ToolBox Detect: Low Cost Detection of Cognitive Decline in Primary Care Settings

项目总结 我们的目标是广泛实施和评估以用户为中心的、可扩展的电子健康记录 (EHR)关联的策略，用于在不同的初级保健环境中常规检测认知下降。 认知障碍在65岁及以上的成年人中最为普遍，但只有不到一半的病例被发现和/或 在初级保健环境中确诊。现在越来越多的人接受，及早发现对 优化护理计划、持续的独立性、慢性病的管理和适当的护理人员 参与其中。2011年，Medicare启动了一项有覆盖的年度健康访问(AWV)，其中包括 评估以发现损害、阿尔茨海默病和相关痴呆(ADRD)。虽然这已经呈现了 发现病例的新机会，AWV的实施情况多种多样，包括认知功能如何 评估过了。临床医生可能会依赖于更基本的、基于纸质的、由面试者管理的测试，这些测试可能会更少 临床工作流程的精确性和更繁琐--影响早期检测策略的保真度。此外， 许多做法缺乏明确的转介协议，当确定损害时，缺乏针对家庭的程序 参与并建立护理目标。迫切需要实用、可持续、可扩展的战略来帮助 站在医疗保健第一线的初级保健提供者通常会将认知功能作为AWV的一部分进行评估 (或每当怀疑认知障碍时)，确定问题并制定转诊和护理方案 管理层。对于资源受限的临床环境尤其如此，例如联邦合格医疗机构 中心(FQHC)照顾更脆弱的患者群体。 西北大学开发并继续创新美国国立卫生研究院神经病学和神经病学评估工具箱 行为功能®。自2017年以来，我们的团队与初级保健实践密切合作，制定了一份简要的、 来自美国国立卫生研究院工具箱的技术支持的、自我管理的、与EHR相关的认知评估。我们也 为它的使用以及我们的测试结果如何通知患者设计了一个详细的方案，称为ToolboxDetect 关心。我们提出了一个大规模的初级保健实践-随机试验来实施和全面 评估工具箱检测作为AWV的标准护理，链接到EHR(EPIC)。多样化、学术性和 包括社区环境，以优化未来的传播工作。 我们的主要目标是评估与增强的日常护理相比，工具箱检测的有效性，以促进 认知功能减退的及时发现及其护理管理。我们的次要目标是：2)传播和 在联邦认证的大型卫生中心网络中实施工具箱检测，并评估其可行性和 使用可接受性；3)调查工具箱检测的保真度，并确定任何患者、护理人员、医疗保健人员 供应商和/或系统障碍阻碍其最佳、可持续的实施；以及4)确定与以下各项相关的成本 从初级保健的角度实施工具箱检测。

PROJECT SUMMARY Our objective is to widely implement and evaluate a user-centered, scalable, electronic health record (EHR) - linked strategy for the routine detection of cognitive decline among diverse primary care settings. Cognitive impairment is most prevalent among adults 65 and older, yet less than half of cases are detected and/or diagnosed in primary care settings. It is now increasingly accepted that early detection is critically important to optimize care planning, sustained independence, management of chronic conditions and appropriate caregiver involvement. In 2011, Medicare initiated a covered, Annual Wellness Visit (AWV) that includes a cognitive assessment to detect impairment, Alzheimer’s disease and related dementias (ADRD). While this has presented new opportunity for case finding, implementation of AWVs has been variable, including how cognitive function is assessed. Clinicians may rely on more basic, paper-based, interviewer-administered tests that may be less precise and more cumbersome to clinical workflow – affecting the fidelity of an early detection strategy. Further, many practices lack a clear protocol for referral when impairment is determined, and a process for family involvement and establishing care goals. Practical, sustainable, scalable strategies are urgently needed to help primary care providers who are on the frontlines of healthcare routinely assess cognitive function as part of AWVs (or whenever a cognitive impairment is suspected), identify concerns and have a protocol for referrals and care management. This is especially true for resource-constrained clinical settings, such as Federally Qualified Health Centers (FQHCs) caring for more vulnerable patient populations. Northwestern developed and continues to innovate the NIH Toolbox for the Assessment of Neurological and Behavioral Function®. Since 2017, our team has worked closely with primary care practices to develop a brief, technology-enabled, self-administered, EHR-linked cognitive assessment derived from the NIH Toolbox. We also devised a detailed protocol for its use and how results of our test, known as ToolboxDetect, can inform patient care. We propose a large-scale, primary care practice-randomized trial to implement and comprehensively evaluate ToolboxDetect as a standard of care with AWVs, linked to an EHR (Epic). Diverse, academic and community settings are included to optimize future dissemination efforts. Our primary aim is to evaluate the effectiveness of ToolboxDetect, compared to enhanced usual care, to promote timely detection of cognitive decline and its care management. Our secondary aims are to: 2) Disseminate and implement ToolboxDetect among a large Federally Qualified Health Center Network and assess its feasibility and acceptability for use; 3) Investigate the fidelity of ToolboxDetect, and identify any patient, caregiver, healthcare provider and/or system barriers to its optimal, sustained implementation; and 4) Determine costs associated with implementing ToolboxDetect from a primary care perspective.