Evaluating the Implementation of High Intensity Home-Based Rehabilitation Following Stroke

项目摘要 中风是一种非常普遍的疾病，会导致严重的功能活动障碍，尤其是在 上了年纪的人。为了解决这些缺陷，急性后康复是以证据为基础的护理组成部分。 然而，以设施为基础的康复(即在熟练的护理或住院康复设施中)费用高昂。如果 中风患者可以在高强度的家庭康复(HIHR)方法中获得同样的结果 就像在这些设施中一样，相对价值(结果/成本)会更大。这样一种方法的有效性 方法还没有被研究过。此外，还没有在#年审查HIHR护理模式的实施情况 美国的医疗体系。拟议研究的目标是确定HIHR最初努力的障碍。 在一个卫生系统中实施，并了解其临床有效性，以便为后续 护理模式的改进。采用三角混合方法的混合型2型研究设计将 在学习卫生系统研究框架的两个周期内使用。具体目标是(1)探索 影响卒中患者早期实施HIHR的障碍：(2)HIHR的有效性比较 以设施为基础的康复，以改善患者的功能；以及(3)实施改进的HIHR模型，并重新 审查其执行情况和效果。我们假设临床工作流挑战和 患者/护理者的偏好将影响最初实施的结果以及患者在 HIHR出院至少相当于患者出院时的功能。我们还假设 在以下情况下，将通过完善HIHR模式来改进执行情况和成效成果 从初始模型的评价中学习。这些目标与候选人成为一名 自主学习卫生系统研究员，重点研究健康康复实践 系统。培训的目的是(1)培养混合方法研究及其在护理中的应用方面的专门知识 提供，(2)获得评估卫生系统创新实施成功的专业知识，(3)制定 使用观测数据进行比较有效性研究的专门知识，以及(4)培养参与其中的技能 卫生系统领导人和领导一个学习型卫生系统研究实验室。这些培训目标将是 通过与内容专家的一对一指导以及地方和国家的结合来完成 课程作业。所有科学和培训目标将在一个包括大型 综合学术卫生系统和教学指导伙伴机构。预期的结果 这项工作是对《国际卫生条例》的执行和成效成果的说明。这是一种创新的 中风后急性康复的方法目前在美国卫生系统中还不存在，但 这可能会对旨在改善患者功能独立性的护理价值产生重大影响 中风后。

Project Summary Stroke is a highly prevalent condition that contributes to significant deficits in functional mobility, particularly in older adults. To address these deficits, post-acute rehabilitation is an evidence-based component of care. However, facility-based rehabilitation (i.e., in a skilled nursing or inpatient rehabilitation facility) is costly. If stroke patients can achieve the same outcomes in a high-intensity home-based rehabilitation (HIHR) approach as in these facilities, the relative value (outcomes/costs) would be greater. The effectiveness of such an approach has not been studied. Further, the implementation of a HIHR care model has not been examined in the US health system. The objectives of the proposed research are to identify barriers to initial HIHR efforts implementation in one health system and to understand its clinical effectiveness to inform subsequent improvement of the care model. A hybrid type 2 study design with a triangulated mixed methods approach will be used over two cycles of a learning health system research framework. Specific aims are to (1) explore barriers affecting the initial implementation of HIHR for stroke patients, (2) compare the effectiveness of HIHR to facility-based rehabilitation on improving patients' function, and (3) implement a refined HIHR model and re- examine its implementation and effectiveness. We hypothesize that clinical workflow challenges and patient/caregiver preferences will affect the outcomes with initial implementation and that patients' function at HIHR discharge will be at least equivalent to patients' function at facility discharge. We also hypothesize that improvements in implementation and effectiveness outcomes will be achieved by refining the HIHR model after learning from the evaluation of the initial model. These aims align well with the candidate's goal to become an independent learning health system researcher, with an emphasis on studying rehabilitation practice in health systems. Training aims are to (1) develop expertise in mixed methods research and its application to care delivery, (2) gain expertise in assessing implementation success of a health system innovation, (3) develop expertise in comparative effectiveness research using observational data, and (4) develop skills to engage with health system leaders and lead a learning health system research lab. These training aims will be accomplished via one-on-one mentorship with content experts and combination of local and national coursework. All scientific and training aims will be accomplished in an environment that includes a large integrated academic health system and a partner institution for didactic instruction. The expected outcome of this work is a description of the implementation and effectiveness outcomes for HIHR. This is an innovative approach for post-acute rehabilitation following stroke that does not currently exist in the US health system, but which may substantially affect the value of care that aims to improve patients' functional independence following stroke.