Optimizing the value of community care for Veterans with advanced kidney disease

背景：退伍军人健康管理局提供维持性透析的历史悠久 根据VA费用基础，在社区为患有终末期肾病（ESRD）的退伍军人提供治疗 程序.从2015财年开始，可在社区获得专业肾病护理 更多的患有晚期肾脏疾病的退伍军人尚未在退伍军人计划下进行透析 选择计划（VCP），并预计将继续根据一个综合社区护理计划。喜欢他们的 同行对透析，退伍军人与先进的肾脏疾病不透析是一个高成本高的需求 对他们来说，获得保健、保健的连续性和保健的协调都至关重要， 优化质量和成果。所有这三个指标对于在以下方面建立牢固的关系都很重要： 患者和提供者，并支持评估和再评估以及护理的迭代周期 需要协调，以妥善照顾这些病人 目的：我们将使用混合方法研究VA不断发展的社区护理政策对 结果和成本的退伍军人与先进的肾脏疾病，并确定机会， 改进.因为与这一人群相关的许多结果和护理过程对以下因素敏感： 护理的连续性和协调性，我们假设， 社区将对与该人群相关的一系列临床结局和护理过程产生负面影响 并且将比VA内提供的肾病护理更昂贵。我们预计，对于某些群体， 更及时的护理的好处可能超过护理碎片化和不连续性的潜在危害， 在社区得到必要的照顾。因为一些VA医疗中心可能更有效， 与社区提供者协调护理以减轻护理碎片化的影响，我们假设， VA资助的社区护理在人口内部和整个VA中的效果将是异质性的 医疗中心，可以在改善社区转诊过程中为这一人群提供信息。 方法：我们将使用全国VA管理和临床数据来跟踪VA资助的影响 退伍军人的临床结果、护理流程和退伍军人管理系统成本的社区护理， 使用工具变量方法（Aim 1）研究晚期肾病。确定机会， 为了提高社区转诊对这一人群的价值，我们将收集以下方面的观点和经验： 有资格获得或接受VA资助的社区护理的晚期肾病退伍军人及其VA和 社区护理提供者（目标2）。 影响：该提案将直接解决VA HSR & D的三个优先领域（医疗保健系统变化， 医疗服务和以患者为中心的护理，护理管理和健康促进）。工作提出的 这是非常及时和政策相关的，因为2018年的VA使命法案最近通过了两项 众议院和参议院都得到了两党的支持我们预计，我们的工作，以衡量影响， VA资助的社区肾病护理对患有晚期肾病的退伍军人将有助于识别 更有效地利用机构资源的机会，以优化机构资源的获取、连续性和协调 照顾退伍军人中高成本高需求的部分。以确保我们的工作能够 围绕提供社区护理不断发展的VA政策，调查人员正在与VHA国家合作， 肾脏疾病计划和社区护理办公室。

Background: The Veterans Health Administration has a long history of providing maintenance dialysis treatment for Veterans with end-stage renal disease (ESRD) in the community under the VA Fee Basis program. Starting Fiscal Year 2015, access to specialized nephrology care in the community became available to the much larger population of Veterans with advanced kidney disease not yet on dialysis under the Veterans Choice Program (VCP) and is expected to continue under a consolidated Community Care program. Like their counterparts on dialysis, Veterans with advanced kidney disease not on dialysis are a high-cost high-needs population for whom access to care, continuity of care and coordination of care are all vitally important in optimizing quality and outcomes. All three metrics are important in building strong relationships between patients and providers, and supporting the kind of iterative cycle of evaluation and re-evaluation and care coordination needed to properly care for these patients Objective: We will use mixed methods to study the impact of the VA’s evolving community care policy on outcomes and costs for Veterans with advanced kidney disease and identify opportunities for program improvement. Because many of the outcomes and care processes relevant to this population are sensitive to continuity and coordination of care, we hypothesize that receipt of VA-financed nephrology care in the community will negatively impact a range of clinical outcomes and care processes relevant to this population and will be more costly than nephrology care provided within the VA. We anticipate that for some groups, the potential harms of care fragmentation and discontinuity may be outweighed by the benefits of more timely receipt of needed care in the community. Because some VA medical centers may be more effective in coordinating care with community providers to mitigate the effects of care fragmentation, we hypothesize that there will be heterogeneity in the effect of VA-financed community care within the population and across VA medical centers that could be informative in improving the process of community referral for this population. Methods: We will use national VA administrative and clinical data to track the impact of VA-financed community care on clinical outcomes, care processes and costs to the VA system among Veterans with advanced kidney disease using an instrumental variable approach (Aim 1). To identify opportunities for improving the value of community referral for this population, we will elicit the perspectives and experiences of Veterans with advanced kidney disease eligible for, or receiving VA-financed community care and their VA and community care providers (Aim 2). Impact: This proposal will directly address three VA HSR&D priority areas (Health Care Systems Change, Healthcare Access and Patient-centered Care, Care Management, and Health Promotion). The work proposed here is extraordinarily timely and policy-relevant given that the VA MISSION Act of 2018 recently passed both the House and the Senate with strong bipartisan support. We anticipate that our work to measure the impact of VA-financed community nephrology care on Veterans with advanced kidney disease will help to identify opportunities for more effective use of agency resources to optimize access, continuity and coordination of care for a high-cost high-needs segment of the Veteran population. To ensure that our work is poised to shape evolving VA policy around provision of community care, the investigators are partnering with the VHA National Program for Kidney Disease and the Office of Community Care.