Transitional Care Program for Medicaid Patients and Integrated Care Teams

描述（由申请人提供）：可接受的住院和再入院是卫生系统碎片化的指标，与次优的患者结局和可避免的护理成本相关。再入院通常是因为让出院的病人自己处理，不能遵循他们不理解的指示， 药物治疗或必要的后续护理。有效的护理协调和从医院到家庭的过渡可以防止许多导致再入院的不良结果，并降低医疗保健的经济成本。拟议的倡议将设计和测试一个创新的，系统的方法来管理医疗补助病人谁是由一个负责任的医疗组织（ACO）服务的出院。由于2型糖尿病和合并症的患病率、住院率和相关费用， 对人民进行干预。ACO雇用的护理协调员将接受培训，以便与住院患者及其护理团队一起使用过渡护理规划工具包。该方法的组成部分包括出院后管理药物，协调门诊护理支持，阐明患者如何最好地利用他或她的护理提供者，解决患者出院后在家中成功的特殊需求等。长期目标将是测试这种干预方法的有效性，以减少30天的再住院。在本I期研究期间，我们将：（1）设计一个工具包（材料和流程），以帮助患者及其ACO护理协调员制定出院后保持健康的计划。[(2)培训ACO护理协调员（N= 8）使用这些工具和流程，并让这些护理协调员与Medicaid受益人（N=48）一起使用这些工具和流程。] (3)使用半结构化访谈和焦点小组，测试工具和流程的初始设计在患者和护理协调员中的可接受性。这些访谈和焦点小组的反馈将用于改进方案设计。拟议的研究旨在开发针对ACO交付结构背景下接受护理支持的目标患者的独特需求的干预材料。这些材料将作为一个完整的集成产品进行销售。由于2型糖尿病并发症的流行，相关的住院率很高。如果达到可接受性指标，这种方法可以为未来的疗效测试提供基础，并满足许多州的医疗补助计划的需求。

DESCRIPTION (provided by applicant): Preventable hospital admissions and readmissions are indicators of health system fragmentation and are associated with suboptimal patient outcomes and avoidable costs of care. Readmissions often result from leaving discharged patients to their own devices, unable to follow instructions they didn't understand, and not taking medications or getting the necessary follow-up care. Effective care coordination and transitions from hospital to home can prevent many of the poor outcomes that give rise to hospital readmissions and reduce the economic costs of healthcare. The proposed initiative will design and test an innovative, systematic approach to managing hospital discharges of Medicaid patients who are served by an Accountable Care Organization (ACO). Due to the prevalence, hospitalization rates and associated costs of type 2 diabetes and comorbidities, we will tailor the intervention to that population. Care Coordinators employed by the ACO will be trained to use a transition care planning toolkit with hospitalized patients and their care teams. Components of this approach include managing medications following discharge, coordinating outpatient care supports, clarifying how the patient can best use his or her care providers, addressing special needs of the patient to succeed at home following discharge, etc. The long term goal will be to test the efficacy of this intervention approach to reduce 30-day rehospitalizations. During this Phase I study we will: (1) Design a toolkit (materials and processes) to assist patients and their ACO Care Coordinators plan for a maintaining their health following discharge from the hospital. [(2) Train ACO Care Coordinators (N= 8) in the use of these tools and processes and have these Care Coordinators utilize the tools and processes with Medicaid beneficiaries (N=48).] (3) Test the initial design of tools and processes for acceptability among patients and the Care Coordinators using semi-structured interviews and focus groups. Feedback from these interviews and focus groups will be used to refine the program design. The proposed research is intended to develop intervention materials tailored to the unique needs of targeted patients receiving care support within the context of an ACO delivery structure. These materials will be structured to be marketed as a complete integrated product. Because of the prevalence of type 2 diabetes complications, associated hospitalizations are high. If acceptability metrics are achieved, this approach could provide a base for future efficacy testing and meet the needs of Medicaid programs in many States.