Evaluating Sequential Strategies to Reduce Readmission in a Diverse Population

项目总结/摘要 再次入院是常见的，昂贵的，而且可能是可以预防的。它们也有潜在的反应能力， 卫生系统干预措施。然而，目前还不确定护理过渡干预措施的哪些组成部分是 有效性，对哪些人群，以及以什么样的成本。拟议的研究将评估三个层次的质量 改善（QI）干预，旨在减少出院后30天内的再入院， 城市安全网医院，为不同种族和语言的人群提供服务。很少有研究 评估了护理过渡干预措施，以减少低收入、多样化患者人群的再入院率， 关于这些多方面干预措施对再入院率的影响， 没有结论该项目将利用三个QI创新的独特序列， 从2007年开始，在一个综合安全网保健系统中实施再入院。我们 建议评估每项干预措施对减少再入院和治疗后的 出院护理“排放-转移”干预层次如下：1）第1级包括全面的， 个性化的家庭护理计划（HCP），由医疗服务楼层护士在 出院; 2）第2层增加了HCP到患者初级保健医疗之家的电子传输 在出院后的工作日，注册护士拨打外展电话， 出院患者确认对HCP的理解并解决医疗问题或需求; 3）第3层 进一步增加了一个社区卫生工作者，病人导航，参与床边讨论，以发展 了解患者的家庭情况，每周外展电话，以评估患者的需求， 促进患者和初级护理团队之间的沟通，并在 所有的医疗预约，以消除门诊随访的障碍。我们的项目包括三个研究目标。 首先，在回顾性时间序列分析中，我们将评估再入院和健康的增量效应 相对于先前的护理标准，第1级和第2级干预的护理使用。第二，我们会评估 一个正在进行的随机自然实验，关于再入院，医疗保健使用，药物依从性， 指示，并准备出院。这个自然实验的特点是随机分配到一个 两种QI干预，第2层或第3层，专门针对再入院高风险患者， 再入院的一个或多个以下风险因素：充血性心力衰竭的出院诊断，急性 冠状动脉综合征或肺炎;住院时间> 3天;周末出院;年龄> 60岁;或既往 在过去的六个月里住院。对于我们的第三个目标，我们将分析 Patient Navigator干预（第3层）相对于高风险患者的第2层干预。

Project Summary / Abstract Hospital readmissions are common, costly, and potentially preventable. They are also potentially responsive to health system interventions. However, it is uncertain which components of care transition interventions are efficacious, for which populations, and at what cost. The proposed study will evaluate a three-tiered quality improvement (QI) intervention intended to reduce hospital readmissions within 30 days post-discharge from an urban safety net hospital that serves a racially and linguistically diverse population. Few studies have evaluated care transition interventions to reduce readmissions among low-income, diverse patient populations, and the accumulated evidence on the effects of these multi-faceted interventions on readmission rates has been inconclusive. This project will take advantage of a unique sequence of three QI innovations to reduce hospital readmissions implemented beginning in 2007 in an integrated safety net health care system. We propose to evaluate the additive impact of each intervention on reductions in readmissions and on post- discharge care. The "discharge-transfer" intervention tiers are as follows: 1) Tier 1 includes a comprehensive, individualized home care plan (HCP) reviewed by the medical service floor nurse with the patient prior to discharge; 2) Tier 2 adds the electronic transmission of the HCP to the patient's primary care medical home where, on the business day following discharge, a Registered Nurse makes an outreach telephone call to the discharged patient to confirm comprehension of the HCP and to address medical questions or needs; 3) Tier 3 further adds a community health worker, the Patient Navigator, to participate in bedside discussions to develop rapport and learn about patients' home situations, weekly outreach calls to assess patients' needs and to facilitate communication between the patient and the primary care team, and reminder calls to patients prior to all medical appointments to eliminate barriers to outpatient follow-up. Our project includes three research aims. First, in a retrospective time series analysis, we will assess the incremental effect on readmissions and health care use of intervention tiers 1 and 2 relative to the prior standard of care. Second, we will evaluate the effects of an ongoing randomized natural experiment on readmissions, health care use, adherence to medication instructions, and preparedness for discharge. This natural experiment features random assignment to one of two QI interventions, Tier 2 or Tier 3, and exclusively targets patients at high risk for readmission, those with one or more of the following risk factors for readmission: discharge diagnosis of congestive heart failure, acute coronary syndrome, or pneumonia; length of stay > 3 days; weekend discharge; age > 60; or previous hospitalization within the past six months. For our third aim, we will analyze the costs and cost-effectiveness of the Patient Navigator intervention (Tier 3) relative to the Tier 2 intervention for high-risk patients.