Maximizing Effectiveness of Case Management in Primary Care for Rural Veterans

最大限度地提高农村退伍军人初级保健中病例管理的有效性

• 批准号: 10021440
• 负责人: Portia Yvonne Cornell
• 金额: --
• 依托单位: PROVIDENCE VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-10-01 至 2022-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10021440
• 关键词: Acute; Address; Admission activity; Appointment; Area; Assessment tool; Back; Caregiver support; Caring; Case Management; Case Manager; Chronic; Communities; Complement; Complex; Counseling; Documentation; Economics; Effectiveness; Elderly; Electronic Health Record; Eligibility Determination; Emergency department visit; Evaluation; Face; Family Caregiver; Feedback; Funding; Geography; Goals; Health; Health Personnel; Health Planning; Health Resources; Health Services Accessibility; Health system; Healthcare; Hospice Care; Hospital Costs; Hospitalization; Improve Access; Intervention; Interview; Knowledge; Lead; Medical center; Mental Health; Mental Health Services; Modeling; Modernization; Monitor; Neighborhoods; Nursing Homes; Outcome; Palliative Care; Patient Care; Patients; Pattern; Personal Satisfaction; Positioning Attribute; Primary Health Care; Program Effectiveness; Provider; Psychosocial Influences; Reporting; Resources; Rural; Rural Health; Self Care; Services; Site; Social Values; Social Work; Social Workers; Stress; Structure; System; Testing; Time; Touch sensation; Trust; United States Department of Veterans Affairs; Veterans; Veterans Health Administration; base; care outcomes; care providers; care systems; case finding; cost; design; high risk; implementation facilitators; implementation measures; improved; operation; patient home care; patient oriented; peer; peer coaching; preference; primary care setting; programs; response; rural area; rural patients; social stressor; success; support network; telehealth; therapy design; tool

Veterans with complex health conditions navigate a bewildering array of providers and supportive services. Those Veterans who live in rural areas often face additional challenges in getting the right care at the right time because providers may be geographically dispersed or unavailable in their neighborhood. Social-work case- management (SWCM) addresses the need for better access, coordination, and community support. A licensed social worker, acting as part of a primary-care team, connects the Veteran, their families and caregivers with a support network in their community. Case management is distinct from other forms of social work assistance in its emphasis on comprehensive assessment of the Veteran’s needs followed by intervention, evaluation, and documentation, which continue until treatment goals are met. In response to a shortage of social workers needed to complement its primary-care Patient Aligned Care Teams (PACTs) in rural areas, the Veterans Health Administration (VHA) has implemented a program to place additional social work case managers at rural PACT sites. Little is known, however, about the impact of adding social workers to primary-care teams or the effectiveness of the case-management model. We propose a rigorous evaluation of this initiative. The long-term goal of this partnered evaluation is to improve the implementation of the Rural PACT SWCM Initiative in order to deliver patient-centered, timely, and appropriate care to Veterans. As a necessary step toward that goal, the objective of our partnered evaluation is to assess the Rural PACT SWCM Program’s success an achieving its goals and improve its implementation. Our central hypothesis is that social-work case- managers connect Veterans to services and resources, such as personal care services, better-coordinated primary care, care planning, and mental health services, that ultimately will reduce unplanned health-care use that impose stress on Veterans and costs on the health system. This assessment will be used to create a tailored intervention, designed in cooperation with the operations partners, to improve implementation of Rural PACT SWCM by helping social workers to identify high-risk Veterans who need supportive services and provide case- management assessment and services. The knowledge gained from this evaluation will not only enhance implementation of Rural PACT SWCM Initiative, but also demonstrate the value of SWCM as a key component of primary care in the VHA. That evidence will provide the basis for medical centers to invest in sustaining SWCM for the long term. To do so, the evaluation team will pursue the following aims: (1) Assess the implementation of SWCM and barriers and facilitators of implementation of the case-management model and targeting of high-risk Veterans. (2) Evaluate the effect of social worker placement on Veterans’ access to services and health outcomes. (3) Design and pilot-test a case-management-improvement bundle to help program social workers increase their use of case management tools and identify Veterans in need of SWCM. The product of this QUERI evaluation will be an in-depth appraisal of the Rural PACT SWCM Initiative. The project touches the VA’s highest priorities: connecting Veterans to their choice of providers and community resources, taking advantage of electronic health records to modernize targeting of SWCM resources, improving timeliness of care by addressing barriers to access in rural areas, and connecting high-risk Veterans with needed supportive services, community providers, and mental health resources.

具有复杂健康状况的退伍军人在各种各样的提供者和支持服务中导航。 那些居住在农村地区的退伍军人在正确的时间获得正确的护理通常会面临其他挑战 因为在其附近，提供者可能在地理上分散或无法使用。社会工作案件 - 管理（SWCM）解决了更好访问，协调和社区支持的需求。许可 社会工作者是一支初级保健团队的一部分，将老兵，他们的家人和照顾者与 支持他们社区的网络。案件管理与其他形式的社会工作帮助不同 它强调全面评估退伍军人的需求，然后进行干预，评估和 文档一直持续到达到治疗目标。响应缺乏所需的社会工作者 为了在粗糙地区完成其初级护理患者对齐护理团队（PACT），退伍军人健康 管理（VHA）已实施一个计划，将额外的社会工作案件经理放在法律上 站点。然而，关于将社会工作者添加到初级护理团队或 案件管理模型的有效性。我们提出了对该倡议的严格评估。 这项合作评估的长期目标是改善农村协议SWCM的实施 为了向退伍军人提供以患者为中心，及时和适当的护理的倡议。作为必要的步骤 为了实现这一目标，我们合作评估的目的是评估农村协议SWCM计划的 成功实现其目标并改善其实施。我们的中心假设是社会工作案件 - 经理将退伍军人连接到服务和资源，例如个人护理服务，协调更好 初级保健，护理计划和心理健康服务，最终将减少计划外的医疗保健使用 这会对退伍军人施加压力，并在卫生系统上施加压力。该评估将用于创建量身定制的 与业务合作伙伴合作设计的干预措施，以改善农村公约的实施 通过帮助社会工作者确定需要支持服务并提供案件的高危退伍军人 - 管理评估和服务。从此评估中获得的知识不仅会增强 实施农村协议SWCM计划，但也证明了SWCM作为关键组成部分的价值 VHA中的初级保健。该证据将为医疗中心投资维持SWCM的基础 长期。为此，评估团队将追求以下目标： （1）评估案件管理实施的SWCM和SWCM和障碍的实施 高风险退伍军人的模型和目标。 （2）评估社会工作者安置对退伍军人获得服务和健康成果的影响。 （3）设计和试点测试案件管理 - 改进捆绑包，以帮助计划社会工作者增加他们的 使用案例管理工具并确定需要SWCM的退伍军人。 该QuERI评估的产品将是对农村协议SWCM计划的深入评估。这 项目涉及VA的最高优先事项：将退伍军人与他们选择的提供者和社区联系起来 资源，利用电子健康记录来现代化SWCM资源的目标，改善 通过解决农村地区的障碍，并将高风险的退伍军人与所需 支持服务，社区提供者和心理健康资源。