self-administered screening battery of validated instruments to screen for a range of geriatric syndromes (cognitive impairment, depression, falls, mobility disability, social support needs, and malnutrition). The multidisciplinary dialysis team will integrate the recommendations into their care plans with support from the centralized geriatric team. Ultimately, this geriatric care model could be seamlessly integrated into dialysis clinic structure. The objective of this application is to optimize the care model with key stakeholder input and conduct a pilot randomized controlled trial (RCT) to obtain evidence critical to inform a definitive RCT. We propose three aims: 1) iteratively refine GOLD to achieve acceptable agreement with a geriatrician evaluation, 2) iteratively refine the geriatric care model to ensure acceptability and feasibility to key stakeholders, and 3) conduct a pilot RCT (n=100) to evaluate the geriatric care model’s impact on geriatric syndrome management and inform design of a larger RCT. For Aim 1, we will have participants complete the GOLD and undergo geriatric evaluation. We will assess agreement of each GOLD instrument with its corresponding geriatric evaluation, and if target agreement is not achieved, we will iteratively modify and re-test the GOLD instrument. For Aim 2, we will refine the care model using experience-based co- design with a stakeholder advisory board and multiple phases of feedback from study participants. After patients complete the care model, these patients and their dialysis clinicians will assess acceptability and feasibility of the care model through surveys and interviews. The care model will be iteratively refined until specific metrics of success are achieved. For Aim 3, patients will be randomized to receive the geriatric care model or usual care; geriatric syndrome management measured by patient report and chart abstraction will be compared at 3 months. We will also assess patient reported outcomes, physical function, and health care utilization at intervals up to 12 months to assess their adequacy for inclusion as outcomes in a subsequent definitive RCT. Upon completion, we will have key preliminary data for a large RCT testing a novel dialysis geriatric care model. Overall, this application will address the significant problem of geriatric syndromes in the older dialysis population.