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

描述(由申请人提供)： 退伍军人家庭初级护理(HBPC)是一项基于团队的跨学科家庭护理计划，为年龄最大的老年退伍军人(85岁以上)和患有复杂慢性残疾状况的年轻OIF/OEF退伍军人提供服务。2011年，大约15,000名退伍军人参加了139个退伍军人医疗中心HBPC项目和相关的101个社区门诊地点。尽管HBPC计划的质量是根据许多机构利用维度(例如住院天数)和成本确定的，但在全国各地的HBPC计划中，机构护理的使用情况存在很大差异。机构护理利用率较低可能会建议采取量身定做的方法，优化退伍军人的护理。较高的机构护理利用率可能是潜在不适当或管理不善的护理的一个指标，这些护理可能会使脆弱的HBPC退伍军人面临并发症的风险。这项拟议的研究试图通过调查HBPC组织结构、团队功能和医院、急诊科(ED)和疗养院(NHS)机构使用的八项风险调整质量指标(QMS)之间的关联来确定导致这些差异的因素。重新设计卫生保健系统的出发点是了解保健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方案的组织结构特点。结构是指HBPC计划特征，这些特征会影响系统向退伍军人家中提供初级保健服务的能力，包括HBPC计划标准、团队结构和远程医疗技术。然后，本研究将通过对组织评估问卷(OAQ)调查的管理和分析，评估HBPC跨学科团队在文化、领导力、沟通、协调、冲突管理、团队凝聚力和团队有效性七个维度上的差异。接下来，将分析HBPC组织结构和团队功能之间的关联，以确定与更有效的团队功能相关的组织结构。最后，将从机构使用的风险调整质量管理体系方面考察HBPC组织结构和团队职能对HBPC护理质量的影响：医院和NH的入院和天数、30天和90天的再住院、急诊科就诊和退伍军人死亡地点。这项拟议研究的主要数据将通过调查和现场观察访问获得。次要数据将包括两年的退伍军人事务部和CMS患者数据库(2013-2014)。这项研究的结果将确定与较低的机构护理使用率相关的组织结构和团队职能，这些组织结构和团队职能可以作为最佳实践整合到政策和系统重新设计倡议中，以使表现较差的HBPC项目达到表现最好的项目的水平。归根结底，减少可避免和昂贵的机构护理促进了HBPC计划的目标，因此，HBPC退伍军人能够在家中接受治疗，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.