Quality of Care and Patient Experience in GeriPACT: A Comparative Effectiveness Study

背景：老年保健计划是一项旨在提供全面初级保健的“特殊人口协定” 与复杂的老年和高危退伍军人的专业知识相结合。GeriPACT努力优化 独立性、生活质量和对退伍军人的护理质量，这些退伍军人由于多重疾病而特别脆弱 在老年背景下的认知、功能、心理社会和医学方面的交互挑战。 以老年医学为主导的老年PACT评估的初步结果及扩展护理数据分析 GEC DAC中心(GEC DAC)已经证明，老年PACT中复杂患者的护理费用比 在传统契约中照顾相似的病人。尽管这是一个重要而令人信服的发现，但我们缺乏 有关GeriPACT与传统的PACT护理在临床流程和 耐心的护理体验。这些信息对于理解该模型的总体净收益是必不可少的， 并了解如何最好地将这项服务定位于将从以下方面获得最大好处的患者 招生。 方法：本研究的主要目的是了解GeriPACT对患者体验和 可能导致观察到的费用差异的关键护理质量措施。这一预期匹配 比较有效性研究将涉及以下具体目标：(目标1)检查护理质量 退伍军人在老年PACT中的临床过程措施，与传统的相似患者进行比较 约定。我们假设，在GeriPACT中照顾的退伍军人将有更少的潜在不适当 6个月、12个月和18个月的药物(PIM)；18个月的提前指令完成率较高；以及 在12个月时，虚弱的老年人的表现更好。(目标2)检查患者的体验 与传统契约中的类似患者相比，在GeriPACT中照顾的退伍军人中的护理。我们 假设GeriPACT中的退伍军人将有更多的活着和在家的日子(定义为不在 急诊科(ED)或医院)；在6个月、12个月和18个月时更好地整合感知护理 6个月、12个月和18个月时自我报告的健康和幸福感较高。最后，临床医生和 老年病和长期护理领导者已经确定了预计将从以下方面获得不同好处的亚人群 老年保健，但这些亚群还没有经过实证检验。因此，目标3是检查 GeriPACT暴露和结果之间的关系是否基于认知状态而不同， 功能性残疾，或多种慢性病(MCC)。我们假设认知状态受损， 功能残疾，MCC将缓解GeriPACT对护理质量措施的影响(增加 效果)和护理体验(效果增加)。使用有针对性的招聘策略来增加 GeriPACT和PACT患者之间的同质性，以及粗略匹配和最小距离 为了得出均衡样本，我们将检验GeriPACT之间的人与人之间的变化 和PACT患者，控制最初的健康状况。通过将患者报告的调查数据与 VHA电子健康记录，我们将最大限度地减少通常困扰比较的偏见来源 有效性研究。 预期影响：在VHA接受初级保健的退伍军人中，超过一半的人年龄在65岁或以上， 老年患者的比例正在迅速增长；然而，超过40%的VAMC没有GeriPACT。这个 这项研究的结果将提供急需的信息，以指导关于最佳传播的决策 这种护理模式的规模旨在服务于数量庞大且不断增长的老年和医学人口 复杂的退伍军人。这些结果将在VHA之外具有重大意义，作为卫生系统和问责 美国各地的护理组织都在寻找有效的初级保健模式，以提高质量和价值 年长的美国人。

Background: GeriPACT is a “Special Population PACT” designed to provide comprehensive primary care combined with specialty expertise for complex geriatric and high-risk Veterans. GeriPACT strives to optimize independence, quality of life, and quality of care for Veterans who are particularly vulnerable due to multiple interacting cognitive, functional, psychosocial, and medical challenges in the setting of advanced age. Preliminary findings from the evaluation of GeriPACT led by the Geriatrics and Extended Care Data Analysis Center (GEC DAC) has demonstrated that care for complex patients in GeriPACTs costs 40-60% less than caring for similar patients in traditional PACTs. Although this is an important and compelling finding, we lack essential information about how GeriPACT differs from traditional PACT care in terms of clinical processes and patient experience of care. This information is essential for understanding the overall net benefit of the model, and understanding how best to target this service to patients that stand to yield the greatest benefit from enrollment. Methods: The main objective of this study is to understand the impact of GeriPACT on patient experience and key quality of care measures that may be contributing to observed cost differences. This prospective matched comparative effectiveness study will address the following specific aims: (AIM 1) To examine quality of care clinical process measures among Veterans cared for in GeriPACT, compared to similar patients in traditional PACTs. We hypothesize that Veterans cared for in GeriPACT will have fewer potentially inappropriate medications (PIMs) at 6, 12, and 18 months; higher rates of completed advance directives at 18 months; and higher performance on frail elder quality measures at 12 months. (AIM 2) To examine patient experience of care among Veterans cared for in GeriPACT, compared to similar patients in traditional PACTs. We hypothesize that Veterans in GeriPACT will have more days alive and at home (defined as days not in the emergency department (ED) or hospital) at 18 months; greater perceived care integration at 6, 12, and 18 months; and higher self-reported health and well-being at 6, 12, and 18 months. Finally, clinicians and Geriatrics and Extended Care leaders have identified sub-populations expected to differentially benefit from GeriPACT care but these subpopulations have not been examined empirically. Thus, Aim 3 is to examine whether the relationship between GeriPACT exposure and outcomes differs based on cognitive status, functional disability, or multiple chronic conditions (MCC). We hypothesize that impaired cognitive status, functional disability, and MCC will moderate the effects of GeriPACT on quality of care measures (increased effects) and experience of care (increased effects). Using targeted recruiting strategies to increase homogeneity between GeriPACT and PACT patients, along with coarsened matching and minimum distance score methods to derive a balanced sample, we will examine between-person changes between GeriPACT and PACT patients, controlling for initial health status. By combining data from a patient-reported survey and VHA electronic health records, we will minimize sources of bias that commonly plague comparative effectiveness studies. Anticipated Impact: More than half of all Veterans receiving primary care in VHA are aged 65 or older and the proportion of older patients is growing rapidly; however more than 40% of VAMCs do not have GeriPACT. The results of this study will provide critically-needed information to guide decisions about optimal dissemination and scale of this model of care designed to serve a large and growing population of older and medically complex Veterans. The results will be of great relevance outside VHA as health systems and Accountable Care Organizations throughout the U.S. look for effective primary care models to improve quality and value for older Americans.