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

高危患者的护理协调和结果：建立实施证据

• 批准号: 10315963
• 负责人: Denise M. Hynes
• 金额: --
• 依托单位: PORTLAND VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-10-01 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10315963
• 关键词: Address; Adoption; Assessment tool; COVID-19 pandemic; Caring; Case Management; Chronic Care; Clinical; Communities; Complex; Consult; Data; Data Sources; Development; Diffusion of Innovation; Electronic Health Record; Elements; Emergency medical service; Ensure; Evaluation; Evidence based practice; Exposure to; Future; Goals; Group Interviews; Health; Health Services Accessibility; Health system; Healthcare; Hybrids; Impact evaluation; Interview; Life; Medicare; Methodology; Methods; Modeling; Needs Assessment; Nursing Care Management; Nursing Services; Observational Study; Office Nursing; Outcome; Patient Care; Patients; Perception; Primary Health Care; Process; Process Assessment; Provider; Qualitative Methods; Reporting; Research; Research Design; Role; Services; Site; Social Work; Surveys; System; Time; Trust; Veterans; Vital Status; base; care coordination; care outcomes; care systems; comparison group; cost; data warehouse; design; evidence base; experience; formative assessment; health care availability; health care service; health service use; high risk; implementation facilitation; implementation strategy; improved; innovation; insight; migration; mortality; multiple data sources; programs; psychosocial; satisfaction; service coordination; telehealth; theories; tool; uptake

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.

抽象的 背景：护理协调对于改善患者获得医疗保健，临床结果至关重要， 增强患者体验，提高提供商的满意度以及降低或维持成本，但 对于那些有复杂护理需求的人来说，似乎最成功。虽然VA已建立的初级保健 模型，患者对齐护理团队（PACT）已被证明有效地增加了退伍军人的经验和 信任同时降低成本，许多高需求，高风险退伍军人缺乏对其复杂临床的支持 以及影响其医疗保健使用，成果和成本的社会心理需求。两个主要VA 由护理服务（ONS），护理管理和社会工作（SW）的倡议以及 社区护理办公室（OCC）打算通过新的护理协调需求来解决这一差距 2019年，评估（CCNA）工具将退伍军人与适当水平的护理协调和服务相匹配。然而， CCNA工具和组织过程尚未评估。 意义：评估和实施有效的护理协调惯例是优先事项 弗吉尼亚州，是针对《任务法》获得护理目标的两项主要国家计划的重点。 创新/影响：我们将使用常规收集的CCNA数据来利用正在进行的计划 使用医疗保健使用数据以及资深和提供者的观点，可以系统地评估护理协调 需要评估工具，实践以及对退伍军人服务，成果和费用的影响。 具体目的：我们将建立有关CCNA，流程和结果的证据，高风险 寻求VA的退伍军人在VA设施和社区遗址涵盖医疗保健。我们的目标是： 1。表征和比较退伍军人需求评估，收到的服务，健康之间的关系 通过匹配的比较组，接触CCNA的退伍军人的成果和成本。 2。调查和比较退伍军人关于他们在护理协调服务的经验，与其他集成的经验 医疗服务以及感知的健康影响。 3.进行形成性评估，以评估有关CCNA工具的早期采用站点的提供者的看法 以及与确定创新扩散，护理整合以及告知和进行的过程有关的过程 提供者的更广泛调查。 方法论：我们将使用组织理论方法，包括护理协调和创新 扩散框架指导我们的研究和员工使用定量和 定性方法。从2019年开始的早期采用者网站接受治疗的退伍军人，并被归类为需要 使用多个数据源将基于CCNA的复杂护理与匹配的退伍军人进行比较。数据 来源将包括来自CC/ICM和OCT站点的资深CCNA； CDW，VA社区护理，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。 定性分析将描述和比较退伍军人的卫生服务使用，死亡率和成本。定性 分析将集中于了解CCNA工具的感知属性以及感知到的 组织环境和实施，影响吸收和采用。这些分析的结果将 告知正在进行的CCNA适应，建立证据证明现实生活的创新属性 实施并确保评估CCNA工具可捕获最重要的要素。 下一步/实施/可持续性：建立护理协调过程的证据将告知 最佳实践和实施。随着VA的电子健康记录迁移，本研究可能会告知 适应新的CCNA电子工具，以促进和维持基于证据的实践的实施。