Improving care transitions for Veterans withsocial needs

改善有社会需求的退伍军人的护理过渡

基本信息

批准号：
10638723
负责人：
Portia Yvonne Cornell
金额：
--
依托单位：
PROVIDENCE VA MEDICAL CENTER
依托单位国家：
美国
项目类别：
财政年份：
2023
资助国家：
美国
起止时间：
2023-07-01 至 2028-06-30
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10638723
关键词：
Accident and Emergency department Acute Address Assessment tool Caregivers Caring Case Management Characteristics Code Communities Community Healthcare Data Data Analyses Diagnosis Effectiveness Effectiveness of Interventions Emergency Care Evaluation Face Feedback Funding Goals Health Home Homelessness Hospitalists Hospitalization Hospitals Hunger Inpatients Intervention Interview Knowledge Lead Length of Stay Medical Medical center Methodology Methods Neighborhoods Outcome Outpatients Patients Phase Policies Poverty Program Evaluation Provider Qualitative Methods Questionnaires Research Research Methodology Research Personnel Risk Risk Factors Site Social Conditions Social Work Social Workers Social isolation Structure Testing Text Training Variant Veterans Violence Work acute care care coordination career case finding clinical practice design effectiveness evaluation experience follow-up hazard health record high risk hospital care hospital readmission housing instability human centered design improved information display insight mortality novel outreach pilot test pragmatic trial primary care team programs prototype response screening skills social tool usability

Accident and Emergency department Acute Address Assessment tool Caregivers Caring Case Management Characteristics Code Communities Community Healthcare Data Data Analyses Diagnosis Effectiveness Effectiveness of Interventions Emergency Care Evaluation Face Feedback Funding Goals Health Home Homelessness Hospitalists Hospitalization Hospitals Hunger Inpatients Intervention Interview Knowledge Lead Length of Stay Medical Medical center Methodology Methods Neighborhoods Outcome Outpatients Patients Phase Policies Poverty Program Evaluation Provider Qualitative Methods Questionnaires Research Research Methodology Research Personnel Risk Risk Factors Site Social Conditions Social Work Social Workers Social isolation Structure Testing Text Training Variant Veterans Violence Work acute care care coordination career case finding clinical practice design effectiveness evaluation experience follow-up hazard health record high risk hospital care hospital readmission housing instability human centered design improved information display insight mortality novel outreach pilot test pragmatic trial primary care team programs prototype response screening skills social tool usability

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项目摘要

PROJECT SUMMARY BACKGROUND: Veterans who have experienced social needs—such as hunger, homelessness, poverty, violence, or isolation—face greater dangers of mortality or readmission after an acute hospitalization than those who have not. In the VA, social workers are trained to assess and address social needs through case management, care coordination, and community support. In recent work, I have shown that social workers in VA primary-care teams reduce unplanned hospital and emergency care. Information on Veterans’ social risks is available in the VA health record, but social workers lack a ready way to locate it, pull it up, and display it. Having a tool to find, organize, and present the relevant information would allow the social workers to prioritize their efforts toward helping the Veterans whom they most need to reach. SIGNIFICANCE/IMPACT: This research will provide new insight into how specific social risks can exacerbate the risk of adverse post-acute health outcomes. A new tool for identifying and addressing Veterans’ social risks will help social workers focus their efforts and may allow them to reduce unplanned post-discharge inpatient and emergency department use. The proposed project and training will help me to launch an independently funded research program investigating how addressing the social needs of Veterans can improve their medical care. INNOVATION: I will leverage VA data on social risks in a novel way that will enable social workers to deploy their efforts more effectively. The human-centered-design approach iterates between design and stakeholder- input phases in order to hone the effectiveness of a case-finding tool. SPECIFIC AIMS: Aim 1: Determine the effects of Veterans’ specific social risks on unplanned care after hospital discharge. Aim 2: Design a case-finding tool for social workers to prioritize Veterans with a recent hospital stay who have experienced social risks. Aim 3: Pilot-test the case-finding tool to assess its feasibility, acceptability, and usability. While carrying out the research, I will pursue four training goals: 1) to gain knowledge of social work and care-transition practices, 2) to obtain training in mixed-methods research, 3) to develop expertise in human-centered design, and 4) to prepare to design and lead a pragmatic trial to evaluate the effectiveness of the intervention. METHODOLOGY: In Aim 1, I will determine the association of unplanned care after a VA hospital stay (i.e., inpatient or emergency department use) with the social risks identified in a Veteran’s health record through screenings, diagnosis codes, social work assessments, and neighborhood characteristics. I will also examine variation across the VA in follow-up from social workers among Veterans with social risk. In Aim 2, I will design a case-finding tool to display information on the most critical social risk factors identified in Aim 1. I will refine the tool’s content using a human-centered design methodology with iterative define–prototype–test cycles. I will 1) define requirements through observation and semi-structured interviews with stakeholders, including hospitalists, inpatient social workers, outpatient social workers, PACT providers, and Veteran– caregiver dyads; and 2) incorporate feedback from social workers in rapid iterative prototype revision. In Aim 3, my approach will be to implement the tool at 3 VA medical center pilot sites for 12 months. I will collect quantitative data (usage data together with scale-based questionnaires) and qualitative data (semi-structured interviews) to assess the tool's feasibility, acceptability, and usability. NEXT STEPS & IMPLEMENTATION: I will use the findings from this research and the case-finding tool that we have created to plan a study to evaluate the effectiveness of the case-finding tool in improving Veterans’ outcomes.