Integrating personal values into primary care for Veterans with multimorbidity

将个人价值观融入患有多种疾病的退伍军人的初级保健中

基本信息

批准号：
10538185
负责人：
Linnaea Schuttner
金额：
--
依托单位：
VA PUGET SOUND HEALTHCARE SYSTEM
依托单位国家：
美国
项目类别：
财政年份：
2023
资助国家：
美国
起止时间：
2023-01-01 至 2027-12-31
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10538185
关键词：
Address Adherence Affect Benchmarking Caring Chronic Chronic Disease Clinic Clinic Visits Clinical Clinical Practice Guideline Clinical Trials Clinical effectiveness Complex Decision Analysis Decision Making Diagnostic tests Disease Effectiveness Eligibility Determination Feedback Foundations Future Goals Guidelines Health Health Priorities Health system Healthcare Home Hour Individual Intervention Interview Leadership Life Link Methodology Methods Modeling Outcome Outpatients Pathway interactions Patient Care Patient Care Planning Patient Outcomes Assessments Patient-Centered Care Patient-Focused Outcomes Patients Physicians Prevalence Primary Care Process Prognosis Quality of Care Recommendation Research Research Personnel Resources Role Self Management Service delivery model Services Specificity Structure Symptoms Testing Time Translating Triage Trust Veterans Veterans Health Administration acceptability and feasibility adverse event risk career clinical care clinically actionable compliance behavior cost design experience high risk human centered design implementation strategy improved individual patient innovation multiple chronic conditions novel patient engagement patient oriented person centered personalized care pilot test poor health outcome primary care clinic primary care provider primary care team provider communication psychosocial randomized, clinical trials reduce symptoms skills skills training tool wasting whole health

项目摘要

Background: Veterans with > 2 chronic conditions (multimorbidity) comprise almost 50% of patients in the Veterans Health Administration (VA). Primary care providers (PCPs) provide over 90% of outpatient VA care for the most complex, high-risk Veterans with multimorbidity. At present, these patients and their PCPs must juggle numerous healthcare and psychosocial needs with limited time and resources, both in clinic and in self- management at home. Patients and PCPs also make decisions about what care needs to prioritize without adequate guidance from clinical practice guidelines, many of which focus on single-disease processes. Patients and PCPs often disagree about what is most important; patients prioritize symptoms, while PCPs emphasize prognosis. Studies suggest that helping patients and PCPs communicate about what is most meaningful in life to patients (i.e., “personal values”) and align preferred health outcomes (i.e., “health priorities”) streamlines care, lowers treatment burden, and reduces unwanted interventions. To date, no study has clarified the circumstances in which personal values can guide health decisions or developed an approach linking personal values and actionable clinical care that helps navigate tensions between conflicting priorities. To address these gaps, this CDA will integrate a patient’s personal values into high-quality primary care by developing and testing an intervention (“Vet-Align”), a values-based approach to care for higher-risk Veterans with multimorbidity. Significance/Impact: This CDA advances VA and HSR&D priorities by improving patient-centric primary care and addressing what matters most to Veterans. This has long-term implications, including improving the specificity and personalization of VA quality metrics, advancing universal health outcomes, promoting patient engagement and adherence in care, and reducing waste and harm from unwanted or inappropriate care. Innovation: This CDA develops and tests a novel intervention using patient values and priorities to align primary care planning and delivery. This CDA will advance multimorbidity care and draws on novel methods including human-centered design (HCD) and multi-criteria decision analysis (MCDA), a participatory decision process. Specific Aims: 1) Understand how and when Veterans with multimorbidity connect values, health, and healthcare, to clarify the life and health circumstances where patient values directly influence PCP-patient care planning and self-management decisions; 2) Examine how VA ambulatory quality metrics align with and support patient priorities and values, to develop guidance for aligning disease-oriented quality metrics with patient- centered priorities of Veterans within a personal values-based care delivery model; 3) Refine and pilot test the acceptability and feasibility of Vet-Align, a values-based intervention for Veterans with multimorbidity, including tools and workflows for VA primary care to translate patient values into actionable clinical care plans. Methodology: Patients with > 2 chronic diseases at higher risk for adverse events are eligible for Aims 1 and 3. Aim 1 uses 25-30 semi-structured patient interviews, analyzed with content analysis. Aim 2 uses MCDA to combine healthcare expert perspectives and clinical evidence to rank outpatient VA quality metrics according to a patient’s preferred health priority. Building from findings and products from prior Aims, Aim 3a develops a novel, PCP-facing action-planning tool and workflows using HCD. Aim 3b pilot tests the tool in a clinical intervention (Vet-Align) for 30-36 patients and 15-20 PCPs. Vet-Align includes staff skills training and patient sessions with health coaches to elicit patient values, set health priorities, and personalize the action planning tool to send to PCPs. Feasibility and acceptability will be assessed from patient and staff perspectives. Next Steps/Implementation: The intervention developed in this CDA-2 will provide the foundation for a full randomized clinical trial evaluating clinical effectiveness through change in patient-centered outcomes and care quality, and testing implementation strategies for sustainment. Long term goals of this research trajectory are to strengthen the patient-centeredness and quality of VA primary care for Veterans with multimorbidity.

背景：患有超过 2 种慢性病（多发病）的退伍军人几乎占该地区患者的 50% 退伍军人健康管理局 (VA) 为退伍军人健康管理局 (VA) 提供超过 90% 的门诊 VA 护理。目前，这些患者及其 PCP 必须应对最复杂、高风险的多种疾病。在有限的时间和资源下，无论是在诊所还是在自我治疗中，都有大量的医疗保健和社会心理需求患者和 PCP 也可以在无需进行护理的情况下决定需要优先考虑的护理。临床实践指南提供了足够的指导，其中许多指南侧重于单一疾病的过程。 PCP 经常对最重要的问题存在分歧；患者优先考虑症状，而 PCP 则强调研究表明，帮助患者和 PCP 沟通生活中最有意义的事情。患者（即“个人价值观”）并调整首选健康结果（即“健康优先事项”）简化护理，减轻治疗负担，减少不必要的干预，迄今为止，还没有研究澄清这一情况。其中个人价值观可以健康指导决策或开发出一种将个人价值观与健康联系起来的方法为了解决这些差距，可以采取可行的临床护理来帮助解决相互冲突的优先事项之间的紧张关系。 CDA 将通过开发和测试一种将患者的个人价值观融入高质量初级保健的方法。干预（“Vet-Align”），一种基于价值观的方法，用于护理患有多种疾病的高风险退伍军人。意义/影响：该 CDA 通过改善以患者为中心的初级保健来推进 VA 和 HSR&D 的优先事项并解决对退伍军人最重要的问题，这具有长期影响，包括改善 VA 质量指标的特异性和个性化，促进全民健康成果，促进患者参与和坚持护理，并减少不必要或不适当护理造成的浪费和伤害。创新：该 CDA 使用患者价值观和优先事项来开发和测试一种新颖的干预措施，以调整主要治疗方案该 CDA 将推进多病态护理并利用新方法，包括以人为本的设计（HCD）和多标准决策分析（MCDA），一种参与式决策过程。具体目标： 1) 了解患有多种疾病的退伍军人如何以及何时将价值观、健康和医疗保健，阐明患者价值观直接影响 PCP 患者护理的生活和健康状况规划和自我管理决策；2) 检查 VA 动态质量指标如何配合和支持患者的优先事项和价值观，制定指导，使以疾病为导向的质量指标与患者的需求相一致在基于个人价值观的护理服务模式中以退伍军人的优先事项为中心 3) 完善和试点测试 Vet-Align 的可接受性和可行性，这是一种针对患有多种疾病的退伍军人的基于价值观的干预措施，包括 VA 初级护理的工具和工作流程，可将患者价值观转化为可行的临床护理计划。方法：患有 2 种以上慢性疾病且不良事件风险较高的患者符合目标 1 和 3。目标 1 使用 25-30 名半结构化患者访谈，并通过内容分析进行分析。结合医疗保健专家的观点和临床证据，根据以下因素对门诊 VA 质量指标进行排名根据之前 Aims 的研究结果和产品，Aim 3a 开发了一个患者优先考虑的健康问题。新颖的、面向 PCP 的行动规划工具和工作流程使用 Aim 3b 在临床中对该工具进行了试点测试。针对 30-36 名患者和 15-20 位 PCP 的干预 (Vet-Align) 包括员工技能培训和患者培训。与健康教练进行会议，以激发患者价值观、设定健康优先事项并制定个性化的行动计划发送给 PCP 的工具的可行性和可接受性将从患者和工作人员的角度进行评估。后续步骤/实施：本 CDA-2 中制定的干预措施将为全面的通过改变以患者为中心的结果和护理来评估临床有效性的随机临床试验该研究轨迹的长期目标是质量和测试实施策略。加强以患者为中心的退伍军人管理局对患有多种疾病的退伍军人的初级护理和质量。