Harnessing Health IT for Self-Management Support and Medication Activation in a M

描述（由申请人提供）：UCSF协作研究网络（CRN）的愿景是通过强调健康促进，预防性健康和慢性病护理创新的研究议程，为初级保健的转型做出贡献。与UCSF临床和转化科学研究所（CTSI）的目标一致，CRN正在迅速扩大其在弱势群体的有效性和实施研究方面的努力。这一扩展加强了社区康复网络与临床医生的接触，这些临床医生为弗朗西斯科社区卫生网络中的城市、服务不足、弱势群体提供服务，其集水区被指定为医疗服务不足的地区，社区资源和服务面向这些人群。在AHRQ的支持下，CRN研究人员最近完成了一项在英语、西班牙语和汉语糖尿病控制不良患者中进行的自动电话自我管理支持（ATSM）随机试验。ATSM采用健康信息技术，通过帮助患者制定和维持行为改变，通过患者产生的“行动计划”，以促进自我效能。与ATSM的参与尤其是在有沟通障碍的参与者中，如识字能力有限和英语水平有限，以及医疗补助接受者和未投保者。接受ATSM与以患者为中心的慢性病护理维度的显著改善相关，包括慢性病护理评估、人际沟通、自我效能和功能状态。此外，ATSM提供了一种新颖的实时监测功能，用于识别以前未检测到的潜在不良事件和在家中发生的实际不良事件，通常是在患者自我管理糖尿病药物的背景下。然而，接受ATSM与血压或血糖控制的改善无关。我们假设，这种缺乏代谢控制方面的好处可以解释，在一定程度上，事实上，药物强化/激活不是一个明确的目标，健康IT促进ATSM模型。CRN领导层现在已经与旧金山弗朗西斯科健康计划（SFHP）保持一致，该计划是当地为医疗补助管理式医疗受益人提供的非营利健康计划，也是医疗补助管理式医疗创新的领导者。SFHP管理委员会决定在未来12个月内为越来越多的糖尿病患者采用我们的ATSM模式，专门安排工作人员响应ATSM数据，并与注册者及其提供者互动，并承担ATSM实施的成本。因此，我们现在有一个前所未有的机会，进一步探索基于人群的健康IT创新对弱势患者慢性病护理质量关键方面的影响。在这个提案中，我们在他们更大的实施计划中嵌入了一个具有准实验设计的“实用临床试验”。我们打算：（a）测量ATSM对不同种族糖尿病健康计划参与者中以患者为中心的结局的影响;（B）探索将ATSM与额外的以患者为导向的健康IT创新（由药房索赔数据触发的药物激活沟通策略）相结合是否与单独使用ATSM相比对以患者为中心的结局产生不同的影响;（c）量化和表征通过ATSM参与者中的主动监测识别的患者安全事件，并测量仅接受ATSM与ATSM加药物激活的参与者中患者安全事件的频率和性质的差异;以及（d）探讨在HEDIS相关代谢和临床过程以及结果测量方面，任一ATSM模型是否上级常规护理。这将使我们能够通过“真实世界”的有效性研究来检查ATSM对以患者为中心的结果和安全性的影响;测量健康IT促进的药物激活在以患者为中心，安全性和代谢结果方面的增量效益，超过健康IT促进的自我管理支持;并将CRN和健康计划之间先前的合作扩展到包括转化和实施研究。

DESCRIPTION (provided by applicant): The vision of the UCSF Collaborative Research Network (CRN) is to contribute to the transformation of primary care through a research agenda that emphasizes innovations in health promotion, preventive health, and chronic illness care. Consistent with the aims of the UCSF Clinical and Translational Sciences Institute (CTSI), the CRN is rapidly expanding its efforts in both effectiveness and implementation research with vulnerable populations. This expansion has intensified engagement of the CRN with the clinicians that serve urban, underserved, vulnerable populations in the Community Health Network of San Francisco, whose catchment area is designated to be a medically underserved area, and the community resources and services oriented to these populations. With support from AHRQ, CRN investigators have recently completed a randomized trial of automated telephone self-management support (ATSM) among English, Spanish, and Chinese speaking patients with poorly controlled diabetes. ATSM employs health IT to promote self-efficacy by assisting patients in developing and maintaining behavioral changes through patient-generated "action plans". Engagement with ATSM was especially high among participants with communication barriers, such as limited literacy and limited English proficiency, and among Medicaid recipients and the uninsured. Receipt of ATSM was associated with robust improvements in patient-centered dimensions of chronic disease care, including assessment of chronic illness care, interpersonal communication, self-efficacy, and functional status. In addition, ATSM provided a novel, real-time surveillance function for identifying previously undetected potential adverse events and actual adverse events occurring at home, often in the context of patients' self-management of diabetes with regard to medications. Receipt of ATSM, however, was not associated with improvements in either blood pressure or glycemic control. We hypothesize that this lack of benefit with respect to metabolic control can be explained, in part, by the fact that medication intensification/activation was not an explicit goal of the health IT-facilitated ATSM model. The CRN leadership has now aligned its efforts with the San Francisco Health Plan (SFHP), the local nonprofit health plan for Medicaid managed care beneficiaries and a leader in Medicaid managed care innovation. The SFHP Governing Board decided to adopt our ATSM model for its growing number of diabetes patients in the next 12 months, to dedicate staff to respond to ATSM data and engage with enrollees and their providers, and to underwrite the costs of ATSM implementation. As a result, we now have an unprecedented opportunity to further explore the impact of a population-based health IT innovation on key dimensions of chronic disease care quality among vulnerable patients. In this proposal, we have embedded within their larger implementation plan a "practical clinical trial" with a quasi-experimental design. We intend to: (a) measure the effects of ATSM on patient-centered outcomes among ethnically diverse health plan enrollees with diabetes; (b) explore whether combining ATSM with an additional patient-directed health IT innovation - a medication activation communication strategy triggered by pharmacy claims data - yields differential effects on patient-centered outcomes compared to ATSM alone; (c) quantify and characterize patient safety events identified through active surveillance among ATSM participants and measure differences in the frequency and nature of patient safety events among participants receiving ATSM only versus ATSM plus medication activation; and (d) explore whether either ATSM model is superior to usual care with respect to HEDIS-relevant metabolic and clinical process and outcome measures. This will enable us to examine the effects of ATSM on both patient-centered outcomes and safety through a "real-world" effectiveness study; measure the incremental benefits of health IT-facilitated medication activation with respect to patient-centeredness, safety, and metabolic outcomes above and beyond health IT-facilitated self-management support; and extend previous collaborations between the CRN and health plans to include translational and implementation research.