Paramedic-coached ED Care Transitions to Help Older Adults Maintain their Health

 描述（由申请人提供）：老年人使用急诊科（艾德）作为急性护理的重要来源，每年有2000万艾德就诊。到艾德就诊的老年人病情严重程度不足以保证住院;因此，他们接受治疗并出院回家。不幸的是，老年人从艾德出院回家后表现不佳，20%的人在30天内重复艾德就诊。ED到家庭的过渡已被确定为这些可避免的不良结果的原因，但以ED为重点的干预措施，以改善这种过渡已经有了不确定的结果，并遭受可行性，可持续性和可扩展性的问题。科尔曼的护理过渡干预（CTI）已被验证，以改善医院到家庭的过渡，减少住院和成本。CTI使用教练（通常是护士或社会工作者）通过传授技能来激励患者，为出院回家的患者提供支持。将CTI应用于艾德到家庭的过渡是一种自然的延伸，但尚未在这种独特而苛刻的环境中进行评估。在这项研究中，我们将测试我们的总体假设，即以社区为基础，护理人员协调的艾德到家庭CTI将改善社区居住的老年人的后艾德健康结果，并降低成本。我们将通过测试随机分配到CTI的受试者是否表现出对指示其病情恶化的红旗的更好理解，更频繁地实施药物改变，以及在艾德出院后更快地随访其初级保健医生，来评估CTI过程结局。我们还将通过测试随机分配至CTI的受试者是否在出院后30天内改善了患者激活测量评分、降低了艾德使用频率以及降低了艾德出院后30天内的医疗保健费用，来评估CTI的有效性和成本效益。此外，我们认识到CTI不会消除所有重复艾德访视。因此，我们将确定与CTI接受者重复艾德访视相关的独立因素，以便未来的计划可以确保他们的需求得到充分解决。这项研究将提供关键的经验证据有关的显着问题，穷人ED到家庭的过渡。通过利用CTI，一个广泛提供和有效的干预和护理人员，一个高技能和受人尊敬的医疗保健提供者存在于所有社区，我们将采用创新的方法，以改善老年人的健康后，艾德访问。通过严格的研究，我们将测试这种方法的有效性和成本效益，特别关注最终的可持续性和传播。

 DESCRIPTION (provided by applicant): Older adults use the emergency department (ED) as an important source of acute care, making 20 million ED visits annually. Older adults who visit the ED do not have conditions of sufficient severity to warrant hospital admission; thus, they are treated and discharged home. Unfortunately, older adults do poorly after being discharged home from the ED, with 20% having repeat ED visits within 30 days. The ED-to-home transition has been identified as a cause for these avoidable poor outcomes, but ED-focused interventions to improve this transition have had inconclusive outcomes and have suffered from feasibility, sustainability and scalability problems. Coleman's Care Transition Intervention (CTI) has been validated to improve the hospital-to-home transition, decreasing both hospital readmissions and costs. The CTI uses coaches, usually nurses or social workers, to support patients being discharged home by transferring skills to activate patients. Applying the CTI to the ED- to-home transition is a natural extension, but it has not been evaluated in this unique and demanding setting. In this study, we will test our overall hypothesis that the community-based, paramedic-coordinated ED- to-home CTI will improve community-dwelling older adults' post-ED health outcomes and reduce costs. We will evaluate CTI process outcomes by testing if participants randomized to the CTI demonstrate better understanding of red flags that indicate a worsening of their condition, implement medication changes more frequently, and follow up with their primary care physicians more rapidly after ED discharge, as compared to the control group. We will also evaluate the effectiveness and cost-effectiveness of the CTI by testing if participants randomized to the CTI have improved Patient Activation Measure scores 30 days after discharge, have decreased frequency of ED use, and decreased health care costs within 30 days of ED discharge. Additionally, we recognize that the CTI will not eliminate all repeat ED visits. Thus, we will identify factors independently associated with repeat ED visits among CTI recipients such that future programs can ensure their needs are adequately addressed. This research will provide critical empiric evidence regarding the significant problem of poor ED-to-home transitions. By leveraging the CTI, a widely available and efficient intervention and paramedics, a highly-skilled and respected health care provider present in all communities, we will apply an innovative approach to improve older adults' health following an ED visit. Through rigorous research, we will test the effectiveness and cost- effectiveness of this approach, with a specific focus on ultimate sustainability and dissemination.