Inpatient-Outpatient Transitions: Reducing the Rate of Readmission

描述（由申请人提供）：目标和目的：本研究的目的是降低心力衰竭（HF）患者从住院转到门诊的可预防再入院的风险。本研究的具体目的是：1)建立一个广泛适用的理想住院-门诊转换的操作模型；2a)使用失效模式和影响分析（FMEA）来确定住院/门诊护理过渡中导致可预防再入院的关键失效模式（及其原因），2b)使用FMEA来完善模型并确定最小化可预防再入院所需的关键能力；3)开发和试点测试“过渡能力评估”工具草案，该工具可用于评估实体提供高质量过渡护理的能力。背景：住院到门诊的转变是一个复杂的过程，伴随着医疗差错和药物不良事件的风险，而且，当这种转变管理不善时，它甚至可能导致可预防的住院再入院。有效的过渡需要

DESCRIPTION (provided by the applicant): Goals and Aims: The goal of this study is to reduce the risk of preventable readmission for heart failure (HF) patients transitioning from inpatient to ambulatory care. The specific aims of this study are: 1) To develop a broadly applicable operational model of idealized inpatient-ambulatory transitions; 2a) To use Failure Mode and Effects Analysis (FMEA) to identify the key failure modes (and their causes) in inpatient/outpatient transitions of care that contribute to preventable readmissions, 2b) To use FMEA to refine the model and to identify the key capabilities necessary to minimize preventable readmissions; and 3) To develop and pilot test a draft "transitional capability assessment" tool that can be used to evaluate an entity's ability to deliver high quality transitional care. Background: The inpatient-to-ambulatory care transition is a complex process that carries with it the risk of medical errors, adverse drug events, and, when the transition is poorly managed, it may even lead to preventable inpatient readmission. An effective transition requires that 4 key steps be completed: notification, transfer of information, transfer of responsibility, and care plan oversight. Methods: With stakeholder input, we will develop an "ideal" model of transitional care for HF that is designed to reliably accomplish the 4 key steps. We will conduct a FMEA of the ideal model to identify sources of risk and the capabilities necessary to reduce those risks. We will then conduct a gap analysis to test the validity of the ideal model; the ideal model will be applied to transitional care for a different condition (bypass surgery) and in different care environments. Finally, using FMEA and gap analysis results, we will develop an initial draft of a "transitional care capability" assessment tool to aid other organizations to assess whether a healthcare entity (e.g. hospital, provider) has the necessary capabilities to provide high quality transitional care. The draft instrument will be used by Geisinger's RHIO partners as a preliminary assessment of its validity. Relevance: Preventable hospital readmission is a problem associated with the complex process of transitioning a patient to primary care management following a hospital admission for heart failure treatment. This study aims to reduce the rate of preventable hospitalizations by developing a new model for transitional care, using risk analysis to make sure it is safe, and then developing a tool that can be used to assess whether a healthcare entity can provide quality transitional care.