Care Coordination and Outcomes for High Risk Patients: Building the Evidence for Implementation

摘要 背景：护理协调对于改善患者获得医疗保健的机会、临床结果、 改善患者体验，提高提供商满意度，降低或维护成本，但 对于那些有复杂护理需求的人来说似乎是最成功的。虽然退伍军人事务部已建立的初级保健制度 事实证明，以患者为中心的护理团队(PACT)在增加退伍军人的经验和 在降低成本的同时，许多高需求、高风险的退伍军人缺乏对其复杂临床的支持 和心理社会需求，影响他们的卫生保健使用、结果和成本。两大退伍军人管理局 由护理服务办公室(ONS)和护理管理和社会工作办公室(SW)领导的倡议，以及 社区护理办公室(OCC)打算通过启动新的护理协调需求来解决这一差距 2019年，评估(CCNA)工具将使退伍军人与适当水平的护理协调和服务相匹配。然而， CCNA的工具和组织流程尚未得到评估。 意义：评估和实施有效的护理协调做法是 弗吉尼亚州和是两个主要的国家倡议的重点，以解决使命法获得护理的目标。 创新/影响：我们将利用正在进行的计划，使用常规收集的CCNA数据，补充 使用医疗保健使用数据，以及退伍军人和提供者的视角，系统地评估护理协调 需求评估工具、做法以及对退伍军人所接受服务、结果和成本的影响。 具体目标：我们将为高需求、高风险的CCNA、流程和结果建立证据 寻求退伍军人管理局的退伍军人涵盖了退伍军人管理局设施和社区站点的医疗保健。我们的目标是： 1.描述和比较退伍军人需求评估、接受的服务、健康之间的关系 暴露于CCNA的退伍军人与匹配的对照组的结果和成本。 2.调查和比较退伍军人在护理协调服务、与其他组织的融合方面的经验 医疗保健服务，以及感知的健康影响。 3.进行形成性评估，以评估早期采用VA站点的提供商对CCNA工具的看法 和与创新扩散、关怀整合的决定因素有关的流程，并通报和开展 对供应商进行更广泛的调查。 方法：我们将使用组织理论方法，包括关怀、协调和创新 指导我们的研究的扩散框架，并使用定量和 定性研究方法。从2019年开始，退伍军人在早期采用者网站接受治疗，并被归类为需要 基于CCNA的复杂护理将与使用多个数据源的匹配退伍军人进行比较。数据 来源将包括来自CC/ICM和OCC站点的资深CCNA；CDW、VA社区关怀、咨询 工具箱、医疗保险、生命状态和成本数据。调查数据将从退伍军人和提供者那里收集。 定量分析将描述和比较退伍军人的医疗服务使用、死亡率和成本。定性的 分析将侧重于了解CCNA工具的感知属性以及感知的 组织背景和实施影响接受和采用。这些分析的结果将 告知正在进行的CCNA调整，为创新属性在现实生活中的实用性建立证据 实施，并确保对CCNA工具的评估包含最重要的要素。 下一步/实施/可持续性：建立护理证据协调进程将 最佳做法和实施。随着退伍军人管理局电子健康记录的迁移，这项研究可能会告诉我们 调整CCNA的新电子工具，以促进和维持循证做法的实施。

Abstract Background: Care coordination is essential to improve patients’ access to healthcare, clinical outcomes, enhancing patients experience, increasing provider satisfaction, and decreasing or maintaining costs, yet appears to be most successful for those with complex care needs. While the VA’s established primary care model, the Patient Aligned Care Team (PACT) has proven effective in increasing Veterans’ experience and trust while decreasing costs, many high need, high risk Veterans lack support for their complex clinical and psychosocial needs that impacts their health care use, outcomes and costs. Two major VA initiatives led by the Offices of Nursing Service (ONS) and Care Management and Social Work (SW), and the Office of Community Care (OCC) intend to address this gap with initiation of new care coordination needs assessment (CCNA) tools to match Veterans with the right level of care coordination and services in 2019. Yet, the CCNA tools and organizational processes have not been evaluated. Significance: Evaluation and implementation of effective care coordination practices are a high priority for the VA and is the focus of two major national initiatives to address MISSION Act access to care goals. Innovation/Impact: We will leverage ongoing initiatives, using routinely collected CCNA data, supplemented with health care use data, and Veteran and provider perspectives to systematically evaluate care coordination needs assessment tools, practices, and impacts on Veterans’ services received, outcomes and costs. Specific Aims: We will build evidence about the CCNA, processes, and outcomes for high need, high risk Veterans seeking VA covered healthcare at VA facilities and community sites. Our aims are to: 1. Characterize and compare the relationship between Veteran needs assessment, services received, health outcomes and costs for Veterans exposed to CCNA with a matched comparison group. 2. Survey and compare Veterans about their experience with care coordination services, integration with other healthcare services, and perceived health impacts. 3. Conduct formative evaluation to assess provider perceptions at early adoption VA sites about CCNA tools and processes related to determinants of innovation diffusion, care integration, and to inform and conduct a broader survey of providers. Methodology: We will use an organizational theoretical approach including care coordination and innovation diffusion frameworks to guide our research and employ an observational design using quantitative and qualitative methods. Veterans treated at early adopter sites beginning in 2019 and categorized as needing complex care based on the CCNA will be compared to matched Veterans using multiple data sources. Data sources will include Veteran CCNA from the CC/ICM and OCC sites; CDW, VA Community Care, Consult Toolbox, Medicare, vital status, and cost data. Survey data will be collected from Veterans and providers. Quantitative analyses will describe and compare Veterans’ health services use, mortality and costs. Qualitative analyses will focus on understanding how perceived attributes of the CCNA tools, as well the perceived organizational context and implementation, influence uptake and adoption. The results of these analyses will inform ongoing CCNA adaptation, build the evidence for the utility of the innovation attributes for real-life implementation, and ensure evaluation of CCNA tools captures the most important elements. Next Steps/Implementation/Sustainability: Building the evidence for care coordination processes will inform best practices and implementation. With the VA’s electronic health record migration, this study may inform how to adapt new CCNA electronic tools to facilitate and sustain implementation of evidenced-based practices.