Project HoPe: Achieving Home Discharge for institutionally-bound Patients with PROMs, AI, and the EHR

HoPe 项目：利用 PROM、AI 和 EHR 使住院患者出院回家

• 批准号: 10456362
• 负责人: Andrea Lynne Cheville
• 金额: $ 104.76万
• 依托单位: MAYO CLINIC ROCHESTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-08-03 至 2027-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10456362
• 关键词: Address; Advance Care Planning; Alzheimer' s Disease; Alzheimer' s disease related dementia; Area; Attention; Caregivers; Caring; Clinical; Cognition; Cognitive; Computers; Data; Decision Making; Detection; Disadvantaged; Discharge Plannings; Discipline of Nursing; Early identification; Electronic Health Record; Elements; Expenditure; Future; Goals; Health care facility; Home; Home Health Care Agencies; Hospitalization; Hospitals; Impaired cognition; Institution; Institutionalization; Length of Stay; Multi-Institutional Clinical Trial; Outcome; Outcome Measure; Pathway interactions; Patient Outcomes Assessments; Patients; Probability; Process; Provider; Rehabilitation therapy; Reporting; Risk; Savings; Services; Site; Skilled Nursing Facilities; Social isolation; Standardization; System; Testing; Time; Work; acceptability and feasibility; acute care; base; care systems; clinical decision support; cognitive rehabilitation; computerized; cost; experience; functional loss; health data; improved; machine learning algorithm; mortality; novel; patient portal; patient-level barriers; pragmatic trial; preference; premature; pressure; prevent; prototype; rehabilitation service; service delivery; social factors; social health determinants; usability; user centered design

Unnecessary discharges from a hospital to a skilled nursing facility (SNF) are costly and may accelerate patients’ functional losses and requirement for long-term institutionalization. Patients with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD) and other types of cognitive impairment are uniquely disadvantaged by this status quo in that they are twice as likely to be hospitalized, four times more likely to be discharged to SNFs with less than 50% returning to their homes. This situation can be addressed as it is the product of a typically rushed discharge planning process with inadequate time to discover, much less address, a patient’s barriers to home discharge. Recent reports suggest that as many as a third of patients dismissed to SNFs, including those with AD/ADRD, could return directly home if their post-acute care (PAC) needs and barriers were anticipated and addressed. Several key deficits prevent broad realization of a patients’ potential to discharge directly home, or their Home PAC Potential (HoPe). These include a limited ability to: 1) quantify factors that determine PAC needs, 2) identify and address remediable barriers to home discharge, and 3) mobilize stakeholders for advancement of individualized discharge plans. Collectively, these deficits prevent the timely initiation of acute care services that can realize a patient’s potential for home discharge, with PAC as necessary. Rehabilitation-focused, hospital-Home Healthcare Agency (HHA) partnerships have established that interdisciplinary care plans enacted early in a hospital stay with patient and caregiver involvement increase the likelihood of a patient’s return home. Our team developed an Epic electronic health record (EHR)-based discharge planning system that triangulates EHR, patient reported outcomes (PROs), and social determinants of health data to identify HoPe barriers and direct needs-matched rehabilitation service delivery. A pilot of the system among 358 patients increased the home discharge rate by over 25% and revealed high user acceptability. However, the pilot also identified the need to improve addressing of cognitive impairments, targeting of high-yield HoPe barriers, and engagement of non-clinical stakeholders. We propose to address these limitations by pursuing three Specific Aims: 1) Develop a low-burden computerized adaptive test PRO to assess the domains of functional cognition relevant to a safe home discharge; 2) Develop a machine learning algorithm to prioritize actionable HoPe barriers and estimate the degree of change needed for home discharge; and 3) Apply user-centered design principles to refine the EHR discharge planning system for optimal usability and enhanced EHR portal patient, caregiver, and HHA staff access. Our goal is to both integrate and pilot these deliverables in a mature and optimally usable EHR discharge planning system, and to evaluate the feasibility and acceptability of its implementation. We anticipate that the system will be scalable, and amenable to inter-institution transfer for testing in a multi-site pragmatic trial.

不必要地从医院出院到专业护理机构 (SNF) 的成本高昂，并且可能会加速 阿尔茨海默病患者的功能丧失和长期住院的需要。 阿尔茨海默病相关痴呆 (AD/ADRD) 和其他类型的认知障碍是独特的 由于这种现状而处于不利地位，他们住院的可能性是普通人的两倍，住院的可能性是普通人的四倍 出院到 SNF 的人只有不到 50% 返回家园 这种情况可以得到解决，因为这是 通常是匆忙的出院计划过程的产物，没有足够的时间来发现，更不用说解决了， 最近的报告表明，多达三分之一的患者出院时遇到障碍。 SNF，包括患有 AD/ADRD 的患者，如果他们的急性后护理 (PAC) 需要并且可以直接回家 预期并解决了一些阻碍患者潜力广泛实现的关键缺陷。 直接出院，或他们的家庭 PAC 潜力 (HoPe) 其中包括以下能力有限：1) 量化。 决定 PAC 需求的因素，2) 识别并解决家庭出院的可补救障碍，以及 3) 动员利益相关者推进个性化出院计划。 及时启动急症护理服务，以实现患者出院回家的潜力，其中 PAC 作为 以康复为重点的医院与家庭医疗保健机构 (HHA) 的合作伙伴关系已经建立起来。 在住院早期制定的、患者和护理人员参与的跨学科护理计划可增加 我们的团队开发了基于 Epic 的电子健康记录 (EHR)。 出院计划系统，可对 EHR、患者报告结果 (PRO) 和社会决定因素进行三角测量 健康数据以确定 HOPe 障碍并直接提供需求匹配的康复服务。 358名患者的系统使出院率提高了25%以上，显示出高用户 然而，该试点项目还发现需要改进解决认知障碍的问题， 我们建议解决高收益希望障碍以及非临床利益相关者的参与问题。 这些限制通过追求三个具体目标来实现：1) 开发一个低负担的计算机化自适应测试 PRO 评估与安全家庭出院相关的功能认知领域 2) 开发机器学习； 算法优先考虑可操作的 HoPe 障碍并估计家庭出院所需的改变程度； 3) 应用以用户为中心的设计原则来完善 EHR 出院计划系统，以实现最佳可用性 并增强 EHR 门户患者、护理人员和 HHA 工作人员的访问权限 我们的目标是整合和试点。 这些可交付成果包含在成熟且最佳可用的 EHR 出院计划系统中，并评估 我们预计该系统将具有可扩展性和适应性。 到机构间转移进行多地点实用试验的测试。