Enhancing Complex Care through an Integrated Care Coordination Information System

描述(由申请人提供)：由于已经支离破碎的医疗保健系统缺乏协调和质量，慢性病患者面临并发症和不必要的疾病恶化的风险。许多护理管理模式，如护理管理加(CMP)，已经通过使用健康信息技术(HIT)的临床重新设计成功地改善了健康结果。为了改善对有复杂需求的患者的护理，这些模式使用了人口管理、以患者为中心的目标、质量衡量标准和临床提醒。拟议的研究有三个目标。1)了解是否可以使用经认证的EHR和现有标准在不同的诊所中创建综合护理协调信息系统(ICCIS)。2)评估ICCIS系统中的功能是否可供诊所使用。3)评估这些系统变化是否会改善患者的预后。首先，研究小组将评估参与网站的现有点击能力。在初步评估的基础上，将实施ICCIS，以了解HIT是否可能用于护理有复杂医疗需求的患者。接下来，将使用格拉斯哥REAIM模型评估实施过程及其预期的好处。REAIM旨在衡量个人、计划、组织和政策层面的成功。一项随机对照试验将检查六家参与的诊所是否可以使用HIT来监测和提供具有护理协调模型(AR1)或质量性能模型(ARM2)的高危患者的护理。将审查两项结果衡量标准。1)利用-住院和急诊科就诊的变化；2)患者在临床层面的满意度。将通过使用账单数据比较实施前后的住院率和急诊率来检查利用率。患者满意度将通过在干预前和干预后随机抽样1200名患者进行评估。研究人员将管理ACAHPS调查，并提出有关护理过渡和护理协调的具体附加问题。

DESCRIPTION (provided by the applicant): Patients with chronic illness are at risk for complications and unnecessary disease exacerbations from a lack of coordination and quality in an already fragmented health care system. Many models of care management, like Care Management Plus (CMP), have been successful in improving health outcomes through clinical redesign using health information technology (HIT). To improve care for patients with complex needs these models use population management, patient-centered goals, quality measures, and clinical reminders. There are three objectives for proposed study. 1) To understand if an integrated care coordination information system (ICCIS) can be created in a diverse set of clinics using certified EHRs and existing standards. 2) To assess if the functions in the ICCIS system can be used by the clinics. 3) To evaluate if these system changes lead to improved patient outcomes. First, the research team will assess existing HIT capabilities of participating sites. Based on the initial assessment ICCIS will be implemented to see if HIT use in care of patients with complex healthcare needs is possible. Next, the implementation process and its perceived benefits will be assessed using the Glasgow REAIM model. REAIM is designed for measuring success at individual, programmatic, organizational, and policy levels. A randomized controlled trial will examine whether six participating clinics can use HIT to monitor and deliver care for high risk patients with a care coordination model (arm 1) or quality performance model (arm 2). Two outcome measures will be examined. 1) Change in utilization - hospitalizations and ED visits and 2) Patient satisfaction at the clinic level. Utilization will be examined by comparing hospitalization rates and ED visits before and after implementation using billing data. Patient satisfaction will be assessed by surveying a random sample of 1200 patients pre- and post-intervention. Research personnel will administer the ACAHPS survey with specific additional questions about transitions of care and care coordination.