Outpatient Palliative Care Implementation to Improve Outcomes for AgingVeterans

实施门诊姑息治疗以改善老年退伍军人的治疗结果

• 批准号: 10552533
• 负责人: Brystana G. Kaufman
• 金额: --
• 依托单位: DURHAM VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-01-01 至 2026-12-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10552533
• 关键词: Acceleration; Adoption; Aging; Award; Businesses; Caregivers; Caring; Case Study; Cessation of life; Characteristics; Chronic Disease; Communities; Complex; Consult; Consultations; Data; Development; Effectiveness; Eligibility Determination; Ensure; Family; Geriatrics; Goals; Home; Hospitalization; Infrastructure; Inpatients; Interview; Investments; Knowledge; Leadership; Learning; Life; Long-Term Care; Measures; Medical; Mentors; Methods; Modeling; Outcome; Outpatients; Palliative Care; Pathway interactions; Patients; Pattern; Patterns of Care; Perception; Policies; Practical Robust Implementation and Sustainability Model; Primary Care; Quality of Care; Quality of life; Quantitative Evaluations; Reporting; Research; Research Design; Research Personnel; Resources; Site; Structure; Surveys; System; Telephone Interviews; Testing; Training; Veterans; Work; care systems; career; caregiving; clinical practice; cognitive interview; comparative effectiveness study; compare effectiveness; design; econometrics; end of life care; experience; falls; field survey; health service use; implementation evaluation; implementation outcomes; implementation research; implementation science; improved; improved outcome; innovation; member; multiple chronic conditions; operation; preservation; primary care practice; programs; psychosocial; satisfaction; skills; usability

Nearly one in three older veterans have multi-morbidity, many of whom manage life-limiting conditions (LLC) and may benefit from palliative care (PC).1,2 A PC consultation is an opportunity to review care goals and manage complex medical and psychosocial needs for veterans with LLCs. PC improves quality of life and quality of end-of-life (EOL) care; however, most research has been conducted in the inpatient setting.3-7 In 2009, the VA Comprehensive End of Life Care Initiative established Palliative Care Consult Teams (PCCT) with infrastructure investments largely in inpatient settings. In 2013, VA Geriatrics and Extended Care began expanding outpatient PC (OPC) services. Despite increasing use of OPC in the VA, little is known about the implementation and effectiveness of OPC in the VA. Preliminary evidence suggests OPC consults may be effective in patients with certain LLCs; however, effects are heterogeneous across potentially eligible patients. To improve appropriate PC use, critical gaps include lack of knowledge about OPC patterns (OPC consult characteristics and timing relative to inpatient PC, hospitalization, death) and PCCT structural characteristics and care practices. This project will generate the foundational knowledge needed to support an IIR proposal to compare effectiveness of OPC models and evaluate under what conditions OPC improves Veteran outcomes. My CDA employs an explanatory sequential design starting with quantitative analyses of OPC reach and patterns of use (aim 1) followed by enhanced interpretation using qualitative data (aim 2) and together these findings will inform the development of a site-level survey measuring PCCT structural characteristics and OPC practices (aim 3). Veteran engagement will include additional discussions with the local Veteran engagement board, and an advisory board (with representatives from the Veteran Engagement Board), ensuring this research is integrated with operational and veteran priorities. Aim 1.1 uses CDW data to Identify and describe common OPC patterns among aging veterans with LLC. Aim 1.2 will evaluate veteran- and site-level predictors of OPC patterns and identify sites with high and low OPC reach to inform Aim 2. Through interviews with PCCT members and leadership (n=18-24), Aim 2 will characterize OPC patterns and perceived organizational determinants of OPC reach, applying PRISM constructs from the Organizational Perspective domain. Themes will be compared between 3 high and 3 low reach sites. Aim 3 will adapt and pilot a recent GEC survey for Home Based Primary Care (HBPC) to collect data in 5 domains: structure/resources, leadership/team characteristics, referral workflows, patient groups served, and care components. Finally, Aim 4 will evaluate health services use associated with OPC consult and how outcomes differ across common OPC patterns. My CDA will culminate in the development and dissemination of a Palliative Care Pathways report that describes common patterns, sequencing, and outcomes of OPC in the VA in years 4-5. The IIR will implement the survey developed in the CDA and use these data to support a comparative effectiveness study of OPC using mixed methods. This evidence generated by the proposed research program is needed to identify strategies for tailoring PCCT to local needs and resources while retaining fidelity to the components that will improve appropriate PC use for veterans with LLC. Using this knowledge, we will work with operational partners to identifying opportunities for system redesign to improve veterans’ quality of life and families’ satisfaction with EOL care.

几乎有三分之一的老兵有多种多样的人，其中许多人管理生命的条件 （LLC）并可能受益于姑息治疗（PC）。1,2PC咨询是审查护理目标和 通过有限责任公司来管理对退伍军人的复杂医疗和社会心理需求。 PC改善了生活质量和 临终关怀的质量（EOL）护理；但是，大多数研究都是在住院环境中进行的。3-7 2009年，VA综合生命护理计划建立了姑息治疗咨询小组（PCCT） 基础设施投资主要在住院环境中。 2013年，VA老年医学和扩展护理开始 扩展门诊PC（OPC）服务。尽管VA中OPC的使用越来越多，但对 OPC在VA中的实施和有效性。初步证据表明OPC的关注可能是 对于某些LLC的患者有效；但是，在潜在符合条件的患者中的影响是异质的。 为了改善适当的PC使用，关键差距包括缺乏有关OPC模式的知识（OPC咨询 相对于住院PC，住院，死亡）和PCCT结构特征的特征和时机 和护理实践。该项目将产生支持IIR提案所需的基本知识 比较OPC模型的有效性，并在何种条件下评估OPC改善退伍军人结果。 我的CDA员工是爆炸性的连续设计，从OPC覆盖范围的定量分析开始 使用模式（AIM 1），然后使用定性数据加强解释（AIM 2），并将这些解释 调查结果将为衡量PCCT结构特征和OPC的站点级调查的开发提供信息 实践（目标3）。退伍军人参与将包括与当地退伍军人参与的其他讨论 董事会和顾问委员会（由资深参与委员会代表），确保这项研究 与运营和退伍军人的优先级集成在一起。 AIM 1.1使用CDW数据来识别和描述常见 使用LLC老化退伍军人的OPC模式。 AIM 1.2将评估OPC的资深人士和现场级预测指标 模式并确定OPC高和低的网站以告知AIM 2。通过与PCCT成员的访谈 和领导力（n = 18-24），AIM 2将表征OPC模式和感知的组织决定者 OPC到达，从组织的角度应用棱镜构造。主题将被比较 在3个高到3个低到达地点之间。 AIM 3将适应并试行最近针对家庭基础的GEC调查 护理（HBPC）在5个领域收集数据：结构/资源，领导/团队特征，推荐 工作流，服务组和护理组件。最后，AIM 4将评估健康服务的使用 与OPC咨询以及在常见OPC模式之间的结果如何相关。 我的CDA将在姑息治疗途径的开发和传播中达到顶峰报告 描述了4 - 5年中VA中OPC的常见模式，测序和结果。 IIR将实施 该调查在CDA中开发了，并使用这些数据来支持OPC的比较有效性研究 使用混合方法。需要由拟议的研究计划产生的证据来识别 将PCCT定制为本地需求和资源的策略，同时保留将 改善与LLC退伍军人的适当PC使用。使用这些知识，我们将与运营合作 合作伙伴确定系统重新设计的机会，以改善退伍军人的生活质量和家庭 对EOL护理的满意。