Integrating personal values into primary care for Veterans with multimorbidity

背景：退伍军人有> 2种慢性疾病（多发性硬化症）， 退伍军人健康管理局（VA）。初级保健提供者（PCP）提供超过90%的门诊VA护理， 最复杂，最危险的退伍军人目前，这些患者和他们的PCP必须在 在时间和资源有限的情况下，无论是在诊所还是在自我治疗中， 在家管理。患者和PCP还可以决定哪些护理需要优先考虑， 从临床实践指南中得到充分的指导，其中许多指南侧重于单一疾病的治疗过程。患者 和PCP往往不同意什么是最重要的;患者优先考虑症状，而PCP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 对于患者（即，"个人价值观"）并调整优选的健康结果（即，"健康优先事项"）简化了护理， 降低治疗负担，减少不必要的干预。迄今为止，没有任何研究澄清了这些情况。 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与 可操作的临床护理，有助于解决相互冲突的优先事项之间的紧张关系。为了弥补这些差距， CDA将通过开发和测试 干预（"Vet-Align"），一种基于价值观的方法，用于照顾患有多发性硬化症的高风险退伍军人。 意义/影响：该CDA通过改善以患者为中心的初级保健，推进VA和HSR & D优先事项 和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，促进全民健康结局，促进患者 参与和坚持护理，并减少不必要或不适当的护理造成的浪费和伤害。 创新：该CDA使用患者价值观和优先级开发和测试一种新的干预措施，以调整主要 护理规划和提供。该CDA将推进多患者护理，并借鉴新的方法，包括 以人为本的设计（HCD）和多标准决策分析（MCDA），一个参与式的决策过程。 具体目标：1）了解如何以及何时退伍军人与多morphology连接的价值观，健康， 医疗保健，以澄清患者价值观直接影响PCP患者护理的生活和健康情况 规划和自我管理决策; 2）检查VA门诊质量指标如何与 患者优先级和价值观，以制定指导方针，使疾病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，以退伍军人为中心的优先事项; 3）完善和试点测试 Vet-Align的可接受性和可行性，Vet-Align是一种基于价值观的干预措施，适用于患有多种疾病的退伍军人，包括 用于VA初级护理的工具和工作流程，将患者价值转化为可操作的临床护理计划。 方法学：患有> 2种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个半结构化的患者访谈，用内容分析法进行分析。目标2使用军事和民防资源， 联合收割机结合医疗保健专家的观点和临床证据，根据以下方面对门诊VA质量指标进行排名 病人的健康优先权目标3a以先前目标的调查结果和产品为基础， 新的、面向PCP的行动规划工具和使用HCD的工作流程。Aim 3b在临床中对该工具进行了初步测试 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，以了解患者的价值观，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 通过以患者为中心的结局和护理的变化评价临床有效性的随机临床试验 质量和测试维持的执行战略。本研究的长期目标是 加强以病人为中心和质量的VA初级保健的退伍军人与多mortim。

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.