Enhanced Care Planning and Clinical-Community Linkages to Comprehensively Address the Basic Needs of Patients with Multiple Chronic Conditions

加强护理规划和临床-社区联系，全面解决基本问题 多种慢性病患者的需求 项目总结 在美国，患有多种慢性病(MCC)的患者数量正在增加。很多病人 控制不好的MCC也有不健康的行为、心理健康挑战和未得到满足的社会需求。 如果患者正在努力解决这些基本生活问题，MCC的医疗管理可能会带来有限的好处 需要。卫生系统和社区日益认识到解决这些问题的必要性，并正在 试验和投资新模式，将患者与所需服务联系起来。然而，初级保健 临床医生，他们与病人的定期接触使他们更熟悉病人的需求，但往往不是 包括在这些系统中。响应NOT-HS-16-013特别强调通知，优化护理 MCC患者通过制定加强护理计划，我们提出了临床医生层面的建议 随机对照试验，研究初级保健临床医生如何参与这些社区和 医院的解决方案，以及这样做在控制MCC方面是否有效。这项研究将建立在合作医疗资助的基础上 弗吉尼亚州里士满的责任卫生社区(AHC)。弗吉尼亚州门诊护理中心的60名临床医生 结果研究网络(ACORN)将按年龄和性别匹配，并随机分配到常规护理(对照 条件)或通过临床-社区联动支持(干预)加强护理规划。从 电子健康记录(EHR)，我们将识别所有MCC患者，包括心血管疾病或风险， 糖尿病、肥胖症或抑郁症。一份基线评估将邮寄给随机挑选的50名患者；10 每名临床医生(总共600名患者)中未控制MCC的受访者将被随机选择， 对少数族裔的过度抽样。干预包括两个部分。第一，改进的护理规划工具 名为我自己的健康报告(Mohr)将对患者的健康行为、心理健康和社交进行筛查 需要。临床导航器支持将帮助患者确定需求的优先顺序，根据偏好创建护理计划， 并写一篇个人故事来指导护理团队。患者将每季度更新护理计划。第二, 社区-临床联系支持将包括社区资源登记、人员跨越设置 (临床导航员、社区卫生工作者)和护理团队协调工具(共享Mohr内容、 安全消息传递和虚拟访问)。我们将比较患者水平的干预和控制结果 评估MCC结果(主要结果)和自我报告PROIS-29措施(物理结果)的改善情况 健康、心理健康、社会福利)注册后六个月和两年。我们还将进行一次 对个人、家庭、社区和系统层面的背景影响进行混合方法、多层次评估 关于执行力和有效性。数据源将包括电子病历和Mohr数据、病历回顾、患者 对患者、临床医生和社区利益相关者进行调查、实地笔记和半结构化访谈。如果 这项研究将有效地帮助初级保健临床医生努力参与越来越多的 AHC类系统作为更好地控制MCC的策略。

Enhanced Care Planning and Clinical-Community Linkages to Comprehensively Address the Basic Needs of Patients with Multiple Chronic Conditions PROJECT SUMMARY The number of patients in the United States with multiple chronic conditions (MCC) is growing. Many patients with poorly controlled MCC also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address these basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not included in these systems. Responding to the Special Emphasis Notice NOT-HS-16-013, Optimizing Care for People Living with MCC through the Development of Enhanced Care Planning, we propose a clinician-level randomized controlled trial to study how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. This study will build on the CMS-funded Accountable Health Community (AHC) in Richmond, Virginia. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network (ACORN) will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record (EHR), we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to 50 randomly selected patients; 10 respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected, with oversampling of minorities. The intervention includes two components. First, an enhanced care planning tool called My Own Health Report (MOHR) will screen patients for health behavior, mental health, and social needs. Clinical navigator support will help patients prioritize needs, create care plans based on preferences, and write a personal narrative to guide the care team. Patients will update care plans quarterly. Second, community-clinical linkage support will include community resource registries, personnel to span settings (clinical navigators, community health workers), and care team coordination tools (sharing MOHR content, secure messaging, and virtual visits). We will compare patient-level intervention and control outcomes to assess improvements in MCC outcomes (primary outcome) and self-reported PROMIS-29 measures (physical health, mental health, social wellbeing) six months and two years post-enrollment. We will also conduct a mixed-methods, multilevel assessment of person-, family-, community-, and system-level contextual influences on implementation and effectiveness. Data sources will include EHR and MOHR data, chart reviews, patient surveys, field notes, and semi-structured interviews of patients, clinicians, and community stakeholders. If effective, this study will help inform efforts by primary care clinicians to participate in the growing number of AHC-like systems as a strategy to better control MCC.