Optimizing the value of community care for Veterans with advanced kidney disease

背景：退伍军人健康管理局提供维持性透析的历史由来已久 退伍军人终末期肾病(ESRD)社区治疗 程序。从2015财政年度开始，可以在社区获得专门的肾病治疗 对于更多患有晚期肾病的退伍军人来说，在退伍军人的领导下，他们还没有接受透析 选择方案(VCP)，预计将在综合社区关怀方案下继续实施。就像他们的 同行正在进行透析，退伍军人晚期肾脏疾病不进行透析是一种高成本的高需求 获得护理的机会、护理的连续性和护理的协调在#年都至关重要 优化质量和成果。所有这三个指标对于建立牢固的 患者和提供者，并支持评估、重新评估和护理的那种迭代周期 需要协调才能妥善照顾这些患者 目的：我们将使用混合方法来研究退伍军人管理局不断发展的社区护理政策对 患有晚期肾脏疾病的退伍军人的结果和成本，并确定计划的机会 进步。因为与这一人群相关的许多结局和护理过程对 护理的连续性和协调性，我们假设接受退伍军人管理局资助的肾病治疗 社区将对与该人群相关的一系列临床结果和护理过程产生负面影响 而且将比退伍军人管理局提供的肾病治疗更昂贵。我们预计，对于某些群体来说， 护理分散和中断的潜在危害可能会被更及时的护理的好处所盖过 在社区接受所需的护理。因为一些退伍军人医疗中心在 协调护理与社区提供者以减轻护理支离破碎的影响，我们假设 退伍军人管理局资助的社区护理在人口内部和整个退伍军人管理局之间的效果将是不同的 医疗中心可以为改善这一人群的社区转诊过程提供信息。 方法：我们将使用国家退伍军人管理局和临床数据来跟踪退伍军人管理局资助的影响 社区护理对退伍军人临床结局、护理过程和退伍军人退伍军人系统费用的影响 使用工具变量方法的晚期肾脏疾病(目标1)。找出机会， 为了提高社区转诊对这一群体的价值，我们将汲取以下观点和经验 患有晚期肾病的退伍军人有资格或接受退伍军人管理局资助的社区护理和他们的退伍军人管理局和 社区护理提供者(目标2)。 影响：该提案将直接涉及退伍军人事务部HSR&D的三个优先领域(医疗保健系统变化， 医疗保健准入和以患者为中心的护理、护理管理和健康促进)。建议的工作 鉴于2018年退伍军人事务部任务法案最近通过了两项法案，这是非常及时和与政策相关的 众议院和参议院都得到了两党的大力支持。我们预计，我们的工作是衡量 由退伍军人协会资助的社区肾脏病护理将有助于识别患有晚期肾脏疾病的退伍军人 更有效地利用机构资源以优化获取、连续性和协调的机会 照顾退伍军人群体中的高成本、高需求群体。以确保我们的工作已经准备就绪 退伍军人事务部围绕社区护理提供不断发展的政策，调查人员正在与VHA National合作 肾脏疾病计划和社区护理办公室。

Background: The Veterans Health Administration has a long history of providing maintenance dialysis treatment for Veterans with end-stage renal disease (ESRD) in the community under the VA Fee Basis program. Starting Fiscal Year 2015, access to specialized nephrology care in the community became available to the much larger population of Veterans with advanced kidney disease not yet on dialysis under the Veterans Choice Program (VCP) and is expected to continue under a consolidated Community Care program. Like their counterparts on dialysis, Veterans with advanced kidney disease not on dialysis are a high-cost high-needs population for whom access to care, continuity of care and coordination of care are all vitally important in optimizing quality and outcomes. All three metrics are important in building strong relationships between patients and providers, and supporting the kind of iterative cycle of evaluation and re-evaluation and care coordination needed to properly care for these patients Objective: We will use mixed methods to study the impact of the VA’s evolving community care policy on outcomes and costs for Veterans with advanced kidney disease and identify opportunities for program improvement. Because many of the outcomes and care processes relevant to this population are sensitive to continuity and coordination of care, we hypothesize that receipt of VA-financed nephrology care in the community will negatively impact a range of clinical outcomes and care processes relevant to this population and will be more costly than nephrology care provided within the VA. We anticipate that for some groups, the potential harms of care fragmentation and discontinuity may be outweighed by the benefits of more timely receipt of needed care in the community. Because some VA medical centers may be more effective in coordinating care with community providers to mitigate the effects of care fragmentation, we hypothesize that there will be heterogeneity in the effect of VA-financed community care within the population and across VA medical centers that could be informative in improving the process of community referral for this population. Methods: We will use national VA administrative and clinical data to track the impact of VA-financed community care on clinical outcomes, care processes and costs to the VA system among Veterans with advanced kidney disease using an instrumental variable approach (Aim 1). To identify opportunities for improving the value of community referral for this population, we will elicit the perspectives and experiences of Veterans with advanced kidney disease eligible for, or receiving VA-financed community care and their VA and community care providers (Aim 2). Impact: This proposal will directly address three VA HSR&D priority areas (Health Care Systems Change, Healthcare Access and Patient-centered Care, Care Management, and Health Promotion). The work proposed here is extraordinarily timely and policy-relevant given that the VA MISSION Act of 2018 recently passed both the House and the Senate with strong bipartisan support. We anticipate that our work to measure the impact of VA-financed community nephrology care on Veterans with advanced kidney disease will help to identify opportunities for more effective use of agency resources to optimize access, continuity and coordination of care for a high-cost high-needs segment of the Veteran population. To ensure that our work is poised to shape evolving VA policy around provision of community care, the investigators are partnering with the VHA National Program for Kidney Disease and the Office of Community Care.