Regional Data Exchange to Improve Care for Veterans after Non-VA Hospitalization

 描述(由申请人提供)： 背景：在拥有医疗保险的老年退伍军人管理局患者中，43%同时使用退伍军人管理局和非退伍军人管理局(医疗保险)服务。退伍军人管理局和非退伍军人管理局提供者通常不知道另一个系统中提供的遭遇、治疗和检测结果。特别是，没有或延迟通知非退伍军人管理局的医院遭遇，是退伍军人管理局错过了提供医院后过渡护理服务的机会，这些服务已被证明在预防不良事件和出院后再次入院方面是有效的。目的：本项目的总体目标是检查使用电子健康信息交换(HIE)的退伍军人事务部提供者通知非退伍军人住院或急诊科(ED)就诊的有效性、成本和实施接受度，并提供或不提供循证的医院后过渡护理服务。具体目标1是检查这些方法在防止入院或再入院方面的影响，作为主要结果，以及作为次要结果，增加提供者的跟进，改善患者的状况自我了解，并防止出院后的用药差错。具体目标2是审查这些方法对退伍军人成本和非退伍军人成本的影响。具体目标3是审查退伍军人管理局和非退伍军人管理局利益攸关方对这些办法的接受程度。方法：研究样本包括在布朗克斯和印第安纳波利斯退伍军人管理局的老年病科或初级保健诊所跟踪调查的65岁以上的退伍军人。我们将使用地区HIE组织(即布朗克斯地区健康信息组织和印第安纳健康信息交换组织)提供的技术来监控患者的非退伍军人医院入院或急诊就诊情况。患者将按PACT小组按设施分层1：1随机分为通知+协调组或仅通知组。对于这两个群体，PACT提供者将收到非退伍军人医院入院或急诊室就诊的实时通知(如果发生)。对于通知+协调小组，护理过渡协调员将在家庭和/或退伍军人医院访问期间提供协调活动 并通过1个多月的电话随访。协调活动将包括：对账 对患者的退伍军人管理局和非退伍军人管理局的药物进行评估和咨询，就病情恶化的迹象进行教育，协调退伍军人管理局和非退伍军人管理局的后续预约，并使用结构化方案就与退伍军人管理局和非退伍军人管理局提供者的沟通提供咨询。过渡协调员收集的所有信息都将包括卫生与环境研究所作为信息源。在通知后，只接受通知的小组将得到通常的照顾。将估计多变量回归模型，以比较通知加协调和仅通知对主要和次要结果和费用的影响(目标1和2)。我们将与干预小组成员、患者、退伍军人和非退伍军人以及其他利益相关者进行访谈，以确定实施这些方法的障碍和促进者(目标3)。

 DESCRIPTION (provided by applicant): Background: Among older VA patients who have Medicare coverage, 43% use both VA and non-VA (Medicare-covered) services. VA and non-VA providers are often uninformed about encounters, treatments and test results provided in the other system. In particular, the absent or delayed notification of a non-VA hospital encounter is a missed opportunity for the VA to provide post-hospital transitional care services that have been shown to be effective in preventing adverse events and hospital readmission after hospital discharge. Objectives: The overall objective of this project is to examine the effectiveness, cost, and implementation acceptance of VA provider notification of non-VA hospitalization or emergency department (ED) visit using electronic health information exchange (HIE), with or without provision of evidence-based post-hospital transitional care services. Specific Aim 1 is to examine the impact of these approaches on preventing hospital admission or readmission as the primary outcome, and, as secondary outcomes, increasing provider follow-up, improving patient's condition self-knowledge, and preventing medication errors after discharge. Specific Aim 2 is to examine the effect of these approaches on VA and non-VA costs. Specific Aim 3 is to examine the acceptance of these approaches among VA and non-VA stakeholders. Methods: The study sample consists of veterans followed in geriatrics or primary care clinics at the Bronx and Indianapolis VAs who are older than 65. We will monitor patients for non-VA hospital admission or ED visit using technology provided by regional HIE organizations (i.e., the Bronx Regional Health Information Organization and the Indiana Health Information Exchange). Patients will be cluster-randomized 1:1 to notification-plus-coordination or notification-only groups by PACT team, stratified by facility. For both groups the PACT provider will receive real-time notification of a non-VA hospital admission or ED visit if it occurs. For the notification-plus-coordination group, a care transitions coordinator will deliver coordination activities during a home and/or VA facility visit and via follow-up phone calls over 1 month. Coordination activities will consist of: reconciliation of and counseling on the patient's VA and non-VA medications, education on signs of condition worsening, coordination of VA and non-VA follow-up appointments, and counseling on communicating with VA and non-VA providers, using structured protocols. All information-gathering by the transitions coordinator will include the HIE as an information source. The notification-only group will receive usual care after the notification. Multivariable regression models will be estimated to compare effects of notification-plus-coordination versus notification-only on primary and secondary outcomes and costs (Aims 1 and 2). We will conduct interviews with intervention team members, patients, VA and non-VA staff, and other stakeholders to ascertain the barriers and facilitators to implementation of these approaches (Aim 3).