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

描述(由申请人提供)：加州大学旧金山分校合作研究网络(CRN)的愿景是通过强调健康促进、预防健康和慢性病护理方面的创新的研究议程，为初级保健的转变做出贡献。与加州大学旧金山分校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有效性和实施研究方面的努力。这一扩展加强了CRN与旧金山社区卫生网络中服务于城市、服务不足、弱势群体的临床医生的接触，该网络的集水区被指定为医疗服务不足的地区，以及面向这些人群的社区资源和服务。在AHRQ的支持下，CRN研究人员最近在英语、西班牙语和中文糖尿病控制不佳的患者中完成了自动电话自我管理支持(ATSM)的随机试验。ATSM利用健康信息技术，通过患者生成的“行动计划”，帮助患者发展和维持行为改变，从而提高自我效能。在有沟通障碍的参与者中，ATSM的参与度尤其高，例如识字能力和英语水平有限的参与者，以及接受医疗补助的人和未参保的人。接受ATSM与以患者为中心的慢性病护理维度的强劲改善有关，包括对慢性病护理、人际沟通、自我效能和功能状态的评估。此外，ATSM提供了一种新颖的实时监测功能，用于识别以前未发现的潜在不良事件和在家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情况下发生的。然而，服用ATSM与血压或血糖控制的改善无关。我们假设，代谢控制方面的这种缺乏益处可以部分解释为药物强化/激活不是卫生IT促进的ATSM模型的明确目标。CRN领导层现在已将其努力与旧金山健康计划(SFHP)保持一致，SFHP是为Medicaid管理式医疗受益人提供的当地非营利性医疗计划，也是Medicaid管理式医疗创新的领导者。SFHP理事会决定在未来12个月内为越来越多的糖尿病患者采用我们的ATSM模式，指定工作人员对ATSM数据做出反应，并与参与者及其提供者接触，并为ATSM实施的成本提供担保。因此，我们现在有了一个前所未有的机会，可以进一步探索以人群为基础的医疗信息技术创新对弱势患者慢性病护理质量关键方面的影响。在这项提案中，我们在他们更大的实施计划中嵌入了一种准实验设计的“实际临床试验”。我们打算：(A)在不同种族的糖尿病健康计划参与者中，衡量ATSM对以患者为中心的结果的影响；(B)探索ATSM与额外的以患者为导向的医疗IT创新--由药房索赔数据触发的药物激活沟通策略--是否对以患者为中心的结果产生与单独使用ATSM不同的影响；(C)量化和表征通过在ATSM参与者中积极监测确定的患者安全事件，并衡量仅接受ATSM与ATSM加药物激活的参与者之间患者安全事件的频率和性质的差异；以及(D)探索在与HEDIS相关的代谢和临床过程和结果指标方面，这两种ATSM模式是否都优于常规护理。这将使我们能够通过“现实世界”有效性研究来检验ATSM对以患者为中心的结果和安全性的影响；衡量医疗IT促进的药物激活在医疗IT促进的自我管理支持之外的以患者为中心、安全性和代谢结果方面的增量好处；并将CRN和医疗计划之间之前的合作扩展到包括翻译和实施研究。

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.