Outpatient Palliative Care Implementation to Improve Outcomes for AgingVeterans

实施门诊姑息治疗以改善老年退伍军人的治疗结果

• 批准号: 10552533
• 负责人: Brystana G. Kaufman
• 金额: --
• 依托单位: DURHAM VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-01-01 至 2026-12-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10552533
• 关键词: Acceleration; Adoption; Aging; Award; Businesses; Caregivers; Caring; Case Study; Cessation of life; Characteristics; Chronic Disease; Communities; Complex; Consult; Consultations; Data; Development; Effectiveness; Eligibility Determination; Ensure; Family; Geriatrics; Goals; Home; Hospitalization; Infrastructure; Inpatients; Interview; Investments; Knowledge; Leadership; Learning; Life; Long-Term Care; Measures; Medical; Mentors; Methods; Modeling; Outcome; Outpatients; Palliative Care; Pathway interactions; Patients; Pattern; Patterns of Care; Perception; Policies; Practical Robust Implementation and Sustainability Model; Primary Care; Quality of Care; Quality of life; Quantitative Evaluations; Reporting; Research; Research Design; Research Personnel; Resources; Site; Structure; Surveys; System; Telephone Interviews; Testing; Training; Veterans; Work; care systems; career; caregiving; clinical practice; cognitive interview; comparative effectiveness study; compare effectiveness; design; econometrics; end of life care; experience; falls; field survey; health service use; implementation evaluation; implementation outcomes; implementation research; implementation science; improved; improved outcome; innovation; member; multiple chronic conditions; operation; preservation; primary care practice; programs; psychosocial; satisfaction; skills; usability

Nearly one in three older veterans have multi-morbidity, many of whom manage life-limiting conditions (LLC) and may benefit from palliative care (PC).1,2 A PC consultation is an opportunity to review care goals and manage complex medical and psychosocial needs for veterans with LLCs. PC improves quality of life and quality of end-of-life (EOL) care; however, most research has been conducted in the inpatient setting.3-7 In 2009, the VA Comprehensive End of Life Care Initiative established Palliative Care Consult Teams (PCCT) with infrastructure investments largely in inpatient settings. In 2013, VA Geriatrics and Extended Care began expanding outpatient PC (OPC) services. Despite increasing use of OPC in the VA, little is known about the implementation and effectiveness of OPC in the VA. Preliminary evidence suggests OPC consults may be effective in patients with certain LLCs; however, effects are heterogeneous across potentially eligible patients. To improve appropriate PC use, critical gaps include lack of knowledge about OPC patterns (OPC consult characteristics and timing relative to inpatient PC, hospitalization, death) and PCCT structural characteristics and care practices. This project will generate the foundational knowledge needed to support an IIR proposal to compare effectiveness of OPC models and evaluate under what conditions OPC improves Veteran outcomes. My CDA employs an explanatory sequential design starting with quantitative analyses of OPC reach and patterns of use (aim 1) followed by enhanced interpretation using qualitative data (aim 2) and together these findings will inform the development of a site-level survey measuring PCCT structural characteristics and OPC practices (aim 3). Veteran engagement will include additional discussions with the local Veteran engagement board, and an advisory board (with representatives from the Veteran Engagement Board), ensuring this research is integrated with operational and veteran priorities. Aim 1.1 uses CDW data to Identify and describe common OPC patterns among aging veterans with LLC. Aim 1.2 will evaluate veteran- and site-level predictors of OPC patterns and identify sites with high and low OPC reach to inform Aim 2. Through interviews with PCCT members and leadership (n=18-24), Aim 2 will characterize OPC patterns and perceived organizational determinants of OPC reach, applying PRISM constructs from the Organizational Perspective domain. Themes will be compared between 3 high and 3 low reach sites. Aim 3 will adapt and pilot a recent GEC survey for Home Based Primary Care (HBPC) to collect data in 5 domains: structure/resources, leadership/team characteristics, referral workflows, patient groups served, and care components. Finally, Aim 4 will evaluate health services use associated with OPC consult and how outcomes differ across common OPC patterns. My CDA will culminate in the development and dissemination of a Palliative Care Pathways report that describes common patterns, sequencing, and outcomes of OPC in the VA in years 4-5. The IIR will implement the survey developed in the CDA and use these data to support a comparative effectiveness study of OPC using mixed methods. This evidence generated by the proposed research program is needed to identify strategies for tailoring PCCT to local needs and resources while retaining fidelity to the components that will improve appropriate PC use for veterans with LLC. Using this knowledge, we will work with operational partners to identifying opportunities for system redesign to improve veterans’ quality of life and families’ satisfaction with EOL care.

近三分之一的老年退伍军人患有多种疾病，其中许多人患有限制生命的疾病 (LLC)，并可能受益于姑息治疗 (PC)。1,2 PC 咨询是审查护理目标和 通过有限责任公司管理退伍军人复杂的医疗和社会心理需求，可以提高生活质量并提高他们的生活质量。 临终 (EOL) 护理质量；然而，大多数研究都是在住院环境中进行的。3-7 2009 年，VA 综合临终关怀计划成立了姑息治疗咨询团队 (PCCT) 2013 年，VA 老年病学和延伸护理项目开始进行基础设施投资。 扩大门诊 PC (OPC) 服务 尽管 VA 中 OPC 的使用越来越多，但人们对其知之甚少。 初步证据表明 OPC 咨询可能是 VA 的实施和有效性。 对某些有限责任公司的患者有效；然而，对于可能符合条件的患者，效果是不同的。 为了改进 PC 的正确使用，关键差距包括缺乏有关 OPC 模式的知识（OPC 咨询 相对于住院 PC、住院、死亡的特征和时间）以及 PCCT 结构特征 该项目将产生支持 IIR 提案所需的基础知识 比较 OPC 模型的有效性并评估 OPC 在什么条件下可以改善退伍军人的结果。 我的 CDA 采用解释性顺序设计，从 OPC 范围的定量分析开始， 使用模式（目标 1），然后使用定性数据增强解释（目标 2），并将这些 研究结果将为测量 PCCT 结构特征和 OPC 的现场调查的开展提供信息 实践（目标 3）。退伍军人参与将包括与当地退伍军人参与的额外讨论。 委员会和顾问委员会（由退伍军人参与委员会的代表组成），确保这项研究 目标 1.1 使用 CDW 数据来识别和描述共同点。 LLC 的 OPC 模式将在老年退伍军人中进行评估和现场级别的 OPC 预测。 模式并识别 OPC 覆盖率高和低的站点，以告知目标 2。通过与 PCCT 成员的访谈 和领导力 (n=18-24)，目标 2 将描述 OPC 模式和感知的组织决定因素 OPC 范围，从组织角度主题应用 PRISM 构造。 目标 3 将调整和试点最近的一项家庭小学 GEC 调查。 Care (HBPC) 收集 5 个领域的数据：结构/资源、领导力/团队特征、推荐 最后，目标 4 将评估医疗服务的使用情况。 与 OPC 咨询相关，以及常见 OPC 模式的结果有何不同。 我的 CDA 最终将制定和传播一份姑息治疗途径报告，该报告 描述了 IIR 将在 VA 中实施的 4-5 年 OPC 的常见模式、顺序和结果。 CDA 中开展的调查并使用这些数据来支持 OPC 的比较有效性研究 需要使用混合方法来确定拟议研究计划产生的证据。 根据当地需求和资源定制 PCCT 的策略，同时保持对组件的忠实度 利用这些知识，我们将与 LLC 合作改善退伍军人的 PC 使用情况。 合作伙伴寻找系统重新设计的机会，以改善退伍军人的生活质量和家庭的生活质量 对 EOL 护理的满意度。