Connect-Home: Testing the Efficacy of Transitional Care of Patients and Caregivers during Transitions from Skilled Nursing Facilities to Home

项目总结/摘要 熟练护理设施（SNF）患者在医学上复杂，患有不可治愈的慢性疾病，依赖于 日常生活活动和近期急性疾病（如败血症、髋关节和股骨）的护理人员 程序.尽管SNF患者回家后的急性护理使用率和死亡率很高， （90天内>50%），SNF患者及其护理人员没有接受过渡护理，使他们做好准备， 自我管理患者的严重疾病，并在家中实现患者的医疗保健目标。无功效的 过渡性护理的研究以这一人群为目标，或衡量干预措施是否导致 改善患者和护理人员的结果。拟议的项目将测试Connect-Home的有效性， 成功试点过渡性护理干预，针对出院回家的重症SNF患者 和他们的照顾者。该研究将在六个北卡罗来纳州SNF进行，在干预期间，还将在 病人的家。使用逐步楔形分组随机试验设计，将随机选择6个SNF， 在六个连续的时间段内分配到标准出院计划与Connect-Home干预。 所有SNF将提供患者（N=360）及其护理人员（N=360）的数据，他们将接受标准的 出院计划或患者入组时SNF中的Connect-Home。Connect-Home是一个 两步过渡性护理干预：1）在SNF中创建过渡性护理计划，2） 出院后24小时内支持性护士家访。这两个步骤的重点是准备病人， 在5个临床领域-药物协调， 加强护理过渡计划，指导门诊医疗随访，跌倒安全评估， 以及审查预先指示和护理目标。现有的SNF和家庭保健工作人员将提供 干预要符合条件，患者必须出院回家，讲英语，需要至少25-50%的帮助 对于流动性，被诊断患有严重的医疗状况，并且不得计划在 接下来的90天要成为合格的护理人员，必须在家中帮助患者，并能说英语。 我们将评估患者和护理人员的结局：（a）出院后7天内，我们将评估患者和 使用护理过渡措施-15（主要结局）评估护理人员出院准备情况;以及（B）30例患者 出院后60天，我们将评估患者的生活质量、功能、福尔斯、急性护理使用天数， 照顾者负担和痛苦（次要结局）。我们将使用分层线性模型（HLM）来 比较干预期间和常规护理期间的观察结果以获得我们的主要结局。成果 一项研究将证明一种创新的干预措施对改善过渡期护理的潜在功效， 重症SNF患者，（B）在具有持续风险的人群中预防可避免的急性护理使用日 （c）通过测试过渡性护理的功效， 脆弱的SNF患者及其护理人员。

Project Summary/Abstract Skilled nursing facility (SNF) patients are medically complex with incurable chronic conditions, dependence on caregivers for activities of daily living, and recent acute illness, such as septicemia and hip and femur procedures. Despite the high prevalence of acute care use and mortality after SNF patients return home (>50% in 90 days), SNF patients and their caregivers do not receive transitional care that prepares them to self-manage the patient’s serious illness and achieve the patient’s health care goals at home. No efficacy studies of transitional care have targeted this population, or measured whether interventions resulted in improved patient and caregiver outcomes. The proposed project will test the efficacy of Connect-Home, a successfully piloted transitional care intervention, targeting seriously ill SNF patients who discharge to home and their caregivers. The study will be set in six North Carolina SNFs and, during intervention periods, also in the patient’s home. Using a stepped-wedge cluster-randomized trial design, six SNFs will be randomly allocated to standard discharge planning vs. the Connect-Home intervention over six sequential time-periods. All SNFs will contribute data for patients (N=360) and their caregivers (N=360), who will receive standard discharge planning or Connect-Home in the SNF at the time of the patient’s enrollment. Connect-Home is a two-step transitional care intervention: 1) creation of the Transition Plan of Care in the SNF, and 2) a supportive Nurse Home Visit in 24 hours of discharge. Both of these steps focus on preparing the patient and caregiver for self-care for serious illness at home in 5 clinical domains—medication reconciliation, reinforcement of the Transition Plan of Care, coaching for outpatient medical follow-up, fall safety assessment, and review of advance directives and goals of care. Existing SNF and home health staff will deliver the intervention. To be eligible, patients must discharge home, speak English, require at least 25-50% assistance for mobility, be diagnosed with a serious medical condition, and must not have planned hospital readmission in next 90 days. To be eligible caregivers must assist the patient at home and have the ability to speak English. We will assess patient and caregiver outcomes: (a) in 7 days after discharge, we will assess patient and caregiver preparedness for discharge using the Care Transitions Measure-15 (primary outcome); and, (b) in 30 and 60 days after discharge, we will assess patient quality of life, function, falls, days of acute care use and caregiver burden and distress (secondary outcomes). We will use hierarchical linear models (HLM) to compare observations between intervention and usual care periods for our primary outcome. Results of this study will demonstrate the potential efficacy of an innovative intervention to improve transitional care for seriously ill SNF patients, (b) prevent avoidable days of acute care use in a population with persistent risks related to serious illness, and (c) extend transitional care science by testing the efficacy of transitional care for vulnerable SNF patients and their caregivers.