Improving patient prioritization during hospital-homecare transition: A mixed methods study of a clinical decision support tool

在医院-家庭护理过渡期间改善患者优先顺序：一项混合方法研究 临床决策支持工具。 每年有500多万名患者被大约12,000家家庭护理机构接纳 在美国各地。大约20%的家庭护理患者在家庭护理期间再次住院， 其中高达68%的再住院发生在服务的头两周内。一个重要的 部分再住院可以通过及时和适当有针对性地分配 家庭护理服务。第一次家庭护理访问是家庭护理过程中最关键的步骤之一。 这次访问包括对家庭环境的检查，关于照顾者是否 目前，评估患者的自我护理和药物调节的能力。独一无二的关怀 计划是基于对患者需求的评估而制定的。因此，第一次访问的适当时机是 至关重要，尤其是对于有紧急医疗需求的患者。然而，护士往往有非常有限的和 不准确的入院病人信息和病人优先决策在不同护士之间有很大不同。 我们开发了一个创新的决策支持工具，名为“优先护理访问工具” (预防)协助护士对需要立即进行首次家庭护理访问的病人进行优先排序。在一个 预防高危患者首次家庭护理半天访视效果的初步研究 与对照组相比更快，60天的再住院率比对照组减少了近一半 给对照组。这项拟议的研究组建了一支强大的跨学科健康专家团队 在干预前评估预防的信息学、护理学、家庭护理和社会技术学科 有效性研究。具体地说，本研究的目的是：1)评价预防的效果 关于过程和患者结果的工具。生存分析和Logistic回归与倾向性评分 相匹配，我们将检验以下假设：与在干预前阶段不使用该工具相比， 当家庭护理临床医生使用预防工具时，处于干预阶段的高危患者将：a)接受 更及时的第一次家庭护理访问和b)减少了再住院率并减少了 急诊科(ED)在60天内使用。目标2)探索预防的覆盖范围和采用情况 家庭护理入学人员，并描述该工具在家庭护理入学过程中的实施。目标2 将使用混合方法进行评估，包括家庭护理入学人员面试、有声思考模拟、 以及人员配置和其他相关数据的分析。 这项创新的研究涉及国家护理研究所的几个战略优先事项，例如 作为促进创新和利用技术来改善健康。混合的方法将使我们能够深入了解 了解医院向家庭护理过渡的复杂社会技术方面。

Improving patient prioritization during hospital-homecare transition: A mixed methods study of a clinical decision support tool. Each year, more than 5 million patients are admitted to the approximately 12,000 homecare agencies across the United States. About 20% of homecare patients are rehospitalized during the homecare episode, with as many as 68% of these rehospitalizations occurring within the first two weeks of services. A significant portion of these rehospitalizations may be prevented by timely and appropriately targeted allocation of homecare services. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an examination of the home environment, a discussion regarding whether a caregiver is present, an assessment of the patient's capacity for self-care, and medication reconciliation. A unique care plan is created based on this evaluation of the patient’s needs. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent healthcare needs. However, nurses often have very limited and inaccurate information about incoming patients and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called “Priority for the First Nursing Visit Tool” (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits. In a recent efficacy pilot study of PREVENT, high-risk patients received their first homecare nursing visit a half day sooner as compared to the control group, and 60-day rehospitalizations decreased by almost half as compared to the control group. The proposed study assembles a strong interdisciplinary team of experts in health informatics, nursing, homecare, and sociotechnical disciplines to evaluate PREVENT in a pre-post intervention effectiveness study. Specifically, the study aims are: Aim 1) Evaluate the effectiveness of the PREVENT tool on process and patient outcomes. Using survival analysis and logistic regression with propensity score matching we will test the following hypotheses: Compared to not using the tool in the pre-intervention phase, when homecare clinicians use the PREVENT tool, high risk patients in the intervention phase will: a) receive more timely first homecare visits and b) have decreased incidence of rehospitalization and have decreased emergency department (ED) use within 60 days. Aim 2) Explore PREVENT’s reach and adoption by the homecare admission staff and describe the tool’s implementation during homecare admission. Aim 2 will be assessed using mixed methods including homecare admission staff interviews, think-aloud simulations, and analysis of staffing and other relevant data. This innovative study addresses several National Institute of Nursing Research strategic priorities, such as promoting innovation and using technology to improve health. Mixed methods will enable us to gain in-depth understanding of the complex socio-technological aspects of hospital-homecare transition.