Optimizing the value of community care for Veterans with advanced kidney disease

优化患有晚期肾病退伍军人的社区护理价值

• 批准号: 10668936
• 负责人: ANN M. O'HARE
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-12-01 至 2024-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10668936
• 关键词: Address; Area; Caring; Characteristics; Clinical; Clinical Data; Communities; Community Financing; Community Healthcare; Continuity of Patient Care; Dialysis procedure; Eligibility Determination; End stage renal failure; Evaluation; Fees; Fistula; Health; Health Promotion; Health Services Accessibility; Healthcare Systems; Hemodialysis; Heterogeneity; Hospitalization; Incidence; Intervention; Interview; Kidney; Kidney Diseases; Kidney Transplantation; Learning; Maintenance; Managed Care; Measures; Medical; Medical center; Methods; Mission; Nephrology; Outcome; Outpatients; Patient Care; Patient-Centered Care; Patients; Peritoneal Dialysis; Policies; Population; Preparation; Process; Provider; Quality of Care; Readiness; Recording of previous events; Research Personnel; Resources; Shapes; Specialist; Structure; Subgroup; System; Transplantation; Variant; Veterans; Veterans Health Administration; Work; care coordination; care fragmentation; care providers; cost; design; early experience; experience; health care availability; improved; military veteran; mortality; patient population; poor health outcome; process improvement; programs; shared decision making

Background: The Veterans Health Administration has a long history of providing maintenance dialysis treatment for Veterans with end-stage renal disease (ESRD) in the community under the VA Fee Basis program. Starting Fiscal Year 2015, access to specialized nephrology care in the community became available to the much larger population of Veterans with advanced kidney disease not yet on dialysis under the Veterans Choice Program (VCP) and is expected to continue under a consolidated Community Care program. Like their counterparts on dialysis, Veterans with advanced kidney disease not on dialysis are a high-cost high-needs population for whom access to care, continuity of care and coordination of care are all vitally important in optimizing quality and outcomes. All three metrics are important in building strong relationships between patients and providers, and supporting the kind of iterative cycle of evaluation and re-evaluation and care coordination needed to properly care for these patients Objective: We will use mixed methods to study the impact of the VA’s evolving community care policy on outcomes and costs for Veterans with advanced kidney disease and identify opportunities for program improvement. Because many of the outcomes and care processes relevant to this population are sensitive to continuity and coordination of care, we hypothesize that receipt of VA-financed nephrology care in the community will negatively impact a range of clinical outcomes and care processes relevant to this population and will be more costly than nephrology care provided within the VA. We anticipate that for some groups, the potential harms of care fragmentation and discontinuity may be outweighed by the benefits of more timely receipt of needed care in the community. Because some VA medical centers may be more effective in coordinating care with community providers to mitigate the effects of care fragmentation, we hypothesize that there will be heterogeneity in the effect of VA-financed community care within the population and across VA medical centers that could be informative in improving the process of community referral for this population. Methods: We will use national VA administrative and clinical data to track the impact of VA-financed community care on clinical outcomes, care processes and costs to the VA system among Veterans with advanced kidney disease using an instrumental variable approach (Aim 1). To identify opportunities for improving the value of community referral for this population, we will elicit the perspectives and experiences of Veterans with advanced kidney disease eligible for, or receiving VA-financed community care and their VA and community care providers (Aim 2). Impact: This proposal will directly address three VA HSR&D priority areas (Health Care Systems Change, Healthcare Access and Patient-centered Care, Care Management, and Health Promotion). The work proposed here is extraordinarily timely and policy-relevant given that the VA MISSION Act of 2018 recently passed both the House and the Senate with strong bipartisan support. We anticipate that our work to measure the impact of VA-financed community nephrology care on Veterans with advanced kidney disease will help to identify opportunities for more effective use of agency resources to optimize access, continuity and coordination of care for a high-cost high-needs segment of the Veteran population. To ensure that our work is poised to shape evolving VA policy around provision of community care, the investigators are partnering with the VHA National Program for Kidney Disease and the Office of Community Care.

背景：退伍军人卫生管理局在提供维护透析方面有悠久的历史 在VA费用的基础上，在社区中对终末期肾脏疾病（ESRD）的退伍军人进行治疗 程序。从2015财政年度开始，可以在社区中获得专门的肾脏病护理 对于尚未在退伍军人下透析的退伍军人人口较大的退伍军人人口 选择计划（VCP），预计将在合并的社区护理计划下继续进行。喜欢他们 透析的同类，患有晚期肾脏疾病的退伍军人不是透析的高成本高成本 接受护理，护理连续性和护理协调的人口在 优化质量和结果。这三个指标对于建立牢固的关系很重要 患者和提供者，并支持评估和重新评估和护理的迭代循环 适当照顾这些患者需要协调 目的：我们将使用混合方法研究VA不断发展的社区护理政策的影响 患有晚期肾脏疾病的退伍军人的结果和成本，并确定计划的机会 改进。因为许多与该人群相关的结果和护理过程对 连续性和护理协调，我们假设在接收VA资助的肾脏病护理中 社区将对与该人群相关的一系列临床结果和护理过程产生负面影响 并且将比VA中提供的肾脏病护理成本更高。我们预计对于某些团体， 护理破碎和不连续性的潜在危害可能会超过更多时间的好处 在社区中收到所需的护理。因为某些VA医疗中心可能更有效 与社区提供者协调护理以减轻护理分散的影响，我们假设 VA资助的社区护理在人口和跨VA的影响方面将存在异质性 可以在改善该人群的社区转诊过程中提供信息的医疗中心。 方法：我们将使用国家VA行政和临床数据来跟踪VA资助的影响 对VA系统的临床成果，护理过程和成本的社区护理 使用仪器变量方法（AIM 1）的晚期肾脏疾病。确定机会 提高社区推荐对该人群的价值，我们将引起 有资格有资格或接受VA资助的社区护理及其VA的退伍军人 社区护理提供者（AIM 2）。 影响：该提案将直接解决三个VA HSR＆D优先领域（医疗保健系统的变化， 医疗保健访问和以患者为中心的护理，护理管理和健康促进。提出的工作 鉴于2018年《 VA Mission Act》最近通过 众议院和参议院得到了两党的强烈支持。我们预计我们的工作来衡量 VA资助的社区肾脏病护理患有晚期肾脏疾病的退伍军人将有助于确定 更有效利用代理资源来优化访问，连续性和协调的机会 护理资深人口的高成本高成本段。确保我们的工作被中毒 围绕提供社区护理的VA政策不断发展，调查人员正在与VHA National合作 肾脏病和社区护理办公室计划。