Factors Associated with Institutional Use by Veterans in Home Based Primary Care

描述（由申请人提供）： VA家庭基础初级保健（HBPC）是一个跨学科的团队为基础的家庭护理计划，服务于最古老的老退伍军人（85+）和年轻的OIF/OEF退伍军人与复杂的慢性残疾条件的快速老化队列。2011年，大约15，000名退伍军人参加了139个VA医疗中心HBPC计划和全国101个相关的社区门诊诊所。虽然HBPC计划质量已经在沿着许多机构利用方面（例如，住院天数）和费用，机构护理的使用在全国HBPC计划中差异很大。较低的机构护理利用率可能建议量身定制的方法，优化退伍军人的护理。机构护理的更高利用率可能是潜在的不适当或管理不善的护理指标，使脆弱的HBPC退伍军人面临并发症的风险。拟议中的研究旨在通过调查HBPC组织结构，团队运作和医院，急诊科（艾德）和疗养院（NH）机构使用的8个风险调整质量指标（QM）之间的关联来确定导致这些变化的因素。重新设计卫生保健系统的出发点是了解护理发生的环境的组织结构属性。为此，进行了一项结构调查，以了解HBPC项目的组织结构特征。结构是指影响系统在家中向退伍军人提供初级保健服务的能力的HBPC计划特征，包括HBPC计划标准、团队结构和远程医疗技术。然后，本研究将通过管理和分析组织评估问卷（OAQ）调查，评估HBPC跨学科团队功能在七个方面的差异：文化，领导力，沟通，协调，冲突管理，团队凝聚力和团队效率。接下来，将分析HBPC组织结构和团队运作之间的关联，以确定与更有效的团队运作相关的组织结构。最后，HBPC组织结构和团队功能对HBPC护理质量的影响将通过机构用途：住院和NH入院和天数、30天和90天再住院、艾德访视和退伍军人死亡部位的风险调整QM进行检查。将通过调查和现场观察访视获得本拟定研究的主要数据。次要数据将包括2年的VA和CMS患者数据库（2013-2014）。本研究的结果将确定与机构护理使用率较低相关的组织结构和团队功能，这些组织结构和团队功能可以作为最佳实践整合到政策和系统重新设计计划中，以将绩效较低的HBPC计划提升到绩效最高的计划水平。最终，减少可避免的和昂贵的机构护理推进HBPC计划的目标，因此，使HBPC退伍军人能够在家里接受治疗，并保持他们最大的独立性。

DESCRIPTION (provided by applicant): VA Home Based Primary Care (HBPC) is an interdisciplinary team-based home care program that serves a rapidly aging cohort of oldest old Veterans (85+) and younger OIF/OEF Veterans with complex chronic disabling conditions. In 2011, approximately 15,000 Veterans were enrolled in 139 VA Medical Center HBPC programs and an associated 101 community-based outpatient clinic locations nationwide. Although HBPC program quality has been established along a number of institutional utilization dimensions (e.g., inpatient days) and cost, the use of institutional care varies substantially across HBPC programs nationally. Lower utilization of institutional care may suggest tailored approaches that optimize a veteran's care. Higher utilization of institutional care may be an indicator of potentially inappropriate or mismanaged care that places vulnerable HBPC Veterans at risk for complications. The proposed study seeks to identify the factors contributing to these variations by investigating associations between HBPC organizational structures, team functioning, and eight risk adjusted quality measures (QMs) of institutional use for hospitals, emergency departments (ED), and nursing homes (NHs). The starting place for redesigning the health care system is to understand the organizational structural attributes of the settings in which care occurs. To that end, a structura survey is conducted to develop a profile of the organizational structure characteristics of HBPC programs. Structure refers to HBPC program characteristics that affect the system's capacity to deliver primary care services to Veterans in their home and includes HBPC program standards, team structures, and telehealth technology. The study will then evaluate differences in HBPC interdisciplinary team functioning with regard to seven dimensions: culture, leadership, communication, coordination, conflict management, team cohesion, and team effectiveness through administration and analysis of the organizational assessment questionnaire (OAQ) survey. Next, associations between HBPC organizational structures and team functioning will be analyzed to identify organizational structures associated with more effective team functioning. Finally, the influence of HBPC organizational structures and team functions on the quality of HBPC care will be examined with respect to risk-adjusted QMs of institutional use: hospital and NH admissions and days, 30-day and 90-day rehospitalizations, ED visits, and Veteran's site of death. Primary data for this proposed study will be obtained through surveys and on-site observational visits. Secondary data will include two years of VA and CMS patient databases (2013-2014). Findings from this study will identify organizational structures and team functions associated with lower use of institutional care that can be integrated as best practices into policies and system redesign initiatives to bring lower performing HBPC programs up to the level of the highest performing programs. Ultimately, reducing avoidable and costly institutional care advances HBPC program goals, and as such, enables HBPC Veterans to be treated at home and to retain their maximal independence.