Using Data Analytics and Targeted Whole Health Coaching to Reduce Frequent Utilization of Acute Care among Homeless Veterans

背景：10%的患者占急性护理费用的70%。在这些“超级利用者”中， 无家可归是急性护理利用的一个强大的社会决定因素。通过实地 仪表板和临床辅助工具，热点分析程序协助患者调整护理团队（PACT）， 为最需要的无家可归的退伍军人提供有针对性的照顾。然而，许多退伍军人确定的 分析不参与降低急性护理利用风险的支持性服务。同行专家（PS） 是一个高价值的劳动力，可以促进退伍军人的护理参与。然而，有必要加强 PS角色，采用结构化方法，可以利用已知的护理参与促进者， 无家可归的老兵整体健康指导（Whole Health Coaching，WHC）就是其中之一。通过关注患者的价值观， WHC的目标，而不是治疗特定的条件，减少病人的耻辱，他们的护理需求 并增加患者的积极性和幸福感，这可以增加对支持服务的参与。 意义：通过以患者为中心的护理方法培训高价值的劳动力， 参与支持性服务，我们提出的研究可以减少无家可归的退伍军人对急性 这将有助于改善医疗服务，从而最大限度地减少这些患者对医疗系统造成的经济负担。这项建议 回应几个VA HSR&D研究重点，包括心理健康，医疗保健价值，初级保健 实践，医疗保健信息学和整体健康，以及VA相关的立法优先事项（使命法案）。 创新和影响：本研究的一个关键创新是使用数据驱动的流程（热点 分析），以更好地针对和定制照顾高需要，无家可归的退伍军人在VHA。我们的研究计划是 它还具有创新性，旨在将分析与劳动力（PS）和护理方法（WHC）相结合 在弗吉尼亚州的初级保健服务中迅速扩大。我们的目标干预措施的这些特征是 符合国家医学科学院对高需求高质量护理的建议 患者最后，通过关注与患者的健康目标相一致的个人健康目标的发展， WHC的优先事项和价值，是一个关键的创新，将添加到现有的VHA服务无家可归的退伍军人。 具体目标：该项目的目标是将热点分析与经过培训的同行专家结合使用 在整体健康教练（PS-WHC），并评估这种方法是否减少无家可归的退伍军人 经常使用急性护理。目标1：进行随机对照试验，以测试接受PS-WHC（与增强型WHC相比） 护理; EUC）预测（1a）较低的急性护理利用率，（1b）更好的健康相关结局，以及（1c） PS-WHC对1a和1b的影响是通过增加（i）患者激活和健康，以及（ii） 获得支持性服务。目标2：进行过程评估，以告知VA的潜在广泛性 在PACTs上实施热点分析+ PS-WHC。目标3：进行预算影响分析（BIA） 确定实施PS-WHC对VA护理总成本的影响。 方法：在Palo Alto和贝德福德VA使用混合1型设计，220名退伍军人接受PACT检查 谁是（一）在VA无家可归者登记处，（二）持续的急性护理超级利用者将完成一个 基线访谈，随机分配至任一EUC（常规PACT护理+热点分析和文本提醒 或EUC加12次PS-WHC会议，为期12周，并在第3、6和9次会议上重新面试 个月对于目标2，CFIR框架将指导与7名PACT工作人员/领导和12名PACT工作人员/领导进行的关键线人访谈。 每个站点的患者。对于BIA，我们将仅包括VA、Fee Basis care和Choice care的VA成本。 将估计每例患者从随机化开始并持续9个月的所有治疗的成本。 下一步/实施：根据结果，我们将与全国的VACO合作伙伴合作 退伍军人无家可归中心，以病人为中心的护理和文化转型办公室， 心理健康和自杀预防办公室进行大型多地点实施试验。

Background: Ten percent of patients account for up to 70% of acute care costs. Among these “super-utilizer” patients, homelessness is a robust social determinant of acute care utilization. Through a field-based dashboard and clinical aids, the Hot Spotter Analytic program assists Patient Aligned Care Teams (PACT) with targeting and tailoring care for the highest-need homeless Veterans. However, many Veterans identified by the Analytics do not engage in supportive services that reduce risk for acute care utilization. Peer Specialists (PS) are a high-value workforce that can facilitate Veterans’ engagement in care. Yet, there is a need to enhance the PS role with a structured approach that can capitalize on known facilitators of care engagement among homeless Veterans. Whole Health Coaching (WHC) is one such approach. By focusing on patients’ values and goals rather than treatment of specific conditions, WHC reduces patients’ stigma regarding their care needs and increases patient activation and well-being, which can increase engagement in supportive services. Significance: By training a high-value workforce in a patient-centered approach to care that facilitates engagement in supportive services, our proposed research can reduce homeless Veterans’ reliance on acute care services, thereby minimizing the financial burden these patients exert on the care system. This proposal responds to several VA HSR&D Research Priorities including Mental Health, Healthcare Value, Primary Care Practice, Healthcare Informatics, and Whole Health, as well as VA-related Legislative Priorities (MISSION Act). Innovation and Impact: A critical innovation of this research is use of data-driven processes (Hot Spotter Analytics) to better target and tailor care for high-need, homeless Veterans in VHA. Our proposed research is also innovative in that it seeks to integrate the Analytics with a workforce (PS) and approach to care (WHC) that are rapidly expanding in primary care services VA-wide. These features of our target intervention are consistent with the National Academy of Medicine’s recommendations for high-quality care for high-need patients. Finally, by focusing on the development of personal health goals that are aligned with patients’ priorities and values, WHC is a key innovation to be added to existing VHA services for homeless Veterans. Specific Aims: The goal of this project is to integrate use of Hot Spotter Analytics with Peer Specialists trained in Whole Health Coaching (PS-WHC) and evaluate whether this approach reduces homeless Veterans’ frequent use of acute care. Aim 1: Conduct an RCT to test whether receipt of PS-WHC (vs. Enhanced Usual Care; EUC) predicts (1a) lower acute care utilization, (1b) better health-related outcomes, and whether (1c) the effects of PS-WHC on 1a and 1b are mediated by increased (i) patient activation and well-being, and (ii) access to supportive services. Aim 2: Conduct a process evaluation to inform VA's potential widespread implementation of Hot Spotter Analytics + PS-WHC on PACTs. Aim 3: Conduct a Budget Impact Analysis (BIA) to determine the impact on total costs of VA care due to implementing PS-WHC. Methodology: Using a Hybrid Type 1 design at the Palo Alto and Bedford VAs, 220 Veterans on PACT panels who are (i) on the VA Homeless Registry, and (ii) persistent super-utilizers of acute care will complete a baseline interview, be randomized to either EUC (usual PACT care + Hot Spotter Analytics and text reminders of appointments) or EUC plus 12 sessions of PS-WHC over 12 weeks, and be re-interviewed at 3, 6, and 9 months. For Aim 2, the CFIR framework will guide key informant interviews with 7 PACT staff/leaders and 12 patients from each site. For the BIA, we will include only VA costs from VA, Fee Basis care, and Choice care. Costs will be estimated per patient for all treatment beginning with randomization and continuing for 9 months. Next Steps/Implementation: Depending on the results, we will work with our VACO partners in the National Center for Homelessness Among Veterans, the Office of Patient Centered Care & Cultural Transformation, and the Office of Mental Health & Suicide Prevention to conduct a large multisite implementation trial.