Empowering Formerly Homeless Older Adults to Engage in Advance Care Planning in Permanent Supportive Housing (ACP-PSH): An RCT

帮助以前无家可归的老年人参与永久支持性住房中的预先护理计划 (ACP-PSH)：一项随机对照试验

• 批准号: 10639204
• 负责人: MARGARET Anne HANDLEY
• 金额: $ 93.25万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-04-01 至 2028-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10639204
• 关键词: Acceleration; Address; Adoption; Adult; Advance Care Planning; Advance Directives; Age; Age Years; Aging; Anxiety; Attention; Caring; Chronic; Chronic Disease; Cluster randomized trial; Communities; Consolidated Framework for Implementation Research; Decision Making; Disparity; Effectiveness; Effectiveness of Interventions; Elderly; Evidence based program; Face; Family; Feedback; Focus Groups; Funding; Goals; Healthcare; High Prevalence; Homeless persons; Homelessness; Housing; Hybrids; Individual; Intervention; Intervention Trial; Interview; Left; Measures; Medical; Methods; Modeling; Participant; Patients; Persons; Policies; Population; Premature Mortality; Preparation; Process; Public Health; Quality of life; Randomized; Randomized, Controlled Trials; Reading; Reduce health disparities; Reporting; Research; Resources; Sampling; Services; Site; Social isolation; Surveys; Testing; Time; United States National Institutes of Health; Visit; Work; Writing; arm; behavior change; behavior change wheel; compare effectiveness; contextual factors; design; digital; effectiveness testing; empowerment; end of life; evidence base; experience; fifth grade; follow-up; health literacy; high risk; high risk population; implementation evaluation; implementation science; improved; marginalized population; member; mortality; mortality risk; movie; novel; pet animal; preference; primary outcome; programs; secondary outcome; supported housing; theories; tool; trial comparing; uptake

PROJECT SUMMARY/ABSTRACT Background: The homeless population is aging, with an increasing proportion of individuals over age 50 who experience accelerated aging, high rates of mortality, and a high risk of not having their wishes honored at the end of life. Advance care planning (ACP) aims to elicit patients’ medical preferences; yet older homeless adults have low rates of ACP. Significant policy attention has focused on rehousing chronically homeless people into Permanent Supportive Housing (PSH), subsidized permanent housing with voluntary supportive services. Our previous research indicates that PSH may be the ideal setting to initiate ACP; however, no studies have engaged formerly homeless PSH residents in ACP. Our team has created PREPARE for Your Care (PREPARE) – an easy-to-use, evidence-based, online ACP program with video stories. This program includes easy-to-read advance directives, an ACP group visit guide, and an ACP one-on-one facilitation guide. Through a prior R34, we developed a Community Advisory Board (CAB) and together identified preliminary adaptations to PREPARE for the PSH setting. The project requires a final co-development process with formerly chronically homeless older PSH residents and staff and our CAB. The objective of this proposal is to co-develop PREPARE-PSH and compare the effectiveness of facilitated group versus one-on-one visits among formerly chronically homeless older adults in PSH. Aims: We will (1) co-develop PREPARE-PSH with PSH residents, staff, and our CAB; (2) conduct a Hybrid (NIH Stage III efficacy/effectiveness), Type 1, two-arm, cluster randomized trial comparing the effectiveness of two delivery strategies of the PREPARE-PSH program (i.e., ACP movies and easy-to-read ADs) – facilitated group vs. one-on-one visits; and (3) explore implementation- relevant factors associated with ACP engagement and sustainability of ACP in PSH. Methods: In Aim 1 we will engage in a rigorous co-development process through in-depth interviews and focus groups with 20 PSH residents and the CAB. We will use a theory-informed framework (i.e., Behavior Change Wheel (BCW)) and qualitative content analysis to co-create a PREPARE-PSH program. For Aim 2, the CAB noted that groups may be more feasible to scale vs. one-on-one visits and asked us to randomize by site so residents would not feel “left out” of the alternate intervention. Therefore, we will conduct a Hybrid (NIH Stage III efficacy/effectiveness), Type 1 cluster randomized trial comparing delivery of PREPARE-PSH through facilitated groups vs. one-on-one visits using mixed effects models. Randomization will be at the site level, balanced by site size. In Aim 3 we will purposively sample Aim 2 participants for in-depth interviews (n=40-50), conduct focus groups with PSH staff (n=40), and obtain input from CAB members (total n=15). We will explore implementation-relevant factors associated with: (a) high and low ACP engagement and sustainability of PREPARE-PSH using the BCW and the Consolidated Framework for Implementation Research (CFIR) model. Relevance to NIH and public health: PREPARE-PSH may reduce health disparities in ACP among formerly chronically homeless older adults.

项目概要/摘要 背景：无家可归人口正在老龄化，50 岁以上无家可归者比例不断增加 经历加速老龄化、高死亡率以及无法实现愿望的高风险 临终护理计划 (ACP) 旨在了解患者的医疗偏好； ACP 比率较低。 永久支持性住房（PSH），提供自愿支持服务的补贴性永久住房。 先前的研究表明 PSH 可能是启动 ACP 的理想环境，但尚无研究表明； 我们的团队为 ACP 中的前无家可归的 PSH 居民创建了 PREPARE for Your Care。 (PREPARE) – 一个易于使用、基于证据的在线 ACP 程序，包含视频故事。 易于阅读的预先指示、ACP 团体访问指南和 ACP 一对一协助指南。 在之前的 R34 中，我们成立了社区咨询委员会 (CAB)，并共同确定了初步调整 为 PSH 设置做好准备 该项目需要与以前的长期合作进行最终的共同开发过程。 无家可归的老年 PSH 居民和工作人员以及我们的 CAB 该提案的目标是共同发展。 PREPARE-PSH 并比较以前团体访问与一对一访问的有效性 PSH 中长期无家可归的老年人 目标：我们将 (1) 与 PSH 居民共同开发 PREPARE-PSH， 工作人员和我们的 CAB；(2) 进行混合（NIH III 期疗效/有效性）、1 型、双臂、集群 比较 PREPARE-PSH 计划的两种实施策略（即， ACP 电影和易于阅读的广告）——促进团体访问与一对一访问；以及 (3) 探索实施- 与 PSH 方法中 ACP 参与和 ACP 可持续性相关的相关因素：在目标 1 中，我们将。 通过深入访谈和焦点小组与 20 PSH 参与严格的共同开发流程 我们将使用基于理论的框架（即行为改变轮 (BCW)）和 CAB 指出，为了共同创建 PREPARE-PSH 计划，进行定性内容分析。 与一对一的访问相比，规模化可能更可行，并要求我们按地点随机分配，这样居民就不会 感觉被替代干预“排除在外”，因此，我们将进行混合干预（NIH 第三阶段）。 功效/效果），1 类集群随机试验比较 PREPARE-PSH 的递送 促进小组与使用混合效应模型的一对一访问将在站点层面进行随机化， 在目标 3 中，我们将有目的地对目标 2 参与者进行深入访谈（n=40-50）， 与 PSH 工作人员（n=40）进行焦点小组讨论，并获取 CAB 成员的意见（总共 n=15）。 与实施相关的因素涉及： (a) ACP 参与度的高低和可持续性 PREPARE-PSH 使用 BCW 和实施研究综合框架 (CFIR) 模型。 与 NIH 和公共卫生的相关性：PREPARE-PSH 可能会减少以前 ACP 中的健康差异 长期无家可归的老年人。