Improving Care Coordination Between Clinicians to Optimize Care Transitions to Home Health Care

项目摘要/摘要 这是AHRQ指导的临床科学家研究职业发展奖的修改后的提交 (K08)医学博士克里斯汀·D·琼斯女士我的整个职业目标是开发和实施干预措施 通过临床医生之间更有效的护理协调来改善患者的预后。护理过渡自 医院到家对病人来说可能是危险的，而零散的沟通有助于许多可以预防的 在这一过渡期间发生的不良事件。家庭健康护理(HHC)的使用越来越多，其目的是 改善护理过渡，但即使有家庭支持，老年人仍然容易发生不良事件 出院，包括重新入院，这导致这些患者逐渐丧失能力。使用 这个职业发展奖，我将开发一种干预措施，改善护理之间的协调 旨在减少不良患者结局的住院医生和HHC护士，包括用药错误和 再次入院治疗。 候选人和导师：我是科罗拉多大学的医学助理教授，在那里我 以成人内科医生的身份执业。我完成了一项研究奖学金，并进行了研究 描述护理协调的障碍，对减少再入院的干预措施进行系统审查，以及 医院出院时HHC转诊情况分析。我与我的导师建立了富有成效的关系，并拥有 与我的主要导师弗雷德里克·马苏迪博士一起完成了两份手稿--一份已出版，一份在印刷中。 研究和培训：我将通过三项互补的研究和培训在我之前的研究基础上再接再厉 旨在为改善住院患者和HHC之间的护理质量协调的干预提供信息 护理急性住院后老年人的护士。我将：(1)用定性的方法来理解 HHC护士、患者和护理者的护理协调体验，(2)生成预测模型以确定 在国家医疗保险数据中，从HHC重新入院30天的可修改的风险因素，以及(3)发展， 实施并评估一项试点干预措施，以连接住院医生和HHC护士，以优化出院后 护理协调，减少患者的不良后果。在获奖结束时，我将接受培训并掌握相关技能 成为一名成功的独立研究人员，并将寻求资金进行务实的临床试验，以测试 改善住院医生和HHC护士之间护理协调的干预措施的有效性。 摘要：住院医生和HHC护士之间的有效护理协调是支持高质量的关键 急性住院后易受伤害患者的护理过渡。拟议的研究将为 改善住院医生和HHC护士之间的护理协调并改善预后的干预措施 住院后接受HHC服务的患者。这个奖项将支持我发展成为一名 具有加强临床医生之间护理协调的专业知识的独立调查员，以改善 越来越多的接受HHC服务出院的患者的结果。

Project Summary/Abstract This is a revised submission for an AHRQ Mentored Clinical Scientist Research Career Development Award (K08) by Christine D. Jones, MD, MS. My overall career goal is to develop and implement interventions that improve patient outcomes through more effective care coordination between clinicians. Care transitions from hospital to home can be perilous for patients, and fragmented communication contributes to many preventable adverse events during this transition. Home health care (HHC) is increasingly employed with the intent to improve care transitions, but even with home support, older adults remain vulnerable to adverse events after discharge, including hospital readmissions, which contribute to progressive disability for these patients. With this career development award, I will develop an intervention that improves care coordination between hospitalists and HHC nurses that aims to reduce adverse patient outcomes, including medication errors and hospital readmissions. Candidate and Mentors: I am an Assistant Professor of Medicine at the University of Colorado where I practice as an adult medicine hospitalist. I completed a research fellowship and have conducted studies to describe barriers to care coordination, a systematic review of interventions to reduce readmissions, and analyses of HHC referrals at hospital discharge. I have built productive relationships with my mentors and have completed two manuscripts – one published, one in press - with my primary mentor, Dr. Frederick Masoudi. Research and Training: I will build on my prior research through three complementary research and training aims that will inform an intervention to improve the quality of care coordination between hospitalists and HHC nurses caring for older adults after acute hospitalization. I will: (1) employ qualitative methods to understand HHC nurse, patient, and caregiver experiences of care coordination, (2) generate predictive models to identify modifiable risk factors for 30-day readmissions from HHC within national Medicare data, and (3) develop, implement, and evaluate a pilot intervention to connect hospitalists and HHC nurses to optimize post-discharge care coordination and reduce adverse patient outcomes. At award completion, I will have the training and skills to be a successful independent investigator and will pursue funding for a pragmatic clinical trial to test the effectiveness of an intervention to improve care coordination between hospitalists and HHC nurses. Summary: Effective care coordination between hospitalists and HHC nurses is critical to support high-quality care transitions for vulnerable patients after acute hospitalization. The proposed research will inform an intervention to improve care coordination between hospitalists and HHC nurses and enhance outcomes for patients receiving HHC services after hospitalization. This award will support my development into an independent investigator with expertise in enhancing care coordination between clinicians to improve outcomes for the growing number of patients discharged with HHC services.