Integrating personal values into primary care for Veterans with multimorbidity

背景：患有2种慢性病(多发病)的退伍军人几乎占美国退伍军人总数的50%。 退伍军人健康管理局(VA)。初级保健提供者(PCP)提供超过90%的VA门诊护理 最复杂、高风险的多病退伍军人。目前，这些患者和他们的初级保健医生必须应付 在有限的时间和资源的情况下，在临床和自我保健方面有大量的保健和心理社会需求 国内的管理层。患者和专科医生也会决定哪些护理需要优先处理 来自临床实践指南的充分指导，其中许多指南侧重于单一疾病的过程。病人 儿科医生往往对什么是最重要的意见不一；患者优先考虑症状，而儿科医生则强调 预后。研究表明，帮助患者和儿科医生交流生活中最有意义的事情 对患者(即，“个人价值”)和对齐优选的健康结果(即，“健康优先”)简化了护理， 减轻治疗负担，减少不必要的干预。到目前为止，还没有一项研究澄清这种情况 其中个人价值观可以指导健康决策，或者开发了一种将个人价值观和 可操作的临床护理，帮助处理相互冲突的优先事项之间的紧张关系。为了解决这些差距，这 CDA将通过开发和测试一个 干预(“Vet-Align”)，一种基于价值观的方法，以照顾患有多种疾病的高危退伍军人。 意义/影响：这项CDA通过改善以患者为中心的初级保健，推进了VA和HSR&D的优先事项 以及解决对退伍军人最重要的问题。这具有长期影响，包括改善 VA质量指标的特异性和个性化，提高普遍的健康结果，促进患者 参与和坚持护理，减少不想要或不适当护理造成的浪费和伤害。 创新：此CDA开发并测试了一种使用患者价值和优先顺序的新干预措施，以使初级 护理计划和交付。CDA将推进多发病护理，并借鉴新方法，包括 以人为本的设计(HCD)和多准则决策分析(MCDA)，一种参与式决策过程。 具体目标：1)了解患有多种疾病的退伍军人如何以及何时将价值观、健康和 医疗保健，澄清患者价值观直接影响PCP的生活和健康状况-患者护理 规划和自我管理决策；2)检查退伍军人管理局门诊质量指标如何与其保持一致并提供支持 患者优先事项和价值，制定指导，使以疾病为导向的质量指标与患者- 在基于个人价值观的护理提供模式中以退伍军人的优先事项为中心；3)完善和试点测试 Vet-Align是一种针对患有多种疾病的退伍军人的基于价值观的干预措施，其可接受性和可行性包括 退伍军人事务部初级保健的工具和工作流程，将患者价值转化为可操作的临床护理计划。 方法：有2种慢性病的患者不良事件风险较高，符合AIMS 1和AIMS 3标准。 目的1使用25-30个半结构化的患者访谈，用内容分析进行分析。AIM 2使用MCDA来 结合医疗专家观点和临床证据对门诊VA质量指标进行排名 患者首选的健康优先事项。Aim 3a以先前AIMS的发现和产品为基础，开发了 使用HCD的面向PCP的新型行动规划工具和工作流程。Aim 3b试点在临床上测试该工具 30-36名患者和15-20名PCP的干预(Vet-Align)。VET-ALIGN包括员工技能培训和患者 与健康教练举行会议，以启发患者价值，设置健康优先事项，并个性化行动计划 要发送给PCP的工具。可行性和可接受性将从患者和工作人员的角度进行评估。 下一步/实施：本CDA-2中制定的干预措施将为全面 通过改变以患者为中心的结果和护理来评估临床疗效的随机临床试验 质量，并测试可持续发展实施战略。这一研究轨迹的长期目标是 加强以病人为中心，提高退伍军人多发病初级护理质量。

Background: Veterans with > 2 chronic conditions (multimorbidity) comprise almost 50% of patients in the Veterans Health Administration (VA). Primary care providers (PCPs) provide over 90% of outpatient VA care for the most complex, high-risk Veterans with multimorbidity. At present, these patients and their PCPs must juggle numerous healthcare and psychosocial needs with limited time and resources, both in clinic and in self- management at home. Patients and PCPs also make decisions about what care needs to prioritize without adequate guidance from clinical practice guidelines, many of which focus on single-disease processes. Patients and PCPs often disagree about what is most important; patients prioritize symptoms, while PCPs emphasize prognosis. Studies suggest that helping patients and PCPs communicate about what is most meaningful in life to patients (i.e., “personal values”) and align preferred health outcomes (i.e., “health priorities”) streamlines care, lowers treatment burden, and reduces unwanted interventions. To date, no study has clarified the circumstances in which personal values can guide health decisions or developed an approach linking personal values and actionable clinical care that helps navigate tensions between conflicting priorities. To address these gaps, this CDA will integrate a patient’s personal values into high-quality primary care by developing and testing an intervention (“Vet-Align”), a values-based approach to care for higher-risk Veterans with multimorbidity. Significance/Impact: This CDA advances VA and HSR&D priorities by improving patient-centric primary care and addressing what matters most to Veterans. This has long-term implications, including improving the specificity and personalization of VA quality metrics, advancing universal health outcomes, promoting patient engagement and adherence in care, and reducing waste and harm from unwanted or inappropriate care. Innovation: This CDA develops and tests a novel intervention using patient values and priorities to align primary care planning and delivery. This CDA will advance multimorbidity care and draws on novel methods including human-centered design (HCD) and multi-criteria decision analysis (MCDA), a participatory decision process. Specific Aims: 1) Understand how and when Veterans with multimorbidity connect values, health, and healthcare, to clarify the life and health circumstances where patient values directly influence PCP-patient care planning and self-management decisions; 2) Examine how VA ambulatory quality metrics align with and support patient priorities and values, to develop guidance for aligning disease-oriented quality metrics with patient- centered priorities of Veterans within a personal values-based care delivery model; 3) Refine and pilot test the acceptability and feasibility of Vet-Align, a values-based intervention for Veterans with multimorbidity, including tools and workflows for VA primary care to translate patient values into actionable clinical care plans. Methodology: Patients with > 2 chronic diseases at higher risk for adverse events are eligible for Aims 1 and 3. Aim 1 uses 25-30 semi-structured patient interviews, analyzed with content analysis. Aim 2 uses MCDA to combine healthcare expert perspectives and clinical evidence to rank outpatient VA quality metrics according to a patient’s preferred health priority. Building from findings and products from prior Aims, Aim 3a develops a novel, PCP-facing action-planning tool and workflows using HCD. Aim 3b pilot tests the tool in a clinical intervention (Vet-Align) for 30-36 patients and 15-20 PCPs. Vet-Align includes staff skills training and patient sessions with health coaches to elicit patient values, set health priorities, and personalize the action planning tool to send to PCPs. Feasibility and acceptability will be assessed from patient and staff perspectives. Next Steps/Implementation: The intervention developed in this CDA-2 will provide the foundation for a full randomized clinical trial evaluating clinical effectiveness through change in patient-centered outcomes and care quality, and testing implementation strategies for sustainment. Long term goals of this research trajectory are to strengthen the patient-centeredness and quality of VA primary care for Veterans with multimorbidity.