COST-EFFECTIVE QUALITY--IMPROVING CLIENT OUTCOMES

拟议的四年计划的长期目标是改善 护理质量，从而提高养老院的生活质量 以具有成本效益的方式为居民提供服务。具体目标是： 1.确定通过科学方法得出的居民结果是否会得到改善 APN针对以下常驻问题实施协议：a) 大小便失禁，b)压疮，c)抑郁，d)破坏性 行为。(仅协议/APN干预) 2.确定驻地结果是否使用仅限议定书/APN的干预措施 通过将APN纳入以下组织中而得到改进 角色：在职教育者、组织范围质量的参与者 保证活动；以及工作人员的顾问。(组织 干预，阶段1) 3.确定居民成果是否使用《议定书》/《行动纲领》干预外加 组织干预，阶段1，通过添加以下内容进一步改进 以下组织变革：护理大查房、质量 圈子，以及在每个领域都有专业知识的内部资源团队 协议。(组织干预，阶段2) 4.确定高级实践是否使用科学派生的协议 护士减少疗养院护理的成本：a)居民；b)护理 房屋，以及c)第三方付款人。 5.确定是否将组织干预措施添加到 协议/APN干预进一步降低了养老院护理的成本 对于a)居民，b)疗养院，以及c)第三方付款人。 6.确定员工结果(工作满意度、流失率和认知度 组织氛围)仅因《议定书》/《行动纲领》而得到改善 干预，协议/APN干预加上组织 干预阶段1，以及议定书/APN干预加上 组织干预阶段2。 准实验设计将随机分配两个处理和 对三家疗养院的控制，与 相关特征的数量。新录取的三个队列 每个机构的居民将构成样本(每个机构N=108)。 需要衡量的住院结果包括疗养院的停留时间、使用 急诊科人数、住院人数和住院天数， 压疮的存在和分期，压疮的存在和频率 大小便失禁，精神状态，士气，抑郁的存在和程度， 颠覆性行为的存在和程度、压力水平和功能 状态。此外，还将获得居民和家庭的数据。 满意度、员工工作满意度、离职率、缺勤率和选拔 财政结果。这项研究的结果将提供关于 特定干预方案对大小便失禁、压力的疗效 疼痛、抑郁和破坏性行为，无论是居民还是 财政结果。此外，还将对居民和 有没有实施科学派生的结果 由APN提供的协议以及在添加和不添加组织的情况下 干预措施。

The long-term goal of the proposed four year project is to improve the quality of care and therefore the quality of life of nursing home residents in a cost-effective manner. The specific aims are to: 1. Determine if resident outcomes are improved when scientifically-derived protocols are implemented by APNs for the following resident problems: a) incontinence, b) pressure sores, c) depression, and d) disruptive behavior. (Protocol/APN Only Intervention) 2. Determine if resident outcomes using the Protocol/APN-Only Intervention are improved by the inclusion of the APN in the following organizational roles: inservice educator, participant in organization-wide quality assurance activities; and consultant to staff. (Organizational Intervention, Stage 1) 3. Determine if resident outcomes using the Protocol/APN Intervention plus the Organizational Intervention, Stage 1 are improved further by adding the following organizational changes: nursing grand rounds, quality circles, and in-house resource teams with expertise in each of the protocols. (Organizational Intervention, Stage 2) 4. Determine if scientifically-derived protocols used by advanced practice nurses reduce the costs of nursing home care for: a) residents; b) nursing homes, and c) third party payers. 5. Determine if the addition of Organizational Interventions to the Protocol/APN Intervention further reduces the cost of nursing home care for a) residents, b) nursing homes, and c) third party payers. 6. Determine if staff outcomes (job satisfaction, turnover, and perception of the organizational climate) are improved by the Protocol/APN-Only Intervention, the Protocol/APN Intervention plus the Organizational Intervention Stage 1, and the Protocol/APN Intervention plus the Organizational Intervention Stage 2. The quasi-experimental design will randomly assign the two treatments and the control to three nursing homes that are comparable with respect to a number of relevant characteristics. Three cohorts of newly admitted residents at each facility will comprise the sample (N= 108 per facility). Resident outcomes to be measured include length of nursing home stay, use of emergency department, number of hospitalizations and days hospitalized, Presence and stage of pressure sores, presence and frequency of incontinence, mental status, morale, presence and level of depression, presence and extent of disruptive behavior, stress level, and functional status. In addition, data will be obtained on resident and family satisfaction, staff job satisfaction, turnover, absenteeism, and selected fiscal outcomes. Findings from the study will provide information about the efficacy of specific intervention protocols for incontinence, pressure sores, depression, and disruptive behavior in terms of both resident and fiscal outcomes. In addition, comparisons will be made between resident outcomes with and without the implementation of scientifically-derived protocols by an APN and with and without the addition of organizational interventions.