Improving Transition Outcomes through Accessible Health IT and Caregiver Support

描述（由申请人提供）：背景：老年住院成人经常经历可预防的短期再入院，由于过渡支持不足。虽然积极主动的电话后续行动改善了过渡成果，但这些服务往往缺乏系统性，强度也不高。非正式的照顾者对于确保成功的过渡是非常宝贵的，但许多患者独自生活，有一个家庭照顾者，他们正在努力满足相互竞争的需求，或者与成年子女或其他潜在的支持来源保持距离。过渡支持需要新的模式，包括低成本技术和为患者的非正式医疗网络提供更有条理的援助，同时为患者的临床团队提供避免健康危机所需的信息。目的：与NIA改善过渡结果的目标一致，我们将评估一种新的干预措施，旨在通过三种作用机制提高对患有常见慢性病的老年人的过渡支持的有效性：（a）在出院后通过定期自动呼叫与患者进行直接定制通信，（B）通过关于患者状况的结构化反馈和关于他们如何提供帮助的建议，支持居住在患者家庭之外的非正式护理人员，以及（c）支持主动护理管理，包括基于网络的疾病管理工具、关于潜在问题的自动警报以及与患者及其护理人员进行异步通信的能力。具体而言，该试验将确定：1）CarePartner干预是否改善患者的再入院风险和功能状态; 2）干预对患者自我护理行为和过渡过程质量的影响; 3）干预是否改善护理人员的负担和压力水平。方法：760名患有复杂慢性病的老年人将在入院时被确定为两个社区急性护理医疗服务。将要求患者确定护理伙伴（CP），即，一个成年子女或其他社会网络成员愿意在他们的过渡支持和组织他们的非正式照顾者的更广泛的网络中发挥积极作用。患者将随机接受干预或常规治疗。干预患者将收到自动评估和行为改变电话，他们的CP将在每次评估后收到结构化的反馈和建议。病人的临床小组将可以通过网络访问病人的评估结果，将收到有关紧急健康问题的自动报告，并将能够使用安全的网页和特别设计的语音邮件服务与病人和CP进行异步通信。患者将在基线、出院后30天和90天完成调查;使用数据将从医院记录中获得。CP，其他照顾者和临床医生将接受采访，以评估干预措施对自我护理支持，照顾者压力和沟通过程的影响，以及干预措施在更广泛实施中的潜力。主要结果将是30天的再入院率;在30天和90天测量的2个主要结果包括功能状态、自我护理行为和死亡风险。

DESCRIPTION (provided by applicant): Background: Older hospitalized adults frequently experience preventable short-term readmissions due to inadequate transition support. Although proactive telephone follow-up improves transition outcomes, these services often are unsystematic and of low intensity. Informal caregivers are invaluable for ensuring successful transitions, but many patients live alone, have an in-home caregiver who is struggling with competing demands, or live at a distance from adult children or other potential sources of support. New models are needed for transition support that include low-cost technologies and more structured assistance for patients' informal caregiving network, while providing patients' clinical teams with the information they need to avert health crises. Objectives: Consistent with NIA's goals to improve transition outcomes, we will evaluate a novel intervention designed to improve the effectiveness of transition support for older adults with common chronic conditions via three mechanisms of action: (a) direct tailored communication to patients via regular automated calls post discharge, (b) support for informal caregivers living outside of the patient's household via structured feedback about the patient's status and advice about how they can help, and (c) support for proactive care management including a web-based disease management tool, automated alerts about potential problems, and the capacity for asynchronous communication with patients and their caregivers. Specifically, the trial will determine: 1) whether the CarePartner intervention improves patients' readmission risk and functional status; 2) the impact of the intervention on patients' self-care behaviors and the quality of the transition process; and 3) whether the intervention improves caregiver burden and stress levels. Methods: 760 older adults with complex chronic conditions will be identified upon admission to two community-based acute care medical services. Patients will be asked to identify a CarePartner (CP), i.e., an adult child or other social network member willing to play an active role in their transition support and organizing their broader network of informal caregivers. Patients will be randomized to the intervention or usual care. Intervention patients will receive automated assessment and behavior change calls, and their CPs will receive structured feedback and advice following each assessment. Patients' clinical team will have access to patients' assessment results via the web, will receive automated reports about urgent health problems, and will be able to communicate asynchronously with patients and CPs using a secure web page and a specially designed voicemail service. Patients will complete surveys at baseline, 30- and 90- days post discharge; utilization data will be obtained from hospital records. CPs, other caregivers, and clinicians will be interviewed to evaluate intervention effects on processes of self-care support, caregiver stress and communication, and the intervention's potential for broader implementation. The primary outcomes will be 30 day readmission rates; 2ndary outcomes measured at 30 and 90 days include functional status, self-care behaviors, and mortality risk.