Evaluating Innovative Care Models for High-Utilizing Patients

描述(由申请人提供)： 背景：退伍军人管理局使用率最高的患者通常有复杂的医疗保健需求-包括复杂和多种慢性病、并存的精神健康状况和社会压力源-这导致了高住院率、急救服务和特殊护理使用率。受到针对高利用率患者的新兴重症初级护理模式的启发，VA Palo Alto获得了2012-2013财年专科护理转型办公室(OSCT)的资助，推出了一项新计划，通过由多学科团队提供的重症护理来增强现有的PACT模式。强化管理协定(IMPACT)干预措施包括一系列循证战略，包括全面的摄取过程、专业护理的协调、慢性病病例管理、提供社会服务、对健康恶化的快速反应，以及促进高敏感度事件后的过渡。目的：通过本次HSR&D试点，评价IMPACT的可行性、实施性和有效性，为后续多中心随机对照试验(RCT)奠定基础。方法：我们将与退伍军人事务部帕洛阿尔托Impact诊所的实施团队合作，对该计划的可行性、实施和有效性进行混合类型1评估。在IMPACT的第一阶段，VA Palo Alto确定了PACT患者，他们是该设施成本最高的5%，但没有参加其他强化管理计划。随机选择了150名患者参加IMPACT的即时登记，272名患者被分配到延迟登记，并将继续接受常规的PACT护理，从而作为我们分析的对照组。我们的影响评估将使用退伍军人事务部帕洛阿尔托决策支持系统(DSS)办公室的数据，以及由诊所进行内部评估的调查数据，以实现以下目标：目的1：评估试点影响干预的可行性和实施情况。我们将利用与Impact和PACT团队成员和领导层的半结构化访谈，评估干预交付的成功，包括患者识别、招聘和留住；提供和采用计划服务；以及监测患者参与和关键结果。目的2：获得对影响对医疗服务利用率和费用影响的初步估计，并改进分析技术，为后续的多中心研究做准备。我们将使用差异法，在接受常规PACT护理的Impact患者和高利用率患者中，我们比较VA医疗成本(总成本以及住院、门诊和收费基础)和利用率(包括住院、急诊科就诊和专科护理)的变化。通过这些分析，我们将获得关键结果效应大小的点估计，并为随后的多中心随机对照试验改进我们的分析方法。目的3：检查影响参与和以患者为中心的结果之间的联系，并改进调查工具以供未来评估。使用IMPACT诊所管理的调查数据，我们将评估患者对IMPACT干预和整体护理的满意度，以及患者报告的结果的变化，包括健康状况、症状负担和功能。我们还将评估调查工具，以消除冗余，提高识别能力，并在随后的研究中减轻患者的负担。在综合试验结果后，我们将得出推荐的样本量和抽样策略，细化主要和次要结果，并为随后的多点随机对照试验制定研究方案。我们的试点工作还将产生评估工具，可以传播给正在设计和研究退伍军人管理局内复杂和高利用率患者护理模式的其他人。

DESCRIPTION (provided by applicant): Background: VA's highest-utilizing patients generally have complicated health care needs-including complex and multiple chronic conditions, comorbid mental health conditions, and social stressors-that contribute to high rates of hospitalization, emergency services, and specialty care use. Inspired by emerging intensive primary care models for high-utilizers, VA Palo Alto obtained FY2012-FY2013 Office of Specialty Care Transformation (OSCT) funding to launch a novel program that augments the existing PACT model with intensive care delivered by a multidisciplinary team. The Intensive management PACT (ImPACT) intervention encompasses a number of evidence-based strategies, including a comprehensive intake process, coordination of specialty care, chronic condition case management, provision of social services, rapid response to deteriorations in health, and facilitation of transitions after high-acuity events. Objectives: Through this HSR&D pilot, we will evaluate ImPACT's feasibility, implementation, and effectiveness, and lay the groundwork for a follow-up multi-center randomized controlled trial (RCT). Methods: We will partner with the implementation team of VA Palo Alto's ImPACT clinic to conduct a Hybrid Type 1 evaluation of the program's feasibility, implementation, and effectiveness. For the first phase of ImPACT, VA Palo Alto identified PACT patients who were among the most costly 5% for the facility but were not enrolled in other intensive management programs. A random sample of 150 patients were selected for immediate enrollment in ImPACT, and 272 were assigned to delayed-enrollment and will continue to receive usual PACT care, thereby serving as a control group for our analyses. Our evaluation of ImPACT will use data from VA Palo Alto's Decision Support System (DSS) office, as well as data from surveys that are being administered by the clinic for an internal evaluation, to meet the following objectives: ¿ Aim 1: Evaluate the feasibility and implementation of the pilot ImPACT intervention. Using semi- structured interviews with ImPACT and PACT team members and leadership, we will evaluate the success of intervention delivery, including patient identification, recruitment, and retention; provision and uptake of planned services; and monitoring of patient participation and key outcomes. ¿ Aim 2: Obtain preliminary estimates of ImPACT's effect on utilization and costs of care, and refine analytic techniques for a subsequent multi-center study. We will use a difference-in- differences approach, wherein we compare changes in VA health care costs (total, as well as inpatient, outpatient, and fee-basis) and utilization (including hospitalizations, emergency department visits, and specialty care) among ImPACT patients and high-utilizing patients who are receiving usual PACT care. Through these analyses, we will obtain point estimates for effect sizes of key outcomes and refine our analytic methods for a subsequent multi-center RCT. ¿ Aim 3: Examine the association between ImPACT participation and patient-centered outcomes, and refine survey instruments for future evaluations. Using data from surveys administered in the ImPACT clinic, we will assess patient satisfaction with the ImPACT intervention and overall care, as well as changes in patient-reported outcomes, including health status, symptom burden, and function. We will also evaluate the survey instruments in order to eliminate redundancy, improve discriminatory capacity, and reduce burden to patients in subsequent studies. After synthesizing pilot findings, we will derive a recommended sample size and sampling strategy, refine primary and secondary outcomes, and develop study protocols for a subsequent multi-site RCT of ImPACT. Our pilot efforts will also yield evaluation tools that can be disseminated to others who are designing and studying models of care for complex and high-utilizing patients within VA.