Integrating personal values into primary care for Veterans with multimorbidity

将个人价值观融入患有多种疾病的退伍军人的初级保健中

• 批准号: 10538185
• 负责人: Linnaea Schuttner
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-01-01 至 2027-12-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10538185
• 关键词: Address; Adherence; Affect; Benchmarking; Caring; Chronic; Chronic Disease; Clinic; Clinic Visits; Clinical; Clinical Practice Guideline; Clinical Trials; Clinical effectiveness; Complex; Decision Analysis; Decision Making; Diagnostic tests; Disease; Effectiveness; Eligibility Determination; Feedback; Foundations; Future; Goals; Guidelines; Health; Health Priorities; Health system; Healthcare; Home; Hour; Individual; Intervention; Interview; Leadership; Life; Link; Methodology; Methods; Modeling; Outcome; Outpatients; Pathway interactions; Patient Care; Patient Care Planning; Patient Outcomes Assessments; Patient-Centered Care; Patient-Focused Outcomes; Patients; Physicians; Prevalence; Primary Care; Process; Prognosis; Quality of Care; Recommendation; Research; Research Personnel; Resources; Role; Self Management; Service delivery model; Services; Specificity; Structure; Symptoms; Testing; Time; Translating; Triage; Trust; Veterans; Veterans Health Administration; acceptability and feasibility; adverse event risk; career; clinical care; clinically actionable; compliance behavior; cost; design; experience; high risk; human centered design; implementation strategy; improved; individual patient; innovation; multiple chronic conditions; novel; patient engagement; patient oriented; person centered; personalized care; pilot test; poor health outcome; primary care clinic; primary care provider; primary care team; provider communication; psychosocial; randomized, clinical trials; reduce symptoms; skills; skills training; tool; wasting; whole health

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.

背景：患有超过 2 种慢性病（多发病）的退伍军人几乎占该地区患者的 50% 退伍军人健康管理局 (VA)。初级保健提供者 (PCP) 为 VA 门诊患者提供超过 90% 的护理 最复杂、高风险、患有多种疾病的退伍军人。目前，这些患者及其 PCP 必须兼顾 在有限的时间和资源下，无论是在诊所还是在自我治疗中，都有大量的医疗保健和社会心理需求 在家管理。患者和 PCP 还可以在不考虑需要优先考虑的情况下决定哪些护理需要优先考虑。 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过程。患者 PCP 经常在最重要的问题上存在分歧；患者优先考虑症状，而 PCP 则强调 预后。研究表明，帮助患者和 PCP 沟通生活中最有意义的事情 患者（即“个人价值观”）并调整首选健康结果（即“健康优先事项”）简化护理， 减轻治疗负担，并减少不必要的干预。迄今为止，还没有研究澄清这一情况 其中个人价值观可以指导健康决策或开发出一种将个人价值观与健康决策联系起来的方法 可行的临床护理有助于缓解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 干预（“Vet-Align”），一种基于价值观的方法，用于护理患有多种疾病的高风险退伍军人。 意义/影响：该 CDA 通过改善以患者为中心的初级保健来推进 VA 和 HSR&D 的优先事项 并解决对退伍军人来说最重要的问题。这具有长期影响，包括改善 VA 质量指标的特异性和个性化，促进全民健康成果，促进患者 参与和坚持护理，并减少不必要或不适当护理造成的浪费和伤害。 创新：该 CDA 使用患者价值观和优先事项来开发和测试一种新颖的干预措施，以协调主要 护理计划和交付。该 CDA 将推进多发病护理并利用新方法，包括 以人为本的设计（HCD）和多标准决策分析（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，阐明患者价值观直接影响 PCP 患者护理的生活和健康状况 规划和自我管理决策； 2) 检查 VA 动态质量指标如何配合和支持 患者的优先事项和价值观，制定指导，使以疾病为导向的质量指标与患者的需求相一致 在基于个人价值观的护理服务模式中以退伍军人的优先事项为中心； 3）完善和试点 Vet-Align 的可接受性和可行性，这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，包括 VA 初级护理的工具和工作流程，可将患者价值观转化为可行的临床护理计划。 方法：患有 2 种以上慢性疾病且不良事件风险较高的患者符合目标 1 和 3。 目标 1 使用 25-30 名半结构化患者访谈，并通过内容分析进行分析。目标 2 使用 MCDA 来 结合医疗保健专家的观点和临床证据，根据以下因素对门诊 VA 质量指标进行排名 患者首选的健康优先事项。基于先前 Aims 的发现和产品，Aim 3a 开发了 使用 HCD 的新颖的、面向 PCP 的行动规划工具和工作流程。 Aim 3b 在临床中试点测试该工具 对 30-36 名患者和 15-20 名 PCP 进行干预 (Vet-Align)。 Vet-Align 包括员工技能培训和患者培训 与健康教练进行会议，以激发患者价值观、设定健康优先事项并制定个性化的行动计划 发送给 PCP 的工具。将从患者和工作人员的角度评估可行性和可接受性。 后续步骤/实施：本 CDA-2 中制定的干预措施将为全面的 通过改变以患者为中心的结果和护理来评估临床有效性的随机临床试验 质量，并测试维持的实施策略。该研究轨迹的长期目标是 加强退伍军人管理局针对患有多种疾病的退伍军人的初级护理以患者为中心的态度和质量。