Social and Behavioral Determinants of Health in High-Risk Veterans

高风险退伍军人健康的社会和行为决定因素

• 批准号: 10313362
• 负责人: MATTHEW L MACIEJEWSKI
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-10-01 至 2025-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10313362
• 关键词: Academy; Accident and Emergency department; Address; Affect; Area; Bed Occupancy; Behavioral; Businesses; COVID-19; COVID-19 pandemic; Caregivers; Caring; Clinical; Communities; Community Services; Coupled; Data; Disadvantaged; Economics; Electronic Health Record; Emergency department visit; Environmental Risk Factor; Evaluation; Financial Hardship; Funding; Future; Goals; Health; Health Care Costs; Health system; Healthcare; Hospital Costs; Hospital Departments; Hospitalization; Hospitals; Individual; Integrated Health Care Systems; Intervention; Interview; Lead; Leadership; Life; Light; Link; Measurement; Measures; Medicare; Medicine; Methodology; Minority; Modeling; Outcome; Patients; Population; Positioning Attribute; Predictive Value; Prevalence; Prevention; Primary Health Care; Procedures; Process; Recommendation; Reporting; Research; Research Personnel; Respondent; Rest; Risk; Risk Adjustment; Rural; Rural Health; Sampling; Screening procedure; Shapes; Social isolation; Surveys; System; Time; Transportation; Trust; United States Department of Veterans Affairs; Variant; Veterans; Veterans Health Administration; Woman; Women' s Health; Work; base; clinical care; cost; disadvantaged population; economic outcome; ethnic minority population; experience; food insecurity; health care service utilization; health care settings; health disparity; health equity; health record; high risk; housing instability; implementation barriers; implementation facilitators; improved; innovation; interoperability; operation; outcome prediction; patient population; point of care; racial and ethnic; screening; social; social factors; social health determinants; social vulnerability

Background. Social factors exert a substantially more potent impact on health than does health care, especially among disadvantaged populations such as VA users. Adverse social determinants of health (SDH)—factors such as housing instability, food insecurity, social isolation, and transportation barriers—are linked to problems with access, poorer clinical outcomes, and increased health care costs. Despite the clinical and business case for integrating SDHs into health care, these factors are not systematically assessed or addressed in clinical settings. Significance/Impact. This study will leverage a previous survey of Veterans at high-risk for hospitalization, and a new survey to be fielded to a nationally-representative sample of Veterans, to determine how SDHs influence clinical, health care utilization, and experience outcomes. Review of findings by key stakeholders will generate recommended SDH measures for universal screening within VA. These steps, coupled with qualitative interviews about implementation challenges, will inform the future integration of high-value patient-reported SDH measures into VA’s health record. Innovation. The proposed work is innovative in its evaluation of a broad array of SDHs in high-need Veterans to identify candidate measures for electronic health record (EHR) integration. The study will leverage a theoretically-driven survey of SDH measures with a data-driven approach to identifying the associations between these SDHs and a range of health, utilization, and patient experience outcomes. Results from these analyses will inform a facilitated deliberative process to prioritize high-value, validated, and actionable measures that are predictive of outcomes that are important to Veterans and the VA. Specific Aims. In Aim 1, we will use data from an Office of Primary Care-funded survey of Veterans at high-risk for hospitalization to examine relationships between patient-reported SDH measures and utilization, cost, and days in the community outcomes. In Aim 2, we will field a survey to a nationally-representative sample of VA patients to determine the association between SDH measures and key outcomes, and to examine the prevalence of SDHs in subpopulations of Veterans who are disproportionately affected by disparities (e.g., women, racial/ethnic minorities, and rural Veterans). Aims 1 and 2 will inform partner and stakeholder discussions in Aim 3 to identify measures that are associated with key outcomes and that are perceived by operations partners as actionable (i.e., addressable through VA or community services) and thereby good candidates for EHR integration. Methodology. In Aim 1, we will leverage data from an operations-funded survey that our team administered in 2018. Using survey data for 4,685 Veterans at high-risk for hospitalization, we will examine the association between patient-reported SDHs and utilization (i.e., VA and Medicare emergency department visits and hospitalizations), VA and Medicare costs, and days in the community. In Aim 2, we will field a similar survey to a nationally-representative sample of Veterans, evaluate the association between SDHs, patient experiences (e.g., perceived access and coordination), and 12-month VA emergency department visits, hospitalizations, and costs, and describe the prevalence of SDHs in the general VA population and Veterans who are at risk for health disparities. In Aim 3, we will use a facilitated deliberative process with key stakeholders to prioritize actionable SDH measures for EHR integration, and then conduct qualitative interviews with health system leaders, clinicians, staff, and patients to examine implementation barriers and facilitators to assessing select SDH measures at point of care. Implementation/Next Steps. This study addresses health equity, particularly relevant in light of COVID-19, and will be conducted with partners from VA’s Offices of Primary Care, Health Equity, Rural Health, and Women’s Health. The study is especially timely with VA’s transition to the new Cerner EHR as the proposed aims will identify SDH measures for potential EHR integration that are concise, actionable, and predictive of important outcomes.

背景资料。社会因素对健康的影响比卫生保健大得多，尤其是 在弱势群体中，如退伍军人管理局用户。健康的不利社会决定因素(SDH)--因素包括 住房不稳定、粮食不安全、社会孤立和交通障碍--都与 可获得性、更差的临床结果和更高的卫生保健成本。尽管临床和商业案例 将SDH整合到医疗保健中，这些因素在临床环境中没有得到系统的评估或解决。 重要性/影响力。这项研究将利用之前对住院高危退伍军人的调查，以及 将对具有全国代表性的退伍军人样本进行新的调查，以确定SDH如何影响 临床、卫生保健利用和体验结果。主要利益相关者对调查结果的审查将产生 建议在退伍军人管理局内进行普遍筛查的SDH措施。这些步骤，加上定性的采访 关于实施挑战，将为未来整合高价值患者报告的SDH措施提供信息 退伍军人管理局的健康记录。 创新。拟议的工作在评估一系列高需求退伍军人的SDH方面具有创新性 确定电子健康记录(EHR)集成的候选措施。这项研究将利用 采用数据驱动的方法对SDH测量进行理论驱动的调查，以确定 这些SDH以及一系列运行状况、利用率和患者体验结果。这些分析的结果 将为促进的审议过程提供信息，以优先考虑符合以下条件的高价值、有效和可操作的措施 预测对退伍军人和退伍军人很重要的结果。 明确的目标。在目标1中，我们将使用初级保健办公室资助的对高危退伍军人的调查数据 用于住院检查患者报告的SDH测量与利用率、成本和天数之间的关系 在社区结果中。在目标2中，我们将对具有全国代表性的VA患者样本进行现场调查 确定SDH措施与关键结果之间的关联，并检查SDH在 不成比例地受到差异影响的退伍军人群体(例如，妇女、种族/族裔少数群体、 和农村退伍军人)。目标1和目标2将向目标3中的合作伙伴和利益相关者提供信息，以确定措施 与关键结果相关联并且被运营伙伴认为是可操作的(即， 可通过退伍军人管理局或社区服务解决)，因此是EHR整合的良好候选者。 方法论。在目标1中，我们将利用由运营资助的调查数据，该调查由我们的团队在 2018年。利用4685名住院高危退伍军人的调查数据，我们将检查这种联系 患者报告的SDH和利用率(例如，退伍军人事务部和联邦医疗保险急诊科就诊和 住院费用)、退伍军人事务部和医疗保险费用，以及在社区的天数。在目标2中，我们将进行类似的调查 具有全国代表性的退伍军人样本，评估SDH与患者经历之间的关联 (例如，感知的访问和协调)以及12个月的退伍军人事务部急诊科就诊、住院和 成本，并描述一般退伍军人和面临健康风险的退伍军人中SDH的流行率 差距。在目标3中，我们将利用促进的与主要利益攸关方的审议过程来确定可采取行动的优先顺序 SDH对EHR整合的措施，然后对卫生系统领导人进行定性访谈， 临床医生、工作人员和患者检查实施障碍，并由推动者评估选定的SDH 在护理点采取措施。 实施/后续步骤。这项研究涉及健康公平，特别是与新冠肺炎相关的问题，以及 将与退伍军人事务部初级保健、卫生公平、农村卫生和妇女办公室的合作伙伴一起进行 健康。随着退伍军人管理局向新的Cerner EHR过渡，这项研究尤其及时，因为拟议的目标将确定 SDH措施，用于潜在的电子病历整合，简明、可操作并可预测重要结果。