Telehealth-delivered peer support to improve quality of life among Veterans with multimorbidity

背景：超过50%的退伍军人事务部（VA）患者患有多发性硬化症： >2慢性病的发生。多发性骨髓瘤损害健康相关生活质量（HRQoL）;导致 心理困扰、残疾和死亡率;并导致高医疗保健利用率和成本。最 慢性病需要患者进行疾病自我管理，包括坚持治疗， 改变生活方式，并与他们的医疗团队合作。患有多发性硬化症的患者面临许多 自我管理和亲自参加诊所访问的障碍。鉴于时间有限， 由于初级保健就诊的需求，多发病患者需要更多的自我管理支持。对等 支助-由与其服务的人群相似的非专业人员提供的援助-交付 通过远程保健的方式适合满足这些需求。我们开发了一个虚拟的，退伍军人领导的同伴健康教练 干预，VetASSiST（退伍军人激活自我管理和治疗的社会支持） 参与），以帮助患者克服自我管理的障碍，提高HRQoL。 意义：VetASSiST是及时和有效的，并与HSR&D的优先事项，改善护理应该 支持协调和整合照顾大多数退伍军人谁有多种条件，而不是 而不是建立新的单一疾病干预措施。该提案还与小学的其他HSR&D优先事项保持一致 复杂慢性病的护理实践和管理以及虚拟护理/远程医疗。 创新和影响：先前的同伴支持试验解决了个人慢性病或心理健康问题。 VetASSiST将是支持患有多发性硬化症的退伍军人的首批干预试验之一。还将 第一批利用远程医疗远程提供同伴支持的公司之一，这有可能增加 获得护理。如果有效，干预措施可以广泛实施，以改善患者的预后。 具体目的：1）测试VetASSiST与常规治疗相比对基线主要结局的影响 至12个月的身体HRQoL变化，以及精神HRQoL和医疗保健利用的次要结局; 2a）描述VetASSiST和常规治疗之间基线至12个月中间变化的差异 反映同伴支持和干预目标功能的结果：自我效能，患者激活， 健康行为，社会支持，感知获得护理，患者-提供者沟通，以及共享 2b）检查中间结果是否介导干预相关的差异， HRQoL; 3）评价将VetASSiST转化为实践的可行性，包括评价每例患者 干预成本以及实施的障碍和促进因素。 方法学：我们计划进行一项混合型1型实施-有效性随机对照试验， 退伍军人与复杂的多发性硬化症，定义为>3慢性疾病在>3个身体系统。患者还必须 有>1的：1）身体和精神健康状况; 2）脆弱; 3）频繁的紧急护理; 4）多种药物; （5）治疗负担大。我们将使用电子健康记录中的数据来识别符合条件的患者， 在筛选时通过自我报告的信息进行确认，并将入组的患者以1：1的比例随机分配至VetASSiST或 常规护理控制。主要结局是从基线到12个月的身体HRQoL变化， 和SF-12次要结局包括精神HRQoL（SF-12）和医疗保健利用的变化。 在RE-AIM框架的指导下，我们将使用定量和定性方法来评估障碍， 促进关键利益攸关方群体的执行工作。这些数据将为今后的实施提供信息。 后续步骤/实施：该混合1型试验将提供准备更广泛VA所需的数据 如果干预措施有效，执行活动将与当地现有的 和国家业务伙伴。如果干预无效，目标2和3将阐明退伍军人如何 今后可以更好地支持多部门合作。

Background: More than 50% of Department of Veterans Affairs (VA) patients have multimorbidity: the co- occurrence of >2 chronic conditions. Multimorbidity impairs health-related quality of life (HRQoL); leads to psychologic distress, disability, and mortality; and contributes to high health care utilization and costs. Most chronic conditions require patients to engage in disease self-management, including adhering to treatments, making lifestyle changes, and working with their health care team. Patients with multimorbidity face many barriers to self-management and to attending in-person clinic visits. Given the limited time and competing demands of primary care visits, patients with multimorbidity need additional support for self-management. Peer support – assistance provided by non-professionals who are similar to the populations they serve – delivered via telehealth is suited to address these needs. We developed a virtual, Veteran-led peer health coaching intervention, VetASSiST (Veterans Activating Social Support for Self-management and Treatment engagement), to help patients with multimorbidity overcome barriers to self-management and improve HRQoL. Significance: VetASSiST is timely and efficient and aligns with the HSR&D priority that improving care should support coordination and integration of care for the majority of Veterans who have multiple conditions rather than building new single disease interventions. The proposal also aligns with other HSR&D priorities of Primary Care Practice and Management of Complex Chronic Diseases and Virtual Care/Telehealth. Innovation and Impact: Prior peer support trials address individual chronic conditions or mental health. VetASSiST will be one of the first trials of an intervention to support Veterans with multimorbidity. It will also be one of the first to leverage telehealth to remotely deliver peer support, which has the potential to increase access to care. If effective, the intervention could be broadly implemented to improve patient outcomes. Specific Aims: 1) Test the effect of VetASSiST, compared to usual care, on the primary outcome of baseline to 12-month change in physical HRQoL, and secondary outcomes of mental HRQoL and health care utilization; 2a) Describe differences between VetASSiST and usual care on baseline to 12-month changes in intermediate outcomes reflecting the functions of peer support and intervention targets: self-efficacy, patient activation, health behaviors, social support, perceived access to care, patient-provider communication, and shared decision-making; 2b) Examine whether intermediate outcomes mediate intervention-associated differences in HRQoL; 3) Evaluate feasibility of translating VetASSiST into practice, including evaluation of per patient intervention costs and barriers and facilitators to implementation. Methodology: We plan a hybrid type 1 implementation-effectiveness randomized controlled trial of 320 Veterans with complex multimorbidity, defined as >3 chronic conditions in >3 body systems. Patients must also have >1 of: 1) physical and mental health conditions; 2) frailty; 3) frequent emergency care; 4) polypharmacy; or 5) high treatment burden. We will identify eligible patients using data from the electronic health record, confirmed with self-reported information at screening, and will randomize enrolled patients 1:1 to VetASSiST or usual care control. The primary outcome is change in physical HRQoL from baseline to 12-months, measured with the SF-12. Secondary outcomes include change in mental HRQoL (SF-12) and health care utilization. Guided by the RE-AIM framework, we will use quantitative and qualitative methods to assess barriers and facilitators to implementation among key stakeholder groups. These data will inform future implementation. Next Steps/Implementation: This hybrid type 1 trial will provide data needed to prepare for broader VA implementation if the intervention is effective. Implementation activities will be coordinated with existing local and national operational partners. If the intervention is not effective, Aims 2 and 3 will elucidate how Veterans with multimorbidity could be better supported in the future.