PACT TO IMPROVE HEALTH CARE IN PEOPLE WITH SERIOUS MENTAL ILLNESS (SMI-PACT)

描述(由申请人提供)： 背景/理论：患有严重精神疾病(SMI)的人平均过早死亡多年，过早死亡率是普通人群的2到3倍。在这一人群中，超过60%的过早死亡是由于“自然原因”，特别是治疗不当的心血管、呼吸系统和传染病。尽管退伍军人管理局是一个中央组织的全面医疗系统，但患有SMI的退伍军人仍然难以驾驭该系统，过早死亡的风险大大增加。他们往往不参加预定的预约或不参加初级保健治疗，因此得不到有价值的预防和初级保健服务。在专利对齐护理团队(PACT)模式下，退伍军人事务部的初级护理经历了重大变革，该模式基于以患者为中心的医疗之家(PCMH)概念。PACT的目标是提高初级保健的质量、效率和以病人为中心。但目前尚不清楚Pact将如何影响大量退伍军人，他们的大部分护理都是在专科环境中进行的，比如患有SMI的人。研究可以为在专业设置中应用PACT模式的努力提供参考。例如，尽管SMI患者在通常的初级保健安排中表现不佳，但现在有大量证据表明，综合护理和医疗保健管理方法可以改善SMI患者的医疗和结局，并降低治疗成本。目的：利用现有证据，我们建议实施和评估一个满足SMI患者需求的专门PACT模型(SMI-PACT)。方法：该项目将与一个医疗中心的领导合作，实施SMI-PACT，目标是改善SMI患者的医疗保健和预后，同时减少对急救和医院服务的不必要使用。将使用基于证据的质量改进战略来重组护理流程。在现场级对照试验中，该项目将评估SMI-PACT实施的效果，相对于通常的护理 (A)提供适当的预防和医疗；(B)病人与健康有关的生活质量和对护理的满意度；以及(C)医疗和心理健康治疗的使用情况和费用。该项目包括对日常护理和SMI-PACT实施的混合方法形成性评估，以加强干预，并评估其实施的障碍和促进者。混合方法也将被用来调查组织背景、干预因素以及患者和提供者结果之间的关系；并确定与成功患者结果相关的患者因素。意义：该项目对SMI-PACT的方法与退伍军人管理局的PACT模式以及退伍军人管理局改善对患有精神障碍的退伍军人的护理的努力是一致的。这将是第一批系统地实施和评估初级保健以外的初级保健和初级保健行动概念的项目之一。如果SMI-PACT被证明是可行和有效的，该模式可以更广泛地应用于提高患有严重精神疾病的退伍军人的护理质量和效率。关于专科精神健康方面的PACT的研究结果也可能为改善其他专科医疗保健环境中的护理提供参考。 公共卫生相关性： 患有严重精神疾病的人很难很好地利用初级保健，平均而言，他们比人口中的其他人早死几年。导致过早死亡的最大因素是内科疾病，特别是心血管疾病和癌症。以患者为中心的医疗之家是重组初级保健实践的典范，从而使医疗保健更加有效、高效和用户友好。它正在退伍军人事务部实施，名为“以患者为中心的护理团队”(PACT)。然而，目前尚不清楚这种PACT模式如何适用于那些主要疾病由专家治疗的人。患有严重精神疾病(SMI)的人就是这样，他们中的许多人需要在精神卫生诊所进行持续治疗。为了在患有SMI的人群中实现最佳的健康结果，可能有必要调整PACT模型，使其包括已证明可以改善该人群的医疗保健的方法。该项目在一家退伍军人保健中心实施了改编的“SMI-PACT”模式，并评估了其对患有SMI的退伍军人的影响。

DESCRIPTION (provided by applicant): Background/Rationale: People with serious mental illness (SMI) die, on average, many years prematurely, with rates of premature mortality 2 to 3 times greater than the general population. Over 60% of premature deaths in this population are due to "natural causes," especially poorly treated cardiovascular, respiratory, and infectious diseases. Although the VA is a centrally organized, comprehensive healthcare system, veterans with SMI still have difficulty navigating the system, and are at substantially elevated risk for premature death. Too often, they do not attend scheduled appointments or fail to engage in primary care treatment, and consequently do not get valuable preventive and primary care services. Primary care in VA has undergone significant transformation under the Patent Aligned Care Team (PACT) model, which is based on the Patient Centered Medical Home (PCMH) concept. PACT has the goal of improving the quality, efficiency, and patient-centeredness of primary care. But it remains unclear how PACT will impact the large populations of veterans who get the majority of their care in specialty settings, such as people with SMI. Research can inform efforts to apply the PACT model in specialty settings. For example, while people with SMI do poorly with usual primary care arrangements, there is now substantial evidence that integrated care and medical care management approaches can improve medical treatment and outcomes, and reduce treatment costs, in people with SMI. Objective: Using available evidence, we propose to implement and evaluate a specialized PACT model that meets the needs of individuals with SMI ("SMI-PACT"). Methods: This project will partner with leadership at one medical center to implement SMI-PACT, with the goal of improving healthcare and outcomes among people with SMI, while reducing unnecessary use of emergency and hospital services. Evidence-based quality improvement strategies will be used to reorganize processes of care. In a site-level controlled trial, this project will evaluate the effect, relative to usual care, of SMI-PACT implementation on (a) provision of appropriate preventive and medical treatments; (b) patient health-related quality of life and satisfaction with care; and (c) medical and mental health treatment utilization and costs. The project includes a mixed methods formative evaluation of usual care and SMI-PACT implementation to strengthen the intervention, and assess barriers and facilitators to its implementation. Mixed methods will also be used to investigate the relationships between organizational context, intervention factors, and patient and provider outcomes; and identify patient factors related to successful patient outcomes. Significance: This project's approach to SMI-PACT is consistent with the VA PACT model, and with efforts in VA to improve care for veterans with psychiatric disorders. This will be one of the first projects to systematically implement and evaluate the PCMH and PACT concepts beyond primary care. Should SMI-PACT be demonstrated to be feasible and effective, the model could be used more broadly to improve the quality and efficiency of care for veterans with serious mental illness. Findings regarding PACT in specialty mental health may also inform efforts to improve care in other specialty healthcare settings. PUBLIC HEALTH RELEVANCE: People with serious mental illness have difficulty making good use of primary care, and die, on average, years earlier than others in the population. The greatest contributors to this premature mortality are medical illnesses, especially cardiovascular disease and cancer. The Patient Centered Medical Home is a model for reorganizing primary care practice so that healthcare is more effective, efficient, and user-friendly. It is being implemented across VA as the, "Patient Aligned Care Team" (PACT). It is unclear, however, how this PACT model applies to people whose predominant illness is treated by specialists. This is the case for people with serious mental illness (SMI), many of whom require ongoing treatment at mental health clinics. To achieve optimal health outcomes in the population with SMI, it may be necessary to adapt the PACT model so that it includes approaches that have proven to improve healthcare in this population. This project implements an adapted "SMI-PACT" model at one VA healthcare center, and evaluates its effect on veterans with SMI.