Not listed
TRANSITIONS OF CARE PROGRAM TO MAKE GUIDELINE-BASED RECOMMENDATIONS ACTIONABLE FOR PATIENTS WITH DIABETIC KIDNEY DISEASE (TOGA-DKD) - PROJECT SUMMARY TOGA-DKD IS A PILOT/FEASIBILITY STUDY OF THE USE OF HOSPITALIZATION AS AN OPPORTUNITY TO IDENTIFY PATIENTS WITH HIGH-RISK DIABETIC KIDNEY DISEASE (DKD) AND LINK THEM TO A PHARMACIST-LED TRANSITION OF CARE (TOC) PROGRAM TO ENSURE ACCESS TO GUIDELINES-BASED MEDICATIONS POST-DISCHARGE. KIDNEY DISEASE AFFECTS UP TO 37 MILLION AMERICANS, 800,000 OF WHOM HAVE END STAGE KIDNEY DISEASE (ESKD). DKD IS THE LEADING CAUSE OF ESKD, IS A MAJOR RISK FOR MORTALITY AND DISPROPORTIONATELY AFFECTS RACIAL-ETHNIC MINORITIES. NEW THERAPIES HAVE REVOLUTIONIZED TREATMENT OF DKD AND ADHERENCE TO UPDATED GUIDELINES CAN SAVE LIVES. HOWEVER, IMPLANTATION CHALLENGES PREVENT ADHERENCE TO GUIDELINES IN THOSE PATIENTS THAT NEED THEM THE MOST, PATIENTS LIKE ONES SERVED BY MONTEFIORE HEALTH SYSTEM. FREQUENT HOSPITALIZATIONS AND A FRAGMENTED HEALTHCARE DELIVERY SYSTEM THAT ENABLES CLINICAL INERTIA, BOTH OF WHICH ARE WORSENED BY UNMET SOCIAL NEEDS, EXACERBATE DKD PROGRESSION IN MINORITIZED POPULATIONS. TRANSITIONS BETWEEN HOSPITAL AND DISCHARGE SITE, AND PATIENTS AND THEIR COMMUNITY NETWORKS, ARE FAR FROM SEAMLESS, RENDERING PATIENT SELF-MANAGEMENT AND ADHERENCE TO GUIDELINE-RECOMMENDED CARE CHALLENGING. PHARMACISTS HAVE THE NECESSARY SKILLSET TO OVERCOME THESE CHALLENGES BECAUSE OF THEIR ABILITY TO INTERFACE WITH PATIENTS, NAVIGATE COMPLICATED FORMULARY REQUIREMENTS, TITRATE MEDICATIONS ACCORDING TO CLINICAL FINDINGS, AND COORDINATE CARE WITH HEALTH CARE PROVIDERS. HOSPITALIZATION PRESENTS AN OPPORTUNITY FOR PHARMACISTS TO IMPLEMENT INITIATION OF THESE MEDICATIONS WHILE PROVIDING TRANSITION OF CARE COACHING. THIS STUDY WILL TEST THE FEASIBILITY OF ADAPTING A TRANSITION OF CARE PROGRAM ALREADY EMBEDDED IN THE INSTITUTIONAL MISSION TO REDUCE READMISSIONS AMONG HEART FAILURE PATIENTS, TO MEET THE POPULATION HEALTH GOAL OF REDUCING KIDNEY DISEASE PROGRESSION. AN ESSENTIAL COMPONENT OF THE PHARMACIST INTERVENTION IS DETERMINATION OF SOCIAL NEEDS OF PATIENTS, A NECESSARY PART OF ANY EFFORT TO REDUCE HEALTH DISPARITIES, USING THE VALIDATED MONTEFIORE SOCIAL NEEDS SCREENER. WE WILL TEST RECRUITMENT FEASIBILITY OF 100 PATIENTS BY 2-3 PHARMACISTS WITHIN 7 MONTHS, BECAUSE THIS IS A PILOT STUDY TO INFORM A LARGE MULTICENTER RANDOMIZED CONTROLLED TRIAL THAT TESTS THE EFFECTIVENESS OF TOGA-DKD TO IMPROVE ADHERENCE AND REDUCE DKD PROGRESSION. PROCESS OUTCOMES TESTING WILL HELP DETERMINE BEST WORKFLOW STRATEGIES OF THE PHARMACIST AND COORDINATION EFFORTS AMONG MULTIPLE AMBULATORY DISCIPLINES FOR THE LARGER STUDY. RATE OF COMPLETION AND POSITIVE RESPONSES TO THE MONTEFIORE SOCIAL NEEDS SCREENER WILL SUPPORT ITS USE IN THE TOC PROCESS, AND ANY SUCCESSFUL LINKAGE TO SOCIAL SERVICES OR COMMUNITY RESOURCES WILL SHOW FEASIBILITY OF THIS APPROACH TO IMPACT ON THOSE NEEDS. EXPLORATORY OUTCOMES WILL GIVE INSIGHT INTO SUSTAINABILITY OF INTERVENTION AT 30 DAYS POST-DISCHARGE WHICH WILL INFORM A LONGITUDINAL PROGRAM COMPONENT OF THE FUTURE LARGER INTERVENTION. THE STUDY TEAM AND STUDY ADVISORY BOARD ARE INSTITUTIONAL STAKEHOLDERS, LEADERS, AND EXPERIENCED INVESTIGATORS AT THE FOREFRONT OF HEALTH DELIVERY INNOVATION, SPARKED BY THE UNIQUE NEEDS OF THE PATIENT POPULATION SERVED AND ACCELERATED BY THE COVID-19 PANDEMIC. MONTEFIORE IS A LEARNING HEALTH SYSTEM AND SERVES A PREDOMINANTLY UNDERSERVED RACIAL/ETHNIC MINORITY POPULATION AT DISPROPORTIONATE RISK OF KIDNEY DISEASE. RESEARCH FINDINGS WILL BE DISSEMINATED TO POLICYMAKERS, HEALTH SYSTEM ADMINISTRATORS, THE SCIENTIFIC COMMUNITY, AND PATIENTS. TOGA-DKD WILL LAY THE FOUNDATION FOR THE IMPLEMENTATION, SCALABILITY AND HEALTH DELIVERY REDESIGN FOR THOSE POPULATIONS WHO STRUGGLE WITH COMPLEX COMORBIDITY AND UNFAVORABLE SOCIAL CIRCUMSTANCES.
$0 12/17/24 Not listed
TRANSITIONS OF CARE PROGRAM TO MAKE GUIDELINE-BASED RECOMMENDATIONS ACTIONABLE FOR PATIENTS WITH DIABETIC KIDNEY DISEASE (TOGA-DKD) - PROJECT SUMMARY TOGA-DKD IS A PILOT/FEASIBILITY STUDY OF THE USE OF HOSPITALIZATION AS AN OPPORTUNITY TO IDENTIFY PATIENTS WITH HIGH-RISK DIABETIC KIDNEY DISEASE (DKD) AND LINK THEM TO A PHARMACIST-LED TRANSITION OF CARE (TOC) PROGRAM TO ENSURE ACCESS TO GUIDELINES-BASED MEDICATIONS POST-DISCHARGE. KIDNEY DISEASE AFFECTS UP TO 37 MILLION AMERICANS, 800,000 OF WHOM HAVE END STAGE KIDNEY DISEASE (ESKD). DKD IS THE LEADING CAUSE OF ESKD, IS A MAJOR RISK FOR MORTALITY AND DISPROPORTIONATELY AFFECTS RACIAL-ETHNIC MINORITIES. NEW THERAPIES HAVE REVOLUTIONIZED TREATMENT OF DKD AND ADHERENCE TO UPDATED GUIDELINES CAN SAVE LIVES. HOWEVER, IMPLANTATION CHALLENGES PREVENT ADHERENCE TO GUIDELINES IN THOSE PATIENTS THAT NEED THEM THE MOST, PATIENTS LIKE ONES SERVED BY MONTEFIORE HEALTH SYSTEM. FREQUENT HOSPITALIZATIONS AND A FRAGMENTED HEALTHCARE DELIVERY SYSTEM THAT ENABLES CLINICAL INERTIA, BOTH OF WHICH ARE WORSENED BY UNMET SOCIAL NEEDS, EXACERBATE DKD PROGRESSION IN MINORITIZED POPULATIONS. TRANSITIONS BETWEEN HOSPITAL AND DISCHARGE SITE, AND PATIENTS AND THEIR COMMUNITY NETWORKS, ARE FAR FROM SEAMLESS, RENDERING PATIENT SELF-MANAGEMENT AND ADHERENCE TO GUIDELINE-RECOMMENDED CARE CHALLENGING. PHARMACISTS HAVE THE NECESSARY SKILLSET TO OVERCOME THESE CHALLENGES BECAUSE OF THEIR ABILITY TO INTERFACE WITH PATIENTS, NAVIGATE COMPLICATED FORMULARY REQUIREMENTS, TITRATE MEDICATIONS ACCORDING TO CLINICAL FINDINGS, AND COORDINATE CARE WITH HEALTH CARE PROVIDERS. HOSPITALIZATION PRESENTS AN OPPORTUNITY FOR PHARMACISTS TO IMPLEMENT INITIATION OF THESE MEDICATIONS WHILE PROVIDING TRANSITION OF CARE COACHING. THIS STUDY WILL TEST THE FEASIBILITY OF ADAPTING A TRANSITION OF CARE PROGRAM ALREADY EMBEDDED IN THE INSTITUTIONAL MISSION TO REDUCE READMISSIONS AMONG HEART FAILURE PATIENTS, TO MEET THE POPULATION HEALTH GOAL OF REDUCING KIDNEY DISEASE PROGRESSION. AN ESSENTIAL COMPONENT OF THE PHARMACIST INTERVENTION IS DETERMINATION OF SOCIAL NEEDS OF PATIENTS, A NECESSARY PART OF ANY EFFORT TO REDUCE HEALTH DISPARITIES, USING THE VALIDATED MONTEFIORE SOCIAL NEEDS SCREENER. WE WILL TEST RECRUITMENT FEASIBILITY OF 100 PATIENTS BY 2-3 PHARMACISTS WITHIN 7 MONTHS, BECAUSE THIS IS A PILOT STUDY TO INFORM A LARGE MULTICENTER RANDOMIZED CONTROLLED TRIAL THAT TESTS THE EFFECTIVENESS OF TOGA-DKD TO IMPROVE ADHERENCE AND REDUCE DKD PROGRESSION. PROCESS OUTCOMES TESTING WILL HELP DETERMINE BEST WORKFLOW STRATEGIES OF THE PHARMACIST AND COORDINATION EFFORTS AMONG MULTIPLE AMBULATORY DISCIPLINES FOR THE LARGER STUDY. RATE OF COMPLETION AND POSITIVE RESPONSES TO THE MONTEFIORE SOCIAL NEEDS SCREENER WILL SUPPORT ITS USE IN THE TOC PROCESS, AND ANY SUCCESSFUL LINKAGE TO SOCIAL SERVICES OR COMMUNITY RESOURCES WILL SHOW FEASIBILITY OF THIS APPROACH TO IMPACT ON THOSE NEEDS. EXPLORATORY OUTCOMES WILL GIVE INSIGHT INTO SUSTAINABILITY OF INTERVENTION AT 30 DAYS POST-DISCHARGE WHICH WILL INFORM A LONGITUDINAL PROGRAM COMPONENT OF THE FUTURE LARGER INTERVENTION. THE STUDY TEAM AND STUDY ADVISORY BOARD ARE INSTITUTIONAL STAKEHOLDERS, LEADERS, AND EXPERIENCED INVESTIGATORS AT THE FOREFRONT OF HEALTH DELIVERY INNOVATION, SPARKED BY THE UNIQUE NEEDS OF THE PATIENT POPULATION SERVED AND ACCELERATED BY THE COVID-19 PANDEMIC. MONTEFIORE IS A LEARNING HEALTH SYSTEM AND SERVES A PREDOMINANTLY UNDERSERVED RACIAL/ETHNIC MINORITY POPULATION AT DISPROPORTIONATE RISK OF KIDNEY DISEASE. RESEARCH FINDINGS WILL BE DISSEMINATED TO POLICYMAKERS, HEALTH SYSTEM ADMINISTRATORS, THE SCIENTIFIC COMMUNITY, AND PATIENTS. TOGA-DKD WILL LAY THE FOUNDATION FOR THE IMPLEMENTATION, SCALABILITY AND HEALTH DELIVERY REDESIGN FOR THOSE POPULATIONS WHO STRUGGLE WITH COMPLEX COMORBIDITY AND UNFAVORABLE SOCIAL CIRCUMSTANCES.
$100.0k 4/24/24 Not listed
TRANSITIONS OF CARE PROGRAM TO MAKE GUIDELINE-BASED RECOMMENDATIONS ACTIONABLE FOR PATIENTS WITH DIABETIC KIDNEY DISEASE (TOGA-DKD) - PROJECT SUMMARY TOGA-DKD IS A PILOT/FEASIBILITY STUDY OF THE USE OF HOSPITALIZATION AS AN OPPORTUNITY TO IDENTIFY PATIENTS WITH HIGH-RISK DIABETIC KIDNEY DISEASE (DKD) AND LINK THEM TO A PHARMACIST-LED TRANSITION OF CARE (TOC) PROGRAM TO ENSURE ACCESS TO GUIDELINES-BASED MEDICATIONS POST-DISCHARGE. KIDNEY DISEASE AFFECTS UP TO 37 MILLION AMERICANS, 800,000 OF WHOM HAVE END STAGE KIDNEY DISEASE (ESKD). DKD IS THE LEADING CAUSE OF ESKD, IS A MAJOR RISK FOR MORTALITY AND DISPROPORTIONATELY AFFECTS RACIAL-ETHNIC MINORITIES. NEW THERAPIES HAVE REVOLUTIONIZED TREATMENT OF DKD AND ADHERENCE TO UPDATED GUIDELINES CAN SAVE LIVES. HOWEVER, IMPLANTATION CHALLENGES PREVENT ADHERENCE TO GUIDELINES IN THOSE PATIENTS THAT NEED THEM THE MOST, PATIENTS LIKE ONES SERVED BY MONTEFIORE HEALTH SYSTEM. FREQUENT HOSPITALIZATIONS AND A FRAGMENTED HEALTHCARE DELIVERY SYSTEM THAT ENABLES CLINICAL INERTIA, BOTH OF WHICH ARE WORSENED BY UNMET SOCIAL NEEDS, EXACERBATE DKD PROGRESSION IN MINORITIZED POPULATIONS. TRANSITIONS BETWEEN HOSPITAL AND DISCHARGE SITE, AND PATIENTS AND THEIR COMMUNITY NETWORKS, ARE FAR FROM SEAMLESS, RENDERING PATIENT SELF-MANAGEMENT AND ADHERENCE TO GUIDELINE-RECOMMENDED CARE CHALLENGING. PHARMACISTS HAVE THE NECESSARY SKILLSET TO OVERCOME THESE CHALLENGES BECAUSE OF THEIR ABILITY TO INTERFACE WITH PATIENTS, NAVIGATE COMPLICATED FORMULARY REQUIREMENTS, TITRATE MEDICATIONS ACCORDING TO CLINICAL FINDINGS, AND COORDINATE CARE WITH HEALTH CARE PROVIDERS. HOSPITALIZATION PRESENTS AN OPPORTUNITY FOR PHARMACISTS TO IMPLEMENT INITIATION OF THESE MEDICATIONS WHILE PROVIDING TRANSITION OF CARE COACHING. THIS STUDY WILL TEST THE FEASIBILITY OF ADAPTING A TRANSITION OF CARE PROGRAM ALREADY EMBEDDED IN THE INSTITUTIONAL MISSION TO REDUCE READMISSIONS AMONG HEART FAILURE PATIENTS, TO MEET THE POPULATION HEALTH GOAL OF REDUCING KIDNEY DISEASE PROGRESSION. AN ESSENTIAL COMPONENT OF THE PHARMACIST INTERVENTION IS DETERMINATION OF SOCIAL NEEDS OF PATIENTS, A NECESSARY PART OF ANY EFFORT TO REDUCE HEALTH DISPARITIES, USING THE VALIDATED MONTEFIORE SOCIAL NEEDS SCREENER. WE WILL TEST RECRUITMENT FEASIBILITY OF 100 PATIENTS BY 2-3 PHARMACISTS WITHIN 7 MONTHS, BECAUSE THIS IS A PILOT STUDY TO INFORM A LARGE MULTICENTER RANDOMIZED CONTROLLED TRIAL THAT TESTS THE EFFECTIVENESS OF TOGA-DKD TO IMPROVE ADHERENCE AND REDUCE DKD PROGRESSION. PROCESS OUTCOMES TESTING WILL HELP DETERMINE BEST WORKFLOW STRATEGIES OF THE PHARMACIST AND COORDINATION EFFORTS AMONG MULTIPLE AMBULATORY DISCIPLINES FOR THE LARGER STUDY. RATE OF COMPLETION AND POSITIVE RESPONSES TO THE MONTEFIORE SOCIAL NEEDS SCREENER WILL SUPPORT ITS USE IN THE TOC PROCESS, AND ANY SUCCESSFUL LINKAGE TO SOCIAL SERVICES OR COMMUNITY RESOURCES WILL SHOW FEASIBILITY OF THIS APPROACH TO IMPACT ON THOSE NEEDS. EXPLORATORY OUTCOMES WILL GIVE INSIGHT INTO SUSTAINABILITY OF INTERVENTION AT 30 DAYS POST-DISCHARGE WHICH WILL INFORM A LONGITUDINAL PROGRAM COMPONENT OF THE FUTURE LARGER INTERVENTION. THE STUDY TEAM AND STUDY ADVISORY BOARD ARE INSTITUTIONAL STAKEHOLDERS, LEADERS, AND EXPERIENCED INVESTIGATORS AT THE FOREFRONT OF HEALTH DELIVERY INNOVATION, SPARKED BY THE UNIQUE NEEDS OF THE PATIENT POPULATION SERVED AND ACCELERATED BY THE COVID-19 PANDEMIC. MONTEFIORE IS A LEARNING HEALTH SYSTEM AND SERVES A PREDOMINANTLY UNDERSERVED RACIAL/ETHNIC MINORITY POPULATION AT DISPROPORTIONATE RISK OF KIDNEY DISEASE. RESEARCH FINDINGS WILL BE DISSEMINATED TO POLICYMAKERS, HEALTH SYSTEM ADMINISTRATORS, THE SCIENTIFIC COMMUNITY, AND PATIENTS. TOGA-DKD WILL LAY THE FOUNDATION FOR THE IMPLEMENTATION, SCALABILITY AND HEALTH DELIVERY REDESIGN FOR THOSE POPULATIONS WHO STRUGGLE WITH COMPLEX COMORBIDITY AND UNFAVORABLE SOCIAL CIRCUMSTANCES.
$100.0k 4/24/24