Primary Care Quality and Homeless Service Tailoring

 描述（由申请人提供）： 退伍军人事务部采用了以患者为中心的医疗之家，在 VA 中称为“患者联盟护理团队”(PACT)，这种方法承诺提供全面、以患者为中心、以团队为基础、注重协调和沟通的护理，并能够维持长期持续的关系。对于无家可归或正在摆脱无家可归的患者来说，这些理想往往无法实现。尽管为无家可归者开发以患者为中心的医疗之家做出了巨大努力，但对于为患者创造有价值、持久的初级护理体验的服务设计交付的特定方面却知之甚少。 自 2012 年以来，VA 雄心勃勃地通过无家可归者 PACT（HPACT，n=60）试点针对无家可归者量身定制的初级护理服务设计。这就创造了一个自然的实验，它提出了两个问题，不仅对退伍军人事务部很重要，而且对那些寻求为社会弱势群体推广可行的医疗之家的非退伍军人机构也很重要。首先，退伍军人事务部针对无家可归者量身定制的初级保健计划是否提供了实质上优越的患者体验？其次，哪些特定的组织特征实际上很重要？ 该提案优先考虑无家可归患者的初级保健经历，作为成功参与初级保健的最接近指标。患者体验调查寻求一份体验报告，说明护理服务的各个方面（访问、协调等）与患者和专家认为理想的情况是否相符。在之前由退伍军人管理局资助的研究中，我们询问了患者和医疗服务提供者对无家可归者初级护理的愿望。由此，我们开发了一项心理测量有效的患者体验调查（初级护理质量-无家可归者，PCQ-H），该调查已用于全国各地的无家可归者医疗保健计划。 本研究将结合对有无家可归经历（当前和以前无家可归）退伍军人 (n=6,181) 的患者调查和 HPACT 样本中的组织评估，以推进两个目标： 目标 1：比较在 HPACT 中获得初级护理的无家可归者患者的初级护理体验（即 PCQ-H 评分）与在同一 VA 医疗中心运营的主流 PACT 诊所接受初级护理的患者的初级护理体验（即 PCQ-H 评分）。目标 2：描述与卓越患者体验（即更好的 PCQ-H 分数）最密切相关的 HPACT 服务设计特征。该目标将通过以下方式依次推进：(a) 调整专门针对无家可归者量身定制的初级保健的组织评估工具，供本项目使用； (b) 通过对 HPACT 主管进行调查来进行评估，以确定是否存在潜在相关的 HPACT 服务功能； (c) 分析比较具有每个潜在相关 HPACT 服务功能的 HPACT 与缺乏每个潜在相关 HPACT 服务功能的 HPACT 的 PCQ-H 分数。 这项研究的证据将有助于指导退伍军人事务部和非退伍军人管理局联邦合格健康中心为无家可归者和以前无家可归患者提供初级保健服务的未来。此外，它可能有助于培育一种初级保健文化，这种文化首先要对患者摆脱无家可归者的独特背景需求负责。

 DESCRIPTION (provided by applicant): The Department of Veterans Affairs has embraced the patient-centered medical home, termed the Patient-Aligned Care Team (PACT) in VA, an approach that promises care that is comprehensive, patient- centered, team-based, focused on coordination and communication, and able to sustain a relationship that continues over time. For patients who are homeless or exiting homelessness, these ideals are often not met. Despite significant efforts to develop patient-centered medical homes for people who are homeless, little is known about the particular aspects service design delivery that create valuable, enduring primary care experiences for patients. Since 2012, VA has ambitiously piloted homeless-tailored primary care service design through Homeless PACTs (HPACTs, n=60). This has created a natural experiment that invites two questions important not just to VA but to non-VA agencies seeking to promote viable medical homes for socially-vulnerable populations. First, do VA's homeless-tailored primary care programs offer a substantively superior patient experience? Second, what particular organizational features actually matter? This proposal prioritizes homeless patients' experience of primary care as the proximal indicator of successful engagement in primary care. Patient experience surveys seek an experiential report of how well aspects of care delivery (access, coordination, etc.) map to what patients and experts consider ideal. In prior VA-funded research, we asked patients and providers about their aspirations for primary care of the homeless. From this we developed a psychometrically valid patient experience survey (Primary Care Quality-Homeless, PCQ-H), which has been used in homeless health care programs across the country. This study will combine patient surveys from homeless-experienced (currently and previously homeless) veterans (n=6,181) and organizational assessment among a sample of HPACTs to advance two aims: Aim 1: Compare the primary care experience (i.e. PCQ-H scores) for homeless-experienced patients obtaining primary care in HPACTs to patients receiving primary care in mainstream PACT clinics operated by the same VA Medical Center. Aim 2: Characterize those features of HPACT service design that are most strongly associated with a superior patient experience (i.e. better PCQ-H scores). This Aim will be advanced sequentially through (a) adaptation of an organizational assessment tool specific to homeless-tailored primary care for use in this project; (b) conducting that assessment through surveys of HPACT directors to identify the presence or absence of potentially relevant HPACT service features; (c) analysis to compare PCQ-H scores for HPACTs that have versus those that lack each potentially relevant HPACT service feature. Evidence from this study will help to guide the future of primary care delivery for homeless and formerly homeless patients within VA, and in non-VA Federally Qualified Health Centers. Additionally, it may help to foster a primary care culture that holds itself accountable, first and foremost, to the unique contextual needs of patients as they leave homelessness behind.