Improving Veteran Transitions from VA Community Living Centers to the Community

说明： 根据人-环境匹配模型(P-E匹配)，当环境中的需求和可用资源与个人的日常能力(解决与日常生活相关的问题的能力)不再平衡时，老年人面临不良结果的风险。据估计，29%的社区生活中心(CLC；VA养老院)居民可能不需要养老院级别的护理，并可以在适当的康复服务下安全地居住在社区。在退伍军人管理局，一个主要的重点是通过为社区提供康复和过渡退伍军人来最大限度地减少在CLC的时间。CLC工作人员和退伍军人面临着促进这些过渡的障碍(例如，照料需求、住房等)。存在标准化流程以确保治疗计划包括最大限度地使P-E匹配的流程。这项研究的目标是开发一个可供《中图法》跨学科团队使用的工具包 1)评估退伍军人的日常能力；2)在日常能力的基础上制定个人有意义的康复目标；以及3)进行结构化的治疗计划，以支持居民围绕重返社区的过渡目标。我们认识到，如果没有人实际使用，即使是最有效的干预措施也是毫无价值的，因此我们提出了一个三阶段研究过程：了解开发试验。第一阶段(了解)侧重于了解CLCS的当前环境、排放计划流程和结果。在目标1a中，我们将使用行政数据来检验CLC居民成功/不成功过渡的结果和预测因素。目标1b采用定性访谈，以了解当前过渡CLC居民的障碍和促进者，确定居民面临的日常情景，并收集工作人员对适当目标设定领域的建议。对于Aim 1c，我们将使用现场观察来了解过渡规划期间跨学科团队成员之间的工作流程、关系和互动。第二阶段(开发)将使用第一阶段收集的信息来开发日常能力评估和社区过渡规划(ECAP-CT)工具包组件，包括康复目标设定领域和创建一份结构化手册，以指导CLC跨学科团队完成评估、目标设定和治疗规划步骤。第三阶段(试验)将是ECAP-CT工具包在休斯顿(n=30名居民)和塔斯卡卢萨(n=30名居民)退伍军人事务部的准实验性有效性试验。该工具包将在两个地点按顺序实施，以便进行调整。我们的主要结果是过渡结果(成功/不成功)，它将与从两个匹配的比较站点(n=60)收集的并发管理数据进行比较。我们将在这项试验的背景下，对该工具包与常规护理进行探索性的成本效益分析。PI的总体职业目标是成为一名独立的康复研究人员，在开发和测试针对CLC居民需求的干预措施方面具有专业知识，最大限度地提高自主权、独立性和功能。从长远来看，她的职业目标包括制定评估CLC住院医生日常能力的战略，设定住院医生指导的目标，以及制定让退伍军人重返社区的护理计划。CDA-2指导团队包括老牌退伍军人研究人员，他们在脆弱的老年人、评估日常能力、干预发展和评估以及长期护理过渡方面具有专业知识。在指导团队的指导下，已经确定了将从额外培训中受益的领域。CDA-2奖项中概述的培训目标将在以下领域提供更多经验：1)评估以患者为中心的干预措施，包括成本效益和心理测量学方法；2)干预措施发展；3)VA康复服务的经验和知识；以及4)提交RR&D功绩审查奖。这些目标将通过指导和参加研讨会、正式课程和会议来实现。

DESCRIPTION: According to the model of person-environment fit (P-E fit), older adults are at risk for poor outcomes when the demands and resources available in the environment are no longer in balance with the individual's everyday competence (the ability to solve problems associated with everyday life). It has been estimated that 29% of Community Living Center (CLC; VA nursing homes) residents may not require nursing home levels of care and could safely reside in the community with appropriate rehabilitative services. In VA, a major focus is to minimize time in CLCs by providing rehabilitation and transitioning Veterans to the community. CLC staff and Veterans face barriers to facilitating these transitions (e.g., caregiving needs, housing, etc.). N standardized process exists to assure that treatment planning includes processes to maximize P-E fit. The objective of this study is to develop a toolkit the CLC interdisciplinary team can use to 1) assess the Veteran's everyday competence; 2) develop personally meaningful rehabilitation goals based on everyday competence; and 3) conduct structured treatment planning to support resident goals around transitions back into the community. Acknowledging that even the most effective intervention is worthless if no one actually uses it, we propose a three-phase research process: Understand ¿ Develop ¿ Trial. Phase 1 (Understand) focuses on gaining an understanding of the current environment, discharge planning processes, and outcomes in CLCs. In Aim 1a, we will use administrative data to examine outcomes and predictors of successful/unsuccessful transitions among CLC residents. Aim 1b employs qualitative interviews, to understand the current barriers and facilitators to transitioning CLC residents, identify everyday scenarios residents face, and collect staff suggestions for appropriate goal-setting domains. For Aim 1c, we will use field observation to understand the workflow, relationships, and interactions between members of the interdisciplinary team during transition planning. Phase 2 (Develop) will use information gathered in Phase 1 to develop the Everyday Competence Assessment and Planning for Community Transitions (ECAP-CT) toolkit components, including rehabilitation goal-setting domains and creation of a structured manual to guide the CLC interdisciplinary team through the assessment, goal-setting, and treatment planning steps. Phase 3 (Trial) will be a quasi-experimental effectiveness trial of the ECAP-CT toolkit in the Houston (n=30 residents) and Tuscaloosa (n=30 residents) VA CLCs. The toolkit will be implemented sequentially in the two sites allowing for adaptation. Our primary outcome is transition outcome (successful/not successful), which will be compared to concurrent administrative data gathered from two matched comparison sites (n=60). We will conduct an exploratory cost-effectiveness analysis of the toolkit compared to usual care within the context of this trial. The PI's overall career aim is to become an independent rehabilitation researcher with expertise in developing and testing interventions targeting the needs of CLC residents, maximizing autonomy, independence, and function. Long-term, her career goals include developing strategies for assessment of everyday competence among CLC residents, setting resident-directed goals, and developing care plans to transition Veterans back into the community. The CDA-2 mentoring team includes established VA researchers with expertise in vulnerable older adults, assessing everyday competence, intervention development and evaluation, and long- term care transitions. With the guidance of the mentoring team, areas that would benefit from additional training have been identified The training aims outlined in this CDA-2 award will provide additional experience in these areas: 1) evaluation of patient-centered interventions, including cost-effectiveness and psychometrics methodology; 2) intervention development; 3) experience and knowledge of VA rehabilitation services; and 4) submission of a RR&D Merit Review Award. These objectives will be achieved through mentoring and attending seminars, formal courses, and conferences.