Home-based Primary Care for Homebound Seniors: a Randomized Controlled Trial

 描述（由申请人提供）：本研究的目的是评价家庭初级保健（HBPC）对居家老年人结局的影响，包括住院和急诊（艾德）访视、生活质量和症状控制、护理费用以及非正式护理人员的护理负担。我们还将对HBPC进行混合方法传播和实施评估。在美国，超过一百万老年人有功能限制，使他们无法接受基于办公室的初级保健（OBPC）。因此，居家的成年人通常经历疾病控制差、住院率高以及导致住院和艾德使用的大量医疗保健支出。很少有专门为居家患者设计的医疗保健服务模式得到研究，但观察数据表明，HBPC可以改善这些高度脆弱患者的结局并减少支出。我们提出了一个实用的随机对照试验HBPC与OBPC的居家老年人，有3个具体的目的：比较HBPC和OBPC的影响1）住院率和艾德访问率，症状控制和生活质量，以及对护理的满意度在居家老年人; 2）在非正式照顾者（例如，家庭和朋友）;以及3）居家的医疗保健支出。我们假设HBPC患者及其护理人员的结局优于OBPC患者。我们将在纽约市从门诊临床和社区环境中招募350名≥ 65岁的居家成年人。HBPC将通过西奈山访问医生或切尔西村家访计划提供。随机分配至OBPC的患者将继续接受其常规门诊初级保健提供者的护理，或在西奈山医疗保健系统内分配一名。我们将在基线时用英语和西班牙语进行面试，此后每季度进行一次，最长持续1年。医疗保险和医疗补助索赔数据将用于确定医疗保健利用率和成本。本研究采用了务实的试验设计概念，以促进将研究结果转化为实际的临床、系统和卫生政策应用。该研究小组包括与老龄化相关的卫生服务研究、卫生经济学、卫生政策、随机临床试验以及居家老年人的医疗和护理方面的专家。这项拟议的研究将是对居家老年人的最大的前瞻性研究，也是HBPC对居家老年人的唯一随机试验。它将填补我们对HBPC对居家者影响的理解中的重要知识空白。这项研究与医学研究所呼吁扩大对慢性病护理综合模式的研究是一致的，包括慢性病的多学科管理和医疗之家概念。

 DESCRIPTION (provided by applicant): The objective of this study is to evaluate the impact of home-based primary care (HBPC) on outcomes for homebound older adults, including hospitalization and emergency department (ED) visits, quality of life and symptom control, costs of care, and burden of care for their informal caregivers. We will also conduct a mixed methods dissemination and implementation evaluation of HBPC. Over one million seniors in the U.S. have functional limitations that prevent them from receiving office-based primary care (OBPC). As a result, homebound adults typically experience poor disease control, high rates of hospitalization, and large healthcare expenditures resulting for hospitalizations and ED use. Few modes of healthcare delivery designed specifically for the homebound have been studied, but observational data suggest that HBPC could improve outcomes and reduce spending for these highly vulnerable patients. We propose a pragmatic randomized controlled trial of HBPC vs. OBPC for homebound older adults, with 3 Specific Aims: to compare the impact of HBPC and OBPC 1) on hospitalization and ED visit rates, symptom control and quality of life, and satisfaction with care among homebound elders; 2) on caregiving burden among informal caregivers (e.g., family and friends); and 3) on healthcare expenditures for the homebound. We hypothesize that patients in HBPC and their caregivers will have better outcomes compared to OBPC patients. We will recruit 350 homebound adults ≥ 65 years in New York City from outpatient clinical and community- based settings. HBPC will be delivered through Mount Sinai Visiting Doctors or the Chelsea Village House Calls Program. Patients randomized to OBPC will continue to receive care from their usual outpatient primary care provider or will be assigned one within the Mount Sinai healthcare system. We will conduct interviews in English and Spanish at baseline and quarterly thereafter up to 1 year. Medicare and Medicaid claims data will be used to determine healthcare utilization and costs. The study embraces the concepts of a pragmatic trial design to facilitate the translation of study findings for practical clinical, systms, and health policy applications. The study team includes experts in aging related health services research, health economics, health policy, randomized clinical trials, and the medical and nursing care of homebound older adults. The proposed study would be the largest prospective study of homebound older adults and the only randomized trial of HBPC for the homebound. It would fill important knowledge gaps in our understanding of the effects of HBPC for the homebound. The study is consistent with the Institute of Medicine's call for expanded research on comprehensive models of chronic care, including the multidisciplinary management of chronic diseases and the medical home concept.