I TITRATE PC: An Implementation based Community Health Worker Intervention to address Disparities in Palliative Care

总结 姑息治疗可以减少身体和心理症状，提高生活质量，并确保目标- 晚期癌症患者临终时的协调护理。有持续和恶化 非洲裔美国人患者的临终结局差异，受到以下可能性较低的混淆： 这一人群获得和接受姑息治疗。这些差异的基础是多因素的， 在生命结束时，障碍包括个人或文化价值观与临终关怀哲学相冲突，缺乏对 临终关怀服务，担心家庭负担，经济因素和/或对医疗保健系统的不信任。 护理团队中增加了具有细微差别技能的个人，重点是解决这些护理障碍 是一种很有前途的方法，以提高姑息治疗的吸收。社区卫生工作者（CHW）是非临床医生， 具有文化能力的公共卫生工作者，其作用是促进获得服务的机会，提供卫生教育， 支持提供护理，并促进在得不到充分服务的人群中开展宣传。CHW为患者提供补充护理 晚期慢性疾病，包括艾滋病毒/艾滋病，结核病和癌症，以及它们对改善 在这些环境中的护理是公认的。我们开发了一个集成的CHW模型-基于 社区卫生工作者干预以解决姑息治疗中的差异（I TITRATE PC）-利用 社区卫生工作者作为护理团队成员，为服务不足的晚期- 阶段性疾病。在I TITRATE PC中，社区卫生工作者接受培训，以提供宣传、支持、激励、赋权， 以及对病人及其照顾者进行姑息治疗和临终关怀教育。我们的初步 经验表明，社区卫生工作者可以改善姑息治疗的结果， 满足于照顾。 我们的长期目标是减少非裔美国人晚期癌症姑息治疗的差异。 将社区卫生工作者纳入医疗保健团队可能是改善获得和 提高这一人群对姑息治疗的接受率。为了探索这一点，我们将进行一项随机 在四个不同的癌症中心进行的有效性实施务实试验，比较的有效性 I TITRATE PC干预与标准治疗在改善姑息治疗结局方面的比较，包括 生命，接收质量沟通，预先护理计划文件/讨论，以及临终关怀的使用，以及 2.评估影响I TITRATE PC的有效性、保真度和采用的环境因素 干预我们预计这项工作将建立基于CHW的姑息治疗干预的有效性 并产生可推广的知识，以指导 采取干预措施，在得不到充分服务的人群中增加姑息治疗服务的使用。

SUMMARY Palliative care can reduce physical and psychological symptoms, improve quality of life, and ensure goal- concordant care at the end-of-life for patients with advanced cancer. There are persistent and worsening disparities in end-of-life outcomes for African American patients which are confounded by the lower likelihood of this population to access and receive palliative care. The basis for these disparities are multi-factorial, and at the end of life, barriers include personal or cultural values in conflict with hospice philosophy, a lack of awareness of hospice services, concern about burdening family, economic factors, and/or mistrust of the healthcare system. The addition of individuals to the care team with a nuanced skillset focused on addressing such barriers to care is a promising approach to enhance palliative care uptake. Community Health Workers (CHWs) are non-clinician, culturally competent public health workers whose role is to promote access to services, provide health education, support care delivery, and promote advocacy in underserved populations. CHWs supplement care for patients with advanced chronic diseases, including HIV/AIDS, tuberculosis, and cancer, and their impact on improving care in these settings is well-established. We developed an integrated CHW model – An Implementation based Community Health Worker Intervention to Address Disparities in Palliative Care (I TITRATE PC) – that utilizes CHWs as care team members to augment palliative care outcomes for underserved patients with advanced- stage illnesses. In I TITRATE PC, CHWs are trained to provide advocacy, support, motivation, empowerment, and education regarding palliative and end-of-life care to patients and their caregivers. Our preliminary experience suggests that CHWs can improve palliative care outcomes and improve patient and caregiver satisfaction with care. Our long-term goal is to reduce disparities in palliative care for African Americans with advanced cancer. Integration of CHWs as members of the healthcare team may be an effective means to improve access to and enhance the uptake of palliative care in this population. To explore this, we will conduct a randomized effectiveness-implementation pragmatic trial at four diverse cancer centers to 1. compare the effectiveness of the I TITRATE PC intervention versus standard care in improving palliative care outcomes, including quality of life, receipt of quality communication, advance care planning documentation/discussion, and hospice use, and 2. evaluate contextual factors that influence the effectiveness, fidelity, and adoption of the I TITRATE PC intervention. We anticipate this work will establish the effectiveness of a CHW-based palliative care intervention in a priority population and generate generalizable knowledge to guide the development and implementation of interventions to increase the use of palliative care services in underserved populations.