Factors Associated with Institutional Use by Veterans in Home Based Primary Care

VA家庭基础初级保健（HBPC）是一个跨学科的团队为基础的家庭护理计划， 最年长的老年退伍军人（85岁以上）和年轻的OIF/OEF退伍军人的快速老化队列， 禁用条件。2011年，约有15，000名退伍军人在139 VA医疗中心HBPC注册 在全国范围内有101个社区门诊诊所。虽然HBPC 已经沿着多个机构利用维度（例如，住院 由于住院天数和费用的不同，机构护理的使用在全国各地的HBPC计划中差异很大。低 利用机构护理可能会建议采取量身定制的方法来优化退伍军人的护理。更高的利用率 机构护理可能是潜在的不适当或管理不善的护理指标， HBPC退伍军人有并发症的风险。拟议的研究旨在确定导致这些问题的因素 通过调查HBPC组织结构，团队运作和八个 医院、急诊科（艾德）机构使用的风险调整质量措施（QM），以及 疗养院（NHs）。重新设计医疗保健系统的出发点是了解 护理发生的环境的组织结构属性。为此目的， 进行了开发HBPC计划的组织结构特征的轮廓。结构 是指HBPC计划的特点，影响系统的能力，提供初级保健服务， 退伍军人在他们的家，包括HBPC计划标准，团队结构和远程医疗技术。 然后，该研究将评估HBPC跨学科团队在以下七个方面的差异 维度：文化、领导力、沟通、协调、冲突管理、团队凝聚力和团队 通过管理和分析组织评估问卷（OAQ）提高效率 调查.接下来，将分析HBPC组织结构和团队运作之间的关联， 确定与更有效的团队运作相关的组织结构。最后，影响 HBPC的组织结构和团队功能对HBPC护理质量的影响将在以下方面进行检查： 机构用途：住院和NH入院天数、30天和90天的风险调整QM 再住院、艾德就诊和退伍军人死亡部位。将获得本拟定研究的主要数据 通过调查和现场观察访问。次要数据将包括2年的VA和CMS患者 数据库（2013-2014年）。这项研究的结果将确定组织结构和团队职能 与较少使用机构护理有关，可作为最佳做法纳入政策和系统 重新设计计划，将绩效较低的HBPC计划提升到绩效最高的水平 程序.最终，减少可避免的和昂贵的机构护理推进HBPC计划目标， 这样，使HBPC退伍军人能够在家中接受治疗，并保持他们最大的独立性。

VA Home Based Primary Care (HBPC) is an interdisciplinary team-based home care program that serves a rapidly aging cohort of oldest old Veterans (85+) and younger OIF/OEF Veterans with complex chronic disabling conditions. In 2011, approximately 15,000 Veterans were enrolled in 139 VA Medical Center HBPC programs and an associated 101 community-based outpatient clinic locations nationwide. Although HBPC program quality has been established along a number of institutional utilization dimensions (e.g., inpatient days) and cost, the use of institutional care varies substantially across HBPC programs nationally. Lower utilization of institutional care may suggest tailored approaches that optimize a veteran's care. Higher utilization of institutional care may be an indicator of potentially inappropriate or mismanaged care that places vulnerable HBPC Veterans at risk for complications. The proposed study seeks to identify the factors contributing to these variations by investigating associations between HBPC organizational structures, team functioning, and eight risk adjusted quality measures (QMs) of institutional use for hospitals, emergency departments (ED), and nursing homes (NHs). The starting place for redesigning the health care system is to understand the organizational structural attributes of the settings in which care occurs. To that end, a structural survey is conducted to develop a profile of the organizational structure characteristics of HBPC programs. Structure refers to HBPC program characteristics that affect the system's capacity to deliver primary care services to Veterans in their home and includes HBPC program standards, team structures, and telehealth technology. The study will then evaluate differences in HBPC interdisciplinary team functioning with regard to seven dimensions: culture, leadership, communication, coordination, conflict management, team cohesion, and team effectiveness through administration and analysis of the organizational assessment questionnaire (OAQ) survey. Next, associations between HBPC organizational structures and team functioning will be analyzed to identify organizational structures associated with more effective team functioning. Finally, the influence of HBPC organizational structures and team functions on the quality of HBPC care will be examined with respect to risk-adjusted QMs of institutional use: hospital and NH admissions and days, 30-day and 90-day rehospitalizations, ED visits, and Veteran's site of death. Primary data for this proposed study will be obtained through surveys and on-site observational visits. Secondary data will include two years of VA and CMS patient databases (2013-2014). Findings from this study will identify organizational structures and team functions associated with lower use of institutional care that can be integrated as best practices into policies and system redesign initiatives to bring lower performing HBPC programs up to the level of the highest performing programs. Ultimately, reducing avoidable and costly institutional care advances HBPC program goals, and as such, enables HBPC Veterans to be treated at home and to retain their maximal independence.