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

退伍军人家庭初级护理(HBPC)是一项基于团队的跨学科家庭护理计划，为 患有复杂慢性疾病的年龄最大的老年退伍军人(85岁以上)和较年轻的OIF/OEF退伍军人的快速老龄化队列 禁用条件。2011年，大约15,000名退伍军人参加了139个退伍军人医疗中心HBPC 计划和相关的101个以社区为基础的门诊点。虽然HBPC 计划质量已经建立在许多机构利用维度上(例如，住院患者 天数)和费用，机构护理的使用在全国各地的HBPC项目中有很大差异。更低的位置 机构护理的利用可能会建议采用量身定做的方法，以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的指标，使弱势群体 HBPC退伍军人面临并发症的风险。拟议的研究旨在找出导致这些问题的因素 通过调查HBPC组织结构、团队功能和八个因素之间的关联而产生的差异 医院、急诊科(ED)和医院机构使用的风险调整质量措施 养老院(NHS)。重新设计医疗保健系统的出发点是理解 护理发生的环境的组织结构属性。为此，一项结构性调查是 对HBPC方案的组织结构特点进行了概述。结构 指影响系统向以下人员提供初级保健服务的能力的HBPC方案特征 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运作差异 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)的有效性 调查。接下来，将分析HBPC组织结构和团队功能之间的关联，以 确定与更有效的团队运作相关的组织结构。最后， 将尊重审查HBPC组织结构和团队职能对HBPC护理质量的影响 到机构使用的风险调整质量管理体系：住院和NH入院以及天数、30天和90天 再住院、急诊和退伍军人死亡地点。将获得这项拟议研究的主要数据 通过调查和现场观察访问。次要数据将包括两年的退伍军人管理局和CMS患者 数据库(2013-2014)。这项研究的结果将确定组织结构和团队职能 与较少使用可作为最佳做法整合到政策和系统中的机构护理相关 重新设计计划，使性能较低的HBPC程序达到最高性能的水平 程序。归根结底，减少可避免和昂贵的机构护理促进了HBPC方案的目标， 这样，HBPC退伍军人可以在家中接受治疗，并保持最大限度的独立性。

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.