Discharge Information & Support for Patients Receiving Outpatient Care in the ED

描述(由申请人提供)： 背景：每年有100多万退伍军人在退伍军人医疗中心(VAMCs)的急诊科(ED)接受护理。近五分之一的退伍军人在接受治疗后从VAMC急诊室出院，在30天内在急诊室或医院接受额外的计划外护理。过往曾在急症室接受日间医疗服务的长期病患者，再次到急症室就诊的风险尤其高。新发展的患者对齐护理团队(PACTS)的一个明确目标是促进初级保健诊所的连续性，从而减少ED的使用；然而，很少有研究指导PACTS如何实现这一目标。护士在PACTS中的一个关键作用将是对高危人群进行电话管理，接受治疗并从急诊室出院的退伍军人就是这样一个高危群体。然而，还没有研究在急诊科就诊后使用护士护理经理支持退伍军人的退伍军人和系统层面的影响。目的：这项研究的总体目标是检验以初级保健为基础的护士电话支持计划对从急诊部接受治疗并出院的退伍军人的影响，这些退伍军人具有重复就诊的高风险。我们将检验以下假设：H1：在急诊科就诊后参加以初级保健为基础的护士电话支持计划的退伍军人在随后30天内使用急诊室的比率将低于通常的护理。H2：在急诊科就诊后，参加以初级保健为基础的护士电话支持计划的退伍军人将比通常的护理有更高的满意度。H3：参加以初级保健为基础的护士电话支持计划的退伍军人在急诊科就诊后的180天内，与通常的护理相比，总的VA成本将更低。方法：这项研究是一项两组随机对照试验，旨在评估为急诊室接受治疗并出院的退伍军人提供结构化护士电话支持计划，这些退伍军人具有重复就诊的高风险。在获得知情同意后，退伍军人将被随机分配到护士电话支持或常规护理。Dispao ED将由一名研究护士(模拟PACT RN护理经理的角色)在索引ED访问后7天内致电2次，并可选择在14天内第三次致电。主要结果是定义为在30天内使用或不使用任何ED的两种结果。次要结果是患者在30天和180天内对VA医疗保健的满意度，以及180天内的总VA费用。意义：这项研究将提供关于如何促进大量高危退伍军人获得PACT并与其保持连续性的重要信息。Dispao ED的目标不是评估一个新的护理层次；而是测试一种干预措施，它将有助于为PACT护士护理经理能够和应该做些什么来促进退伍军人的最佳健康和医疗保健利用提供证据基础。在与临床合作伙伴的密切合作下设计，并得到PACT和急救医学领域领导者的认可，如果证明有效，可以利用现有的PACT资源和人员很容易地实施。

DESCRIPTION (provided by applicant): Background: More than 1 million Veterans receive care in Emergency Departments (EDs) in VA Medical Centers (VAMCs) annually. Nearly 1 in 5 Veterans treated and released from a VAMC ED receive additional unscheduled care in the ED or hospital within 30 days. The risk of repeat ED visits is particularly high among patients with chronic medical conditions who have received ambulatory medical services in the ED previously. An explicit goal of newly developed Patient Aligned Care Teams (PACTs) is to promote continuity in primary care clinics and thereby reduce ED utilization; however, there has been little research to guide PACTs in how to accomplish this. A key role for nurses within PACTs will be telephone management of high risk populations, and Veterans treated and released from the ED represent one such high-risk group. However, no studies have examined both the Veteran and system-level impact of using nurse care managers to support Veterans after an ED visit. Objectives: The overall goal of this study is to examine the impact of a primary care-based nurse telephone support program for Veterans treated and released from the ED who are at high risk for repeat visits. We will test the following hypotheses: H1: Veterans who participate in a primary care-based nurse telephone support program after an ED visit will have a lower rate of ED use in the subsequent 30 days compared to usual care. H2: Veterans who participate in a primary care-based nurse telephone support program after an ED visit will have higher satisfaction compared to usual care. H3: Veterans who participate in a primary care-based nurse telephone support program will have lower total VA costs in the 180 days following an ED visit compared to usual care. Methods: The proposed study is a two group randomized, controlled trial to evaluate a structured nurse telephone support program for Veterans treated and released from the ED who are at high risk for repeat visits. After informed consent is obtained, Veterans will be randomized to nurse telephone support [DISPO ED] or usual care. DISPO ED will consist of 2 calls from a study nurse (simulating the role of a PACT RN Care Manager) within 7 days of the index ED visit, with an option for a 3rd call within 14 days. The primary outcome is a dichotomous outcome defined as any ED use within 30 days or not. Secondary outcomes are patient satisfaction with VA health care at 30 and 180 days, and total VA costs within 180 days. Significance: This study will provide important information about how to promote access to and continuity with PACT for a large population of high risk Veterans. The goal of DISPO ED is not to evaluate a new layer of care; but rather to test an intervention that will contribute to the evidence base for what PACT nurse care managers can and should be doing to promote optimal health and health care utilization among Veterans. Designed in close collaboration with clinical partners, and endorsed by leaders in PACT and emergency medicine, DISPO ED could, if proven effective, be readily implemented using existing PACT resources and staffing.