Implementing Advance Care Planning as a Healthy Aging Activity in Rural Primary Care

项目摘要/摘要：项目2(Nelson-BRANTELY) 预计到2060年，美国65岁及以上的人口将达到9470万；目前，超过五分之一 这个国家的老年人居住在美国的农村。高级护理计划(ACP)是一个护理过程，它支持 成年人分享他们的价值观、生活目标和对未来医疗保健的选择。机场核心计划增加了 医疗保健服务体现了患者的价值观，提高了患者和家人的满意度，增加了姑息治疗的使用 护理，并降低成本。尽管全球一致认为老年人应该尽早开始ACP，但ACP通常 要么发生得太晚，要么根本就没有。增加非加太的有效干预措施存在，但在以下方面仍存在巨大差距 将干预转化为日常实践。在农村初级保健诊所尤其如此。 该项目试行了实施促进法(IF)，以改善农村小学对ACP的吸收 护理诊所。如果涉及一套综合的实施战略，以促进采用证据- 基于实践-在本研究中，ACP。建议研究中的如果策略包括尊重选择优先 STEP®ACP培训、ACP工具包，以及用于持续实施和培训支持的远程指导。这个 棱镜核心将协助完善研究程序；首席执行官核心将与诊所地点接洽；以及高铁 核心，确保IRB对研究方案的最终批准。 制定一项有针对性的非加太计划，以便在农村初级保健诊所实施非加太计划(目标1)。 我们将使用实施研究综合框架(CFIR)来确定障碍和 促进者，进行需求评估，并制定适应当地情况的ACP计划 每一家诊所。 使用IF描述实施ACP的范围、估计效果、采用和实施情况 (目标2)。这项研究试行了一种混合型229协议，评估了有效性和实施情况 结果。我们将估计效果大小和相关的可变性，描述覆盖范围、采用率和 使用IF实施ACP，并描述性地将IF与正常实施(IAU)进行比较。 描述使用IF实施机场核心计划(目标3)所产生的成本和收入。 将对最终试验经济评估所需的要素进行可行性评估。 成本将通过诊所服务收据、库存和通过ACP帐单代码的收入来获取。 该项目与拟议的Cobre的目标一致，即改善农村人口的健康公平，并将 通过提供新的实施知识，垂直推进实施科学领域 在农村初级保健诊所奏效的战略。本研究的结果将为以下工作提供证据基础 支持在更大范围内测试IF策略的R01应用程序。最终，这项研究有望 通过将ACP扩展到医疗服务不足的农村地区并改善以下方面的早期ACP产生积极影响 老年人之前，他们不再能够表达自己的愿望。

PROJECT SUMMARY/ABSTRACT: PROJECT 2 (NELSON-BRANTELY) The U.S. population age 65 and over is projected to reach 94.7 million in 2060; presently, more than one-fifth of the nation’s elderly reside in rural America. Advance care planning (ACP) is a process of care that supports adults in sharing their values, life goals, and choices regarding future health care. ACP increases alignment of health care services with patients’ values, improves patient and family satisfaction, increases use of palliative care, and reduces costs. Despite global consensus that ACP should start early for older adults, ACP usually happens too late or not at all. Effective interventions to increase ACP exist, yet an extensive gap remains in translating the intervention into everyday practice. This is particularly true in rural primary care clinics. This project pilots the use of implementation facilitation (IF) for improving the uptake of ACP in rural primary care clinics. IF involves an integrated set of implementation strategies to promote adoption of an evidence- based practice—in this study, ACP. The IF strategies in the proposed study include Respecting Choices First Steps® ACP training, an ACP toolkit, and tele-mentoring for ongoing implementation and training support. The PrISM Core will assist with refining study procedures; the CEO Core with engaging clinic sites; and the HSR Core with securing final IRB approval for the study protocol. Develop a tailored ACP plan for implementing ACP into rural primary care clinics (Aim 1). We will use the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to ACP, conduct a needs assessment, and develop an ACP plan adapted to the local context of each clinic. Characterize the reach, estimated effect, adoption, and implementation using IF for implementing ACP (Aim 2). This study pilots a Hybrid Type 229 protocol, estimating both effectiveness and implementation outcomes. We will estimate effect size and associated variability, describe the reach, adoption, and implementation of ACP using IF, and descriptively compare IF to implementation as usual (IAU). Describe the costs and revenue generated from using IF for implementing ACP (Aim 3). Feasibility assessment of elements necessary for a definitive trial economic evaluation will be conducted. Costs will be captured through a clinic service receipt inventory and revenue through ACP billing codes. The project aligns with the goals of the proposed COBRE to improve health equity for rural populations and will advance the field of implementation science vertically by providing new knowledge of implementation strategies that work in rural primary care clinics. The outcomes of this study will provide an evidence base to support an R01 application testing the IF strategy on a larger scale. Ultimately, this research is expected to have a positive impact by expanding ACP to medically underserved rural areas and improving early ACP for older adults before they are no longer able to make their wishes known.