Implementing and Evaluating INTERACT in VA CLCs

描述（由申请人提供）： 从疗养院（NHs）或社区生活中心（CLC）转移到医院使居民面临医源性事件，护理中断，定向障碍，压力和成本增加的风险。每年有超过50万的出院病例来自社区卫生服务机构，估计有23%至67%的可能避免的住院病例来自社区卫生服务机构。避免住院是一个重要的问题，VA老年病和延伸护理领导已确定为研究和干预的高度优先领域。减少急性护理转移的干预措施（INTERACT）是一项全面的，多层次的护理人员培训和质量改进计划，由Ouslander博士和他的同事设计，并在医疗保险和医疗补助服务中心（CMS）和联邦基金赞助的演示中进行了测试，并发现在参与的设施中减少了17%，24%的住院率。本研究的目的是在VHA CLC中实施和评估INTERACT。我们以基于证据的假设为指导，即参与INTERACT计划将更早地识别居民的临床问题，帮助评估和安全地启动对他们的管理，改善沟通和使用预先护理计划，并减少医院转移。 INTERACT计划、培训课程和工具将得到完善，以适合在VA环境中实施，包括标准CLC操作程序和VHA语言和政策。根据合并的VIREC和医疗保险住院和门诊数据以及CLC护士人员配置和其他组织数据，我们将在住院率、与VAMC医院的接近程度以及他们所服务的短期和长期CLC退伍军人的组合方面与CLC相匹配。将确定总共10对设施，并从每对设施中随机选出一对设施，以便与之接触实施互动方案。我们预计，至少有8个接触的设施将接受，采用和实施该计划在6个月的培训期和额外的12个月的积极干预和监测期。如果被随机选择提供INTERACT项目的CLC拒绝参与，则CLC匹配配对的两名成员将从研究中删除。在6个月的培训期和12个月的主动干预和监测期内，将收集大量的过程测量数据，包括员工在线培训的时间以及CLC员工参加支持电话会议的时间，以用于实施分析和预算影响分析（BIS）。此外，将审查工作人员在6个月培训和12个月干预监测期间用于检查住院特征和“可避免性”的质量改进工具。将不与匹配并随机选择为“对照”的CLC接触，因为其住院率的结果数据将完全来自现有记录数据。将检查干预和对照CLC对的病例组合和季节性调整的住院率的变化，比较引入INTERACT前两年和之后两年的变化。此外，还将审查不适当住院率的变化。我们假设INTERACT将使CLC中退伍军人的住院率降低至少20%，而不会增加不良事件。如果有效，GEC领导层随时准备将INTERACT纳入正在进行的努力，以改变CLC的文化，通过减少再住院，从而增加回家的可能性，使他们更加以退伍军人为中心和重点。

DESCRIPTION (provided by applicant): Transfers from nursing homes (NHs) or community living centers (CLCs) to hospitals place residents at risk for iatrogenic events, disruptions in care, disorientation, stress and increase costs. Over half a million hospital discharges a year emanate from community NHs and estimates of potentially avoidable hospitalizations have ranged from 23% to 67% of NH to hospital transfers. Avoidable hospitalizations are a significant issue that VA Geriatrics and Extended Care leadership has identified as a high priority area for study and intervention. The Interventions to Reduce Acute Care Transfers (INTERACT), a comprehensive, multi-level nursing staff training and quality improvement program, was designed by Dr. Ouslander and his colleagues and has been tested in demonstrations sponsored by the Centers for Medicare & Medicaid Services (CMS) and The Commonwealth Fund, and found to reduce hospitalizations by 17%, 24% among engaged facilities. The goal of this study is to implement and evaluate INTERACT in VHA CLCs. We are guided by the evidence based hypothesis that engagement in the INTERACT program will identify residents' clinical problems earlier, help evaluate and safely initiate management for them, improve communication and use of advance care planning and result in fewer hospital transfers. The INTERACT program, training curriculum and tools will be refined to be appropriate for implementation in a VA setting both in relation to standard CLC operating procedures and VHA language and policies. Based upon merged VIREC and Medicare inpatient and outpatient data and CLC nurse staffing and other organizational data, we will match CLCs in terms of hospitalization rate, proximity to their VAMC hospital and the mix of short and long stay CLC Veterans they serve. A total of 10 pairs of facilities will be identifie and from each pair one will be randomly selected to be approached about implementing the INTERACT program. We expect at least 8 of the facilities approached will accept, adopt and implement the program over the 6 month training period and the additional 12 month active intervention and monitoring period. Both members of the CLC matched pairs will be dropped from the study if the CLC that is randomly selected to be offered the INTERACT program declines to participate. During the 6 month training period and the 12 month active intervention and monitoring period, extensive process measures, ranging from staff time spent in on-line training as well as CLC staff time on the support conference calls, will be gathered for use in both the implementation analyses as well as the Budget Impact Analyses (BIS). Additionally, quality improvement tools applied by staff to examine the characteristics and "avoidability" of hospitalizations during the 6 month training and 12 month intervention monitoring period will be reviewed. There will be no contact with CLCs matched and randomly selected as "controls" since outcome data on their hospitalization rates will come exclusively from existing record data. Changes in the case-mix and seasonally adjusted hospitalization rates of intervention and control CLC pairs will be examined, comparing changes over the two years prior to introducing INTERACT and the two years thereafter. In addition, changes in rates of inappropriate hospitalizations will be examined. We hypothesize that INTERACT will reduce the hospitalization rate by at least 20% without increases in adverse events among Veterans in CLC. If effective, GEC leadership stands ready to integrate INTERACT into ongoing efforts to transform the culture of CLCs to make them more Veteran centered and focused by reducing re-hospitalization thereby increasing the likelihood of returning home.