Improving patient-centered care coordination for high-risk Veterans in PACT

 描述(由申请人提供)： 项目背景：在各种不同的医疗保健支付系统中，少数患者承担了大部分费用。在VHA内，有三种或三种以上慢性病的患者中有三分之一的人承担了三分之二的费用。还有一小部分患者在短期内面临急性护理的高风险，这是成本的最大单一驱动因素。作为VHA患者导向护理团队(PACT)的一部分，由初级保健护理的退伍军人可以使用护理评估需求(CAN)评分确定为死亡风险较高或需要住院的退伍军人。当这些脆弱的患者在护理协调方面遇到差距时，他们很可能会经历负面结果。尽管管理高危患者的各种护理模式已经在VHA外进行了测试，但结果是不同的。在VHA内部，以患者为中心的重症监护团队(IMPACT)试点和五个地点的PACT强化管理(PIM)演示为PACT团队如何更普遍地成功护理高危患者提供了深入的见解。仍然迫切需要制定更好的方法，为这些高危退伍军人实施协调护理。项目目标：拟议的计划旨在实现以下影响目标：改善PACT中高危退伍军人的护理协调和跨环境护理体验。这一目标与卓越转型行动蓝图1a(复杂退伍军人公约中的护理协调)、2a(“三重目标”：更好的健康、护理和价值)、6e(利用社区资源)和8d(与社区组织合作)以及MyVA重点领域1：改善退伍军人体验；3：建立持续业绩改进的文化，以及4：加强退伍军人与社区的战略伙伴关系相一致。在这一方案中，实施项目1旨在通过远程指导战略结合在线工具包，传播协调护理高危退伍军人的战略。质量改进项目旨在通过调整和推广基于试点测试的计算机化患者记录系统(CPRS)的护理协调系统，在退伍军人管理局大洛杉矶医疗系统(VAGLAHS)的所有PACT地点进行ED-PACT移交，从而改善急诊科(ED)和PACT之间的协调。实施项目2旨在通过采用现有的“社区协调”干预措施，改善高危退伍军人出院时与其家乡社区之间的协调。实施核心侧重于评估和改进组织准备情况，以便在PACT和其他护理环境之间进行护理协调；2)反映患者报告的护理经验以及电子数据的核心评价指标；3)制作跨项目的综合护理协调工具包。项目方法：退伍军人事务部患者护理服务、质量、安全和价值办公室将与QUERI合作完成拟议的工作。实施项目1涉及1)开发PACT中护理协调的在线工具包，2)在PACT站点试行远程辅导干预，以及3)将单独使用在线工具包的效果与工具包加辅导的组合进行比较。质量改进项目将通过从急诊科提供者向PACT护士护理经理发送结构化消息来改善急诊科和PACT团队之间的沟通，后者然后牵头对适当的护理进行分流和安排。实施项目2将包括：1)根据VAGLAHS和洛杉矶社区机构对高危退伍军人的需求，调整先前测试过的“社区协调”干预措施；2)在VAGLAHS试行为期6个月的调整干预措施；3)在出院时对450名患者进行全面干预评估，其中一半随机分配到干预措施组，一半接受常规护理。实现核心将与每个项目对接，并在现有文献的基础上开发工具 评估和改善组织对护理协调的准备情况。

 DESCRIPTION (provided by applicant): Project Background: Across a variety of different health care payment systems, a minority of patients account for the majority of costs. Within VHA, the one-third of patients who have three or more chronic conditions account for two-thirds of costs. An even smaller group of patients is at near-term high risk of acute care, the single greatest driver of costs. Veterans cared for by primary care as part of VHA's Patient Aligned Care Teams (PACT) can be identified as at high risk of death or need for hospitalization using the Care Assessment Need (CAN) score. When these vulnerable patients experience gaps in care coordination, they are highly likely to experience negative outcomes. Although a variety of models of care to manage high-risk patients have been tested outside VHA, results have been variable. Within VHA, the Intensive Management Patient-Aligned Care Team (ImPACT) pilot and the five-site PACT Intensive Management (PIM) demonstration are providing insights into how PACT teams more generally can successfully care for high-risk patients. There remains an urgent need to develop better ways to implement coordinated care for these high-risk Veterans. Project Objectives: The proposed program aims to achieve the following impact goal: to improve care coordination and experience of care across settings for high-risk Veterans in PACT. This goal is aligned with Blueprint for Excellence transformational actions 1a (Coordination of Care in PACT for Complex Veterans), 2a ("Triple Aim": Better Health, Care, and Value), 6e (Leverage Community Resources), and 8d (Collaborate with Community-based Organizations), and with MyVA focus areas 1: improving Veteran experience; 3: establishing a culture of continuous performance improvement, and 4: enhancing strategic VA- community partnerships. Within this program, Implementation Project 1 aims to disseminate strategies for coordination of care for high-risk Veterans via a distance-coaching strategy combined with an online toolkit. The quality improvement project aims to improve coordination between the Emergency Department (ED) and PACT by adapting and spreading a pilot-tested Computerized Patient Record System (CPRS)-based care coordination system for ED-PACT handoffs across all PACT sites in the VA Greater Los Angeles Healthcare System (VAGLAHS). Implementation Project 2 aims to improve coordination between high-risk Veterans and their home communities at hospital discharge by adapting an existing "community alignment" intervention. The implementation core focuses on assessing and improving organizational readiness for care coordination between PACT and other care settings; 2) core evaluation metrics reflecting patient-reported care experiences as well as electronic data; and 3) production of a combined care coordination toolkit across projects. Project Methods: The VA Offices of Patient Care Services, and Quality, Safety and Value will partner with QUERI to accomplish the proposed work. Implementation Project 1 involves 1) developing an online toolkit for care coordination in PACT, 2) piloting a distance coaching intervention at PACT sites, and 3) comparing the effectiveness of the online toolkit alone to the combination of the toolkit plus coaching. The quality improvement project will improve communication between the ED and the PACT team by a structured message being sent from the ED provider to the PACT nurse care manager, who then takes lead in triaging and arranging for appropriate care. Implementation Project 2 will involve 1) adapting a previously-tested "community alignment" intervention to the needs of VAGLAHS and Los Angeles community agencies for high- risk Veterans; 2) piloting the adapted intervention at VAGLAHS over a six-month period; 3) evaluating the full intervention at hospital discharge with 450 patients, half randomly assigned to the intervention and half to usual care. The implementation core will interface with each of the projects and build on existing literature to develop tools for assessing and improving organizational readiness for care coordination.