Chronic Care Management Model Translation to Multimorbid Aging Adults at FQHCs

描述（由申请人提供）：尽管慢性护理成本很高，但患者护理满意度、教育、激活和结果都不是最佳的。由于患有多种慢性疾病（即多重疾病）的老年人越来越普遍，以及在不增加成本的情况下提高护理质量的财政紧迫性，迫切需要进行转化研究，以测试创新模式，使高风险患者能够与其保健家庭合作管理慢性病，同时改善护理结果。本应用程序的主要目的是将慢性护理干预（CCI）转化为具有高基线急性护理利用率的多病老年人。为此，将实现以下具体目标：1)评估慢性护理干预（CCI）对拥有联邦合格健康中心（FQHC）家庭的多病和高基线急性护理使用的老年人的健康激活的影响；2)评估CCI对多病、高基线急性护理使用的老年人家庭FQHC的影响；3)评估有FQHC家庭的多病、高基线急性护理使用的老年人CCI的成本-效果。CCI将采用随机、单盲临床试验设计进行测试。研究入组标准包括45岁以上的FQHC家庭患者（n = 300），他们居住在社区，至少有两种慢性疾病。在获得irb批准的书面知情同意后，参与者将使用随机化软件程序被分为两组之一，该程序将根据潜在的混杂因素对每位参与者进行分层。干预将由注册护士和社会工作者小组实施，为干预组参与者提供自我管理支持和护理协调，使参与者成为其保健小组的合作伙伴。注意控制干预将由一名社会服务辅助专业助理实施，该助理将向对照组参与者提供有关社区资源的信息，以便他们在家中获得帮助，如果他们自我确定需要这种支持的话。参与者和/或家庭成员/照顾者可以联系社区资源，如果他们愿意的话。所有参与者将在基线、3、6、9和12个月时评估相关结果（健康激活评分、自评健康状况和健康相关生活质量）。急性护理利用数据将在3,6,9和12个月时进行评估。特异性目标1的主要结局将是参与者激活阶段。具体目标2的主要结果将是第一次急诊科就诊或住院的天数以及急诊科就诊和住院的总次数。具体目标3的结果将是与健康有关的生活质量。为了评估目的，将使用随机效应回归技术来确定各组差异：1)患者随时间的激活，2)急诊科就诊和再住院，以及3)随时间的健康相关生活质量。实验干预的预期结果是参与者的活跃度、健康状况评级和健康相关的生活质量将会增加，急诊科就诊次数、住院次数和费用将会减少。这一贡献意义重大，因为它将促进对社区伙伴关系和最佳做法的了解，以增强保健之家的能力，以积极主动和知情的患者参与的方式提供以患者为中心的团队护理，并导致更有效地利用卫生保健资源。

DESCRIPTION (provided by applicant): Despite high chronic care costs, patient care satisfaction, education, activation and outcomes are sub-optimal. Translational research to test innovative models that will empower high risk patients to manage chronic conditions in collaboration with their health homes while improving care outcomes is critically needed because of the growing prevalence of aging adults with multiple chronic conditions (i.e., multimorbidity), and the fiscal urgency for higher care quality without increased costs. The main objective of this application is to translate the Chronic Care Intervention (CCI) to aging adults with multimorbidity that have a high baseline rate of acute care utilization. To this end, the following specific aims will be achieved: 1) Evaluate the impact of the Chronic Care Intervention (CCI) on health activation among aging adults with multimorbidity and high baseline acute care use who have a Federally Qualified Health Center (FQHC) home; 2) Evaluate the impact of the CCI on acute care utilization among aging adults with multimorbidity and high baseline acute care use who have a FQHC home; and 3) Evaluate the cost-effectiveness of the CCI among aging adults with multimorbidity and high baseline acute care use who have a FQHC home. The CCI will be tested using a randomized, single- blind clinical trial design. Study entry criteria include FQHC home patients over 45 years of age (n = 300) who live in the community and have at least two chronic conditions. After IRB-approved written informed consent, participants will be placed into one of the two groups using a randomization software program that will stratify each participant across potential confounders. The intervention will be implemented by a RN and Social Worker team to provide intervention-arm participants with self-management support and care coordination such that participants are engaged as partners with their health team. Attention control intervention will be implemented by a Social Services Paraprofessional Aide who will provide control participants with information about available community resources for assistance in the home if they self-identify a need for such support. Participants and/or famil members/caregivers could then contact the community resource if they so desired. All participant will be assessed on pertinent outcomes (health activation scores, self-rated health status, and health-related quality of life) at baseline, 3, 6, 9, and 12 months. Acute care utilization data will be assessed at 3, 6, 9 and 12 months. The primary outcome for Specific Aim 1 will be participant activation stage. The main outcomes for Specific Aim 2 will be days to first ED visit or hospitalization and total number of ED visits and hospitalizations. The outcome for Specific Aim 3 will be health-related quality of life. To evaluate the aims, random-effects regression techniques will be performed to identify group differences on 1) patient activation over time, 2) ED visits and rehospitalizations, and 3) health-related quality of life over time. Th expected outcomes of the experimental intervention are that participant activation, health status ratings, and health-related quality of life will increase and that ED visits, hospital admissions, and costs will be reduced. This contribution is significant because it will advance knowledge about community partnerships and best practices to enhance the ability of health homes to provide patient-centered team-based care in a manner that engages activated and informed patients and results in more effective use of health care resources.