Development and evaluation of a palliative-transitional home health care model

摘要 本R21提案的总体目标是“开发和评估一个缓和过渡家庭”， 卫生保健模式”是让关键利益相关者参与，包括住院医生、初级保健提供者、家庭保健提供者、 临床医生（例如，护士，物理治疗师，社会工作者），病人，和非正式的照顾者，发展， 完善和试点测试缓和过渡家庭卫生保健（PT HHC）模式，以提供更强的支持 出院后需要额外姑息治疗和过渡期护理的患者。接受HHC治疗的患者 比没有HHC出院回家的患者年龄更大，病情更重，但目前的HHC没有评估或 满足姑息治疗需求。纳入姑息治疗原则的护理模式减少了医疗保健 提高医院、疗养院和专业护理机构的护理服务质量。 然而，护理模式，包括过渡和姑息治疗HHC缺乏。 通过这项工作，我们的目标是通过额外的姑息治疗和过渡治疗来改善HHC患者的护理 需求本项目的具体目标包括：（1）发展和完善缓和-过渡期HHC模型 通过与临床医生的焦点小组、与患者和护理人员的访谈以及专家咨询小组 指导，以及（2）实施和评估姑息过渡HHC的可接受性和可行性 模型我们的研究团队有经验使用定性和实施科学方法来设计， 执行和传播干预措施。我们计划使用实用、稳健的实施方案， 可持续发展模型（PRISM）框架，其中嵌入了RE-AIM（覆盖范围、有效性、采用率， 实施、维护）评价模型进行设计和评价模型。 这种创新的护理模式将为HHC护士和社会工作者创造一个新的模式， 患者和护理人员讨论预先护理计划、患者症状和护理人员需求，并 与初级保健提供者沟通，在需要时请求专科姑息治疗和临终关怀转诊。 该提案完全符合PA-18-503中所述的NIA感兴趣的主题，包括开发和 评估一个新的HHC模式，包括姑息治疗。我们计划对模型进行前瞻性测试 在未来的一项实用试验中，该基金开发了PTHHC模型，以评估PTHHC模型对结果的影响 包括患者症状、护理人员负担、预先护理计划文件、急诊科 访问和住院治疗。

ABSTRACT The overarching goal of this R21 proposal “Development and Evaluation of a Palliative-Transitional Home Health Care Model” is to engage key stakeholders including hospitalists, primary care providers, home health clinicians (e.g., nurses, physical therapists, social workers), patients, and informal caregivers, to develop, refine, and pilot test a Palliative-Transitional Home Health Care (PT HHC) model to provide enhanced support after discharge for patients with additional palliative and transitional care needs. Patients receiving HHC are older and sicker than patients who are discharged home without HHC, yet current HHC does not assess or address palliative care needs. Care models incorporating palliative care principles have reduced health care utilization and improved the quality of care delivery in hospitals, nursing homes, and skilled nursing facilities. However, care models that incorporate both transitional and palliative care in HHC are lacking. Through this work, we aim to improve care for HHC patients with additional palliative and transitional care needs. The specific aims of this project include: (1) To develop and refine a Palliative-Transitional HHC model through focus groups with clinicians, interviews with patients and caregivers, and expert advisory panel guidance, and (2) To implement and evaluate the acceptability and feasibility of a Palliative-Transitional HHC model. Our investigator team has experience using qualitative and implementation science methods to design, implement, and disseminate interventions. We plan to use the Practical, Robust Implementation and Sustainability Model (PRISM) framework with the embedded RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation model to design and evaluate the model. This innovative care model will create a new paradigm for HHC nurses and social workers to engage with patients and caregivers to discuss advance care planning, patient symptoms, and caregiver needs, and to communicate with the primary care provider to request specialty palliative and hospice referrals when needed. This proposal fits well within the topics of interest for NIA described in PA-18-503, including development and evaluation of a new HHC model that incorporates palliative care. We plan to prospectively test the model developed in this grant in a future pragmatic trial to evaluate the effect of the PT HHC model on outcomes including patient symptoms, caregiver burden, advance care planning documentation, emergency department visits, and hospitalizations.