VA Boston Geriatrics and Extended Care, Brockton, Massachusetts, USA.
VA New England Geriatric Research Education, Boston, Massachusetts, USA.
J Am Geriatr Soc. 2023 Nov;71(11):3445-3456. doi: 10.1111/jgs.18501. Epub 2023 Jul 14.
The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness.
We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival.
The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups.
A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.
协调过渡护理（CTraC）计划是一个基于电话的、由护士驱动的项目，已被证明可以降低再入院率。本项目的目的是实施和评估 CTraC 的一个改编版本，支持性 CTraC，以改善患有严重疾病的退伍军人的过渡和临终护理质量。
我们使用复制有效项目框架来指导改编和实施。一位具有老年病学和姑息治疗经验的注册护士（NCM）与住院和门诊护理团队密切合作，协调护理。符合条件的患者患有危及生命的诊断，且有严重的功能障碍，并且没有参加临终关怀。NCM 在 VA 波士顿医疗保健系统的急性住院期间确定退伍军人，并提供协议化的干预措施来确定护理需求和偏好，使护理与患者价值观保持一致，优化出院计划，并提供持续的、强化的电话病例管理。为了评估疗效，我们将每位支持性 CTraC 入组患者与 1：1 的同期对照患者按年龄、死亡或住院风险和出院诊断进行匹配。我们使用 Kaplan-Meier 图和 Cox 比例风险模型来评估结果。结果包括姑息治疗和临终关怀的使用、急性护理的使用、马萨诸塞州医疗指令以维持治疗文档和生存。
NCM 共招募了 104 名退伍军人，具有很高的方案一致性。在 1.5 年以上的随访中，支持性 CTraC 入组患者接受临终关怀的可能性比对照组高 61%（n=57 比 39；HR=1.61；95%CI=1.07-2.43）。尽管两组的总体急性护理使用情况相似，但支持性 CTraC 患者的 ICU 入院次数较少（n=36 比 53；p=0.005），更有可能在临终关怀中死亡（53 比 34；p=0.008），且两倍可能在家中接受临终关怀死亡（32.0 比 15.5；p=0.02）。两组之间的生存率没有差异。
对于患有严重疾病的退伍军人，由护士驱动的过渡护理计划是可行且有效的，可以改善临终结局。
