Identifying and Delivering Point-of-care Information to Improve Care Coordination

描述(由申请人提供)： 多学科护理团队，如退伍军人管理局(VA)的患者对齐护理团队(PACTS)，已被提议作为改善护理协调的多种战略之一。为使这一战略取得成功，《公约》成员必须擅长协调行动，即，在相互依存的任务上共同努力，提供单一提供者无法有效完成的循证护理。然而，监测团队协调的能力仍处于初级阶段；目前的护理协调措施主要侧重于住院或急诊科利用等利用结果。其中一位PIs之前的研究表明，及时、个性化和可定制的反馈和跟踪工具是成功的转诊团队协调和提高护理质量的重要促进器。此外，在此应用程序的规划会议上，我们的VISN 12合作伙伴确定了辅助设备的需求，以帮助更好地协调患者护理，并指出目前的PACT Compass协调措施是在遭遇后2-3个月实施的。因此，护理点协调辅助对于患者跟踪、反馈和随访是非常必要的。项目目标我们的目标是确定《公约》成员对护理点信息的需求，以便成功地协调护理，并确定在护理点提供该信息的最佳机制。使用PACT环境中三种高危患者护理场景的护理协调作为测试案例：糖尿病患者、癌症诊断延迟风险患者以及最近出院后用药剂量低于最佳剂量的CHF患者，我们将实现以下目标：1.为PACTS中的有效协调制定可衡量的标准，并根据对整体护理质量的贡献进行优先排序和加权。2.利用目标1中制定的可衡量标准，确定护理地点所需的具体信息，以改进协调，并开发提供所需信息的护理地点辅助工具。3.评估采用上述协调标准和护理点辅助工具对PACT临床医生协调行为的影响。项目方法本实施计划预审采用混合方法设计；我们将采用生产力测量和增强系统(PROMES，一种用于制定绩效衡量和评估生产力的结构化方法)来制定有效协调的措施(目标1)，确定基于PACT实践的协调信息需求，并开发用于改善协调的护理辅助工具(目标2)，并评估它们在初级保健诊所通过前和通过后/实施期间的协调效果(目标3)。这项研究将由3个分支机构组成：(1)一个同时控制分支机构(2个VISN 16个分支机构)，它只接受被动监测；(2)一个测量和反馈分支机构(2个分支机构12个分支机构)，它将参与设计协调措施，并定期接受对其协调表现的反馈；(3)一个全面干预分支机构(2个分支机构)，除了测量和反馈分支机构所包括的一切外，还将设计和使用旨在改善协调的护理点辅助工具。我们将在基线结束后(即完成护理协调措施制定和第一次部署护理点援助之间)监测协调长达一年的时间。将使用描述性统计和纵向分析(如多水平建模)来评估不同地点之间以及部署护理点辅助设备前后的协调差异。

DESCRIPTION (provided by applicant): Multidisciplinary care teams, such as the Veterans Administration's (VA) Patient Aligned Care Teams (PACTs), have been proposed as one of multiple strategies to improve care coordination. For such a strategy to succeed, PACT members must excel at the act of coordinating, i.e., working collectively on interdependent tasks to deliver evidence-based care that could not be accomplished as effectively by a single provider. However, the ability to monitor team coordination is still in its infancy; current measures of care coordination focus primarily on utilization outcomes such as hospitalization or Emergency Department utilization. Previous research by one of the PIs identified timely, individualized, and customizable feedback and tracking tools as essential facilitators of successful referral team coordination and improved quality of care. Additionally, in a planning meeting for this application our VISN 12 partners identified a need for aids to help better coordinate patient care, noting that current PACT Compass coordination measures arrive 2-3 months after an encounter. Thus, point-of-care coordination aids are a critical need for patient tracking, feedback, and follow-up. PROJECT OBJECTIVES Our objective is to determine the point-of-care information needs of PACT members to successfully coordinate care and to identify the optimal mechanisms of delivering that information at the point of care. Using as test cases care coordination in PACT settings for three high-risk patient care scenarios: patients with uncontrolled diabetes mellitus, patients at risk for delayed cancer diagnosis, and CHF patients with sub-optimal medication dosage after a recent hospital discharge, we will accomplish the following objectives: 1. Develop measurable criteria for effective coordination in PACTs, prioritized and weighted by contribution to overall quality of care. 2. Using the measurable criteria developed in Aim 1, determine the specific information needed at the point of care to improve coordination and develop point-of-care aids for delivering the needed information. 3. Assess the effect of adopting the aforementioned coordination criteria and point-of-care aids on PACT clinicians' coordination behaviors. PROJECT METHODS This implementation planning pre-trial employs a mixed methods design; we will adapt the Productivity Measurement and Enhancement System (ProMES, a structured methodology for developing performance measures and assessing productivity) to develop measures of effective coordination (Aim 1), identify PACT practice-based coordination information needs and develop point-of-care aids for improving coordination (Aim 2), and assess the effectiveness of their coordination in pre- and post-adoption/implementation periods (Aim 3) in primary care clinics. The study will comprise 3 arms: (1) a concurrent control arm (2 VISN 16 sites), which will only be monitored passively; (2) a measurement and feedback arm (2 VISN 12 sites), which will be involved in designing the coordination measures and receive periodic feedback on their coordination performance; and (3) a full intervention arm (2 VISN 12 sites) which, in addition to everything included in the measurement and feedback arm, will design and use point-of-care aids aimed at improving coordination. We will monitor coordination for up to one year after end of baseline (i.e., the period between the completion of care coordination measure development and the first deployment of point-of-care aids). Differences in coordination both across sites and pre- vs. post- deployment of point-of-care aids will be assessed using descriptive statistics and longitudinal analyses such as multilevel modeling.