Integrating personal values into primary care for Veterans with multimorbidity

背景：患有bbb2慢性疾病（多病）的退伍军人几乎占美国患者的50%

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.