退伍军人健康管理局（VHA）针对高危患者的护理重新设计的运营合作评估：PACT强化管理（PIM）随机质量改进评估的研究方案。

An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation.

作者信息

Chang Evelyn T, Zulman Donna M, Asch Steven M, Stockdale Susan E, Yoon Jean, Ong Michael K, Lee Martin, Simon Alissa, Atkins David, Schectman Gordon, Kirsh Susan R, Rubenstein Lisa V

机构信息

VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.

VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, United States.

出版信息

Contemp Clin Trials. 2018 Jun;69:65-75. doi: 10.1016/j.cct.2018.04.008. Epub 2018 Apr 23.

DOI:10.1016/j.cct.2018.04.008

PMID:29698772

Abstract

BACKGROUND

Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization.

METHODS/DESIGN: Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement.

DISCUSSION

VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.

摘要

背景

以患者为中心的医疗之家在为慢性病患者提供全面护理方面取得了巨大进展，但对于急性护理使用风险最高的患者可能无法提供足够的支持。为了解决这一问题，退伍军人健康管理局（VHA）启动了一个五站点示范项目，以评估通过为住院风险最高的退伍军人配备PACT强化管理（PIM）团队来增强VA的患者对齐护理团队（PACT）医疗之家的有效性。

方法/设计：研究人员与VHA领导层合作，设计了一项混合方法的前瞻性多站点评估，满足了领导层对作为质量改进而非研究进行严格评估的期望。我们进行了一项随机质量改进评估，将高风险患者分配到PIM组，并将他们与通过PACT接受常规护理的高风险退伍军人进行比较。总结性评估考察PIM是否：1）减少VHA急诊科和医院的使用；2）提高对VHA护理的满意度；3）减少提供者倦怠；4）产生正投资回报。形成性评估旨在支持示范站点为高风险患者提供更好的护理，并为未来针对高风险患者的举措提供信息。该评估由VHA研发办公室和研究监督办公室的代表进行审查，并符合质量改进标准。