Evaluating the Implementation of High Intensity Home-Based Rehabilitation Following Stroke

项目摘要 中风是一种非常普遍的疾病，导致功能性活动的严重缺陷，特别是在 老年人为了解决这些缺陷，急性期后康复是护理的循证组成部分。 然而，基于设施的康复（即，在熟练的护理或住院康复设施中）是昂贵的。如果 中风患者在高强度家庭康复（HIHR）方法中可以获得相同的结果 在这些设施中，相对价值（成果/成本）会更大。这样的有效性 方法尚未研究。此外，在2010年， 美国卫生系统。拟议研究的目标是确定初步HIHR努力的障碍 在一个卫生系统中实施并了解其临床有效性，以便为后续提供信息 改善护理模式。采用三角混合方法的混合2型研究设计将 在学习卫生系统研究框架的两个周期内使用。具体目标是（1）探索 影响脑卒中患者HIHR初始实施的障碍，（2）比较HIHR的有效性 以改善患者功能为基础的设施康复;（3）实施精细化的HIHR模式， 检查其执行情况和有效性。我们假设，临床工作流程的挑战和 患者/护理人员的偏好将影响初始实施的结果， HIHR出院将至少等同于患者出院时的功能。我们还假设， 在实施和有效性结果的改进将通过改进HIHR模型来实现， 从初始模型的评估中学习。这些目标与候选人成为一名 独立学习的卫生系统研究员，重点是研究健康康复实践 系统.培训目标是（1）发展混合方法研究及其在护理中的应用方面的专业知识 交付，（2）获得评估卫生系统创新实施成功的专业知识，（3）开发 使用观察数据进行比较有效性研究的专业知识，以及（4）培养参与 卫生系统领导人和领导一个学习卫生系统研究实验室。这些培训目标将是 通过与内容专家一对一的指导以及地方和国家的结合来完成 课程作业所有的科学和训练目标都将在一个环境中完成， 综合学术卫生系统和教学指导伙伴机构。的预期成果 这项工作是对HIHR的实施和有效性结果的描述。这是一个创新 中风后急性康复的方法，目前在美国卫生系统中还不存在，但 这可能会严重影响旨在改善患者功能独立性的护理价值 中风后

Project Summary Stroke is a highly prevalent condition that contributes to significant deficits in functional mobility, particularly in older adults. To address these deficits, post-acute rehabilitation is an evidence-based component of care. However, facility-based rehabilitation (i.e., in a skilled nursing or inpatient rehabilitation facility) is costly. If stroke patients can achieve the same outcomes in a high-intensity home-based rehabilitation (HIHR) approach as in these facilities, the relative value (outcomes/costs) would be greater. The effectiveness of such an approach has not been studied. Further, the implementation of a HIHR care model has not been examined in the US health system. The objectives of the proposed research are to identify barriers to initial HIHR efforts implementation in one health system and to understand its clinical effectiveness to inform subsequent improvement of the care model. A hybrid type 2 study design with a triangulated mixed methods approach will be used over two cycles of a learning health system research framework. Specific aims are to (1) explore barriers affecting the initial implementation of HIHR for stroke patients, (2) compare the effectiveness of HIHR to facility-based rehabilitation on improving patients' function, and (3) implement a refined HIHR model and re- examine its implementation and effectiveness. We hypothesize that clinical workflow challenges and patient/caregiver preferences will affect the outcomes with initial implementation and that patients' function at HIHR discharge will be at least equivalent to patients' function at facility discharge. We also hypothesize that improvements in implementation and effectiveness outcomes will be achieved by refining the HIHR model after learning from the evaluation of the initial model. These aims align well with the candidate's goal to become an independent learning health system researcher, with an emphasis on studying rehabilitation practice in health systems. Training aims are to (1) develop expertise in mixed methods research and its application to care delivery, (2) gain expertise in assessing implementation success of a health system innovation, (3) develop expertise in comparative effectiveness research using observational data, and (4) develop skills to engage with health system leaders and lead a learning health system research lab. These training aims will be accomplished via one-on-one mentorship with content experts and combination of local and national coursework. All scientific and training aims will be accomplished in an environment that includes a large integrated academic health system and a partner institution for didactic instruction. The expected outcome of this work is a description of the implementation and effectiveness outcomes for HIHR. This is an innovative approach for post-acute rehabilitation following stroke that does not currently exist in the US health system, but which may substantially affect the value of care that aims to improve patients' functional independence following stroke.