Optimizing Patient-Centered Routine Care at a Distance for Veterans with Chronic Conditions

背景：由于2019冠状病毒病，弗吉尼亚州经历了相当大的过渡到远程护理

Background: As a result of COVID-19, the VA has undergone a sizable transition to Care at a Distance in order to ensure the safe delivery of services. Components encompass expanded telehealth, distancing measures at routine face to face visits, and other practice changes. How Veterans with chronic conditions who regularly use VA healthcare experience these changes is unknown. This 18-month pilot study assesses a mixed methods approach to describe Care at a Distance for older, chronically ill Veterans, how service changes are experienced by Veterans, and how the experiences affect health management and outcomes. Significance/Impact: The unprecedented impact of COVID-19 provides an opportunity to advance novel Veteran-centered mixed methods to understand the pandemic’s effects on Veteran healthcare. Investigations can identify and test out Veteran-centered system improvements that support preparedness for future emergencies. This study aligns with VA’s strategic goals and objectives for FY2018-2024 to promote ‘customer service,’ and HSR&D’s scientific priorities to improve telehealth’s effectiveness, and to use primary care to optimize complex chronic disease management. It also aligns with ongoing activities in the Veterans Experience Office using journey mapping to understand Veteran experiences of VA care. Innovation: The proposed mixed methods pilot study is interdisciplinary, using novel methods in VA studies. By drawing upon theories and methods of medical anthropology and health services research, the pilot study is positioned to produce deep and actionable knowledge about COVID-19’s impact on Veterans and their care. Specific Aims: Aim 1: Describe components of Care at a Distance, to inform adapting an experience-based journey mapping template, which will describe how Care at a Distance affects the healthcare experiences of older Veterans with comorbidities, and their health outcomes. Aim 2: Test the feasibility and acceptability, and conduct an analysis, of embedding experienced-based journey mapping within in-depth qualitative interviews to describe Care at a Distance for older Veterans with comorbidities, and their routine care providers. Aim 3: Assess the utility of the mixed methods techniques to examine relationships among service changes, Veteran experiences, and health outcomes, incorporating chart review as a comparative and triangulating data source. Methods: The study uses a sequential design carried out at the James J. Peters VA in Bronx, NY and VA Hudson Valley Health Care in upstate, New York. In Aim 1, a documents analysis of VA Care at a Distance changes will be conducted to refine an inventory of components, key features, and their implementation. The inventory will inform an adapted experience-based journey map template and interview topic guide, and a medical chart analysis. In Aim 2, 40 Veterans will be recruited who are 65+ years old with two or more comorbidities (one being HIV or diabetes) and eligible for enrollment in the GeriPact, or HIV clinic. Interviews will use the experience-based survey mapping template to document service encounters and experiences before COVID- 19 (prior to March 2020), in the initial phase (March-May 2020), and during the Moving Forward period (June 2020-time of study). A follow-up interview will discuss feasibility and acceptability of mapping. 12 provider interviews will be conducted about implementation and Veteran experiences of Care at a Distance, and the feasibility of journey mapping. We will analyze for feasibility and acceptability, and conduct a qualitative thematic and process analysis. In Aim 3, a chart review will be performed to examine the record of health use and outcomes, and a comparative analysis will be performed between charts and the maps. Implementation/ Next Steps: Findings will be used to develop an IIR research proposal to: 1) describe Care at a Distance impact across VA facilities; and 2) test out and evaluate interventions to improve care for Veterans, particularly those aging with chronic health conditions. The VA Veteran Experience Office will partner on this study, and continuous Veteran input will be sought.