Decision Support: Optimizing Post Acute Referrals and Effect on Patient Outcomes

描述（由申请人提供）：优化急性后转诊和对患者预后的影响医疗保险和医疗补助中心对21世纪急性后护理的愿景是建立一个以患者为中心的系统，并围绕个人需求而不是围绕接受护理的环境进行组织。每年，临床医生就医疗保险受益人出院后的急症后服务需求做出1300多万次决定；然而，没有经验推导的临床指南来帮助做出这些共同和重要的决定。急症后转诊过程有多个步骤，需要仔细、全面的评估，以确定患者目前的需求，预测未来的需求，做出适当的决定，并协调后续服务。本提案侧重于该过程的前三个步骤，以实现CMS的目标，即每次都为每个人提供正确的护理。本研究小组和其他人的研究结果一致表明，急诊转诊决策的质量受到住院时间缩短、评估不一致、沟通不良、决策中的专业知识水平和风险承受能力不同的负面影响。我们团队最近完成的NINR研究（RO1-NR007674）显示，专家在获得高质量信息和有时间考虑的情况下，将52%的患者转介给急性后护理，而不是由临床医生转介。拟议的竞争性更新将在几个重要方面推进这些发现。利用从4家医院的电子记录中获得的1200多例患者情况，将从老年患者的社会人口统计学和临床代表性样本中分析大量患者特征。此外，一大群临床和学术专家将确保多学科的观点。该模型被称为“专家出院决策支持系统”（D2S2），将嵌入电子记录中，并对其对患者预后的影响进行现场测试。具体目的是：1)确定与专家决定转介住院老年人进行急性后护理显著相关的患者特征（因素）。2)定义并验证模拟专家转诊决策的最显著因素预测模型。3)评价D2S2对决策和患者预后的影响。研究结果将确定并提供专家的知识，以规范和促进识别需要急性后护理的老年患者。结果将提高急性转诊决策的质量和一致性，减少转诊所需的时间，并降低与未满足出院后需求相关的不良结果相关的成本。除了解决知识和护理质量方面的差距之外，拟议的研究还符合医学研究所报告和国家质量论坛提出的提高质量和安全的建议战略，在该论坛中，将患者需求与服务提供相匹配是一项高度优先事项。

DESCRIPTION (provided by applicant): Optimizing Post Acute Referrals and Effect on Patient Outcomes The Centers for Medicare and Medicaid's vision for post acute care in the 21st century is a system that is patient centered and organized around the individual's needs rather than around the setting in which the care is received. Each year clinicians make more than 13 million decisions about the need for post acute services following hospital discharge of Medicare beneficiaries; yet, there are no empirically derived, clinical guidelines to assist in making these common and important decisions. The post acute care referral process has multiple steps that require careful, comprehensive assessment to determine patients' present needs, anticipate future needs, make appropriate decisions, and coordinate follow-up services. This proposal focuses on the first three steps of this process to achieve the CMS goal of getting the right care for every person every time. The findings of this research team and others have consistently shown that the quality of post acute referral decision making is negatively impacted by shortened lengths of stay, inconsistent assessment, poor communication, and varying levels of expertise and risk tolerance in decision-making. Our team's recently completed NINR study (RO1-NR007674) revealed that experts, given high quality information and the time to deliberate, refer 52% more patients for post acute care than were referred by clinicians. The proposed competing renewal will advance these findings in several important ways. Using over 1200 patient scenarios obtained from the electronic records at 4 hospitals, large numbers of patient characteristics will be analyzed from a socio-demographic and clinically representative sample of elderly patients. In addition, a large group of clinical and scholarly experts will assure multidisciplinary perspectives. The model, labeled as the "expert discharge decision support system" (D2S2), will be embedded in the electronic record and field tested for its effects on patient outcomes. The specific aims are: 1) To identify the patient characteristics (factors) that are significantly correlated with experts' decisions to refer hospitalized elders for post acute care. 2) To define and validate the most significantly predictive model of factors to mimic experts' referral decisions. 3) To evaluate the effects of the D2S2 on decision making and patient outcomes. Study findings will identify and make available the knowledge of experts to standardize and facilitate the identification of older patients in need of post acute care. Results will improve the quality and consistency of post acute referral decisions, reduce the time required for referrals to occur, and decrease the costs associated with poor outcomes related to unmet post discharge needs. In addition to addressing gaps in knowledge and care quality, the proposed study meets recommended strategies for improving quality and safety outlined by the Institute of Medicine reports and the National Quality Forum where matching patient needs with service delivery is a high priority. PUBLIC HEALTH RELEVANCE: Currently the decision to refer older adults for post hospital care, such as home care, is made by a variety of clinicians using a variety of criteria. This study will develop and test a computerized system that will provide advice to clinicians about these important decisions. The goal is to improve the identification of who needs post acute care, to get them to the most appropriate care, and to prevent rehospitalization.