Enhanced Care Planning and Clinical-Community Linkages to Comprehensively Address the Basic Needs of Patients with Multiple Chronic Conditions
加强护理规划和临床社区联系,全面满足多种慢性病患者的基本需求
基本信息
- 批准号:9886182
- 负责人:
- 金额:$ 39.45万
- 依托单位:
- 依托单位国家:美国
- 项目类别:
- 财政年份:2019
- 资助国家:美国
- 起止时间:2019-03-05 至 2024-01-31
- 项目状态:已结题
- 来源:
- 关键词:
项目摘要
Enhanced Care Planning and Clinical-Community Linkages to Comprehensively Address the Basic
Needs of Patients with Multiple Chronic Conditions
PROJECT SUMMARY
The number of patients in the United States with multiple chronic conditions (MCC) is growing. Many patients
with poorly controlled MCC also have unhealthy behaviors, mental health challenges, and unmet social needs.
Medical management of MCC may have limited benefit if patients are struggling to address these basic life
needs. Health systems and communities increasingly recognize the need to address these issues and are
experimenting with and investing in new models for connecting patients with needed services. Yet primary care
clinicians, whose regular contact with patients makes them more familiar with patients' needs, are often not
included in these systems. Responding to the Special Emphasis Notice NOT-HS-16-013, Optimizing Care for
People Living with MCC through the Development of Enhanced Care Planning, we propose a clinician-level
randomized controlled trial to study how primary care clinicians can participate in these community and
hospital solutions and whether doing so is effective in controlling MCC. This study will build on the CMS-funded
Accountable Health Community (AHC) in Richmond, Virginia. Sixty clinicians in the Virginia Ambulatory Care
Outcomes Research Network (ACORN) will be matched by age and sex and randomized to usual care (control
condition) or enhanced care planning with clinical-community linkage support (intervention). From the
electronic health record (EHR), we will identify all patients with MCC, including cardiovascular disease or risks,
diabetes, obesity, or depression. A baseline assessment will be mailed to 50 randomly selected patients; 10
respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected, with
oversampling of minorities. The intervention includes two components. First, an enhanced care planning tool
called My Own Health Report (MOHR) will screen patients for health behavior, mental health, and social
needs. Clinical navigator support will help patients prioritize needs, create care plans based on preferences,
and write a personal narrative to guide the care team. Patients will update care plans quarterly. Second,
community-clinical linkage support will include community resource registries, personnel to span settings
(clinical navigators, community health workers), and care team coordination tools (sharing MOHR content,
secure messaging, and virtual visits). We will compare patient-level intervention and control outcomes to
assess improvements in MCC outcomes (primary outcome) and self-reported PROMIS-29 measures (physical
health, mental health, social wellbeing) six months and two years post-enrollment. We will also conduct a
mixed-methods, multilevel assessment of person-, family-, community-, and system-level contextual influences
on implementation and effectiveness. Data sources will include EHR and MOHR data, chart reviews, patient
surveys, field notes, and semi-structured interviews of patients, clinicians, and community stakeholders. If
effective, this study will help inform efforts by primary care clinicians to participate in the growing number of
AHC-like systems as a strategy to better control MCC.
加强护理规划和临床-社区联系,全面解决
多种慢性病患者的需求
项目摘要
在美国,患有多种慢性病(MCC)的患者数量正在增加。许多患者
控制不良的MCC也有不健康的行为,心理健康挑战和未满足的社会需求。
如果患者难以解决这些基本生活问题,MCC的医疗管理可能受益有限
需求卫生系统和社区日益认识到需要解决这些问题,
试验和投资新模式,将患者与所需服务联系起来。然而,初级保健
临床医生经常与病人接触,使他们更熟悉病人的需要,
包括在这些系统中。响应特别强调通知NOT-HS-16-013,优化护理
通过制定加强护理计划,我们提出了一个临床医生级别的MCC患者
随机对照试验,研究初级保健临床医生如何参与这些社区,
医院的解决方案,以及这样做是否能有效控制MCC。这项研究将建立在CMS资助的
弗吉尼亚州里士满的问责卫生社区。弗吉尼亚州门诊护理中心的60名临床医生
结果研究网络(ACORN)将按年龄和性别进行匹配,并随机分配至常规护理(对照
条件)或加强护理规划与临床社区联系的支持(干预)。从
电子健康记录(EHR),我们将识别所有MCC患者,包括心血管疾病或风险,
糖尿病、肥胖症或抑郁症。基线评估将邮寄给50名随机选择的患者; 10
将随机选择每名临床医生的受访者(共600名患者),其中
对少数民族的过度抽样。干预措施包括两个组成部分。第一,加强护理规划工具
名为“我自己的健康报告”(MOHR)的项目将对患者进行健康行为、心理健康和社会方面的筛查。
需求临床导航支持将帮助患者优先考虑需求,根据偏好制定护理计划,
写一篇个人陈述来指导护理团队。患者将每季度更新护理计划。第二、
社区-临床联系支持将包括社区资源登记、人员跨越设置
(临床导航员,社区卫生工作者)和护理团队协调工具(共享MOHR内容,
安全消息传递和虚拟访问)。我们将比较患者水平的干预和控制结果,
评估MCC结局(主要结局)和自我报告的PROMIS-29指标(体格检查)的改善
健康,心理健康,社会福利)六个月和两年后登记。我们亦会进行一项
混合方法,个人,家庭,社区和系统层面的背景影响的多层次评估
执行和有效性。数据源将包括EHR和MOHR数据、图表审查、患者
调查、现场记录和对患者、临床医生和社区利益相关者的半结构化访谈。如果
有效的,这项研究将有助于通知初级保健临床医生的努力,参与越来越多的
AHC类系统作为更好地控制MCC的策略。
项目成果
期刊论文数量(0)
专著数量(0)
科研奖励数量(0)
会议论文数量(0)
专利数量(0)
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Alexander H Krist其他文献
Alexander H Krist的其他文献
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{{ truncateString('Alexander H Krist', 18)}}的其他基金
Practice Facilitation to Promote Evidence-based Screening and Management of Unhealthy Alcohol Use in Primary Care
实践便利化,促进初级保健中不健康饮酒的循证筛查和管理
- 批准号:
10260467 - 财政年份:2019
- 资助金额:
$ 39.45万 - 项目类别:
Enhanced Care Planning and Clinical-Community Linkages to Comprehensively Address the Basic Needs of Patients with Multiple Chronic Conditions
加强护理规划和临床社区联系,全面满足多种慢性病患者的基本需求
- 批准号:
10548165 - 财政年份:2019
- 资助金额:
$ 39.45万 - 项目类别:
Enhanced Care Planning and Clinical-Community Linkages to Comprehensively Address the Basic Needs of Patients with Multiple Chronic Conditions
加强护理规划和临床社区联系,全面满足多种慢性病患者的基本需求
- 批准号:
10335134 - 财政年份:2019
- 资助金额:
$ 39.45万 - 项目类别:
Implementing Personal Health Records to Promote Evidence-Based Cancer Screening
实施个人健康记录以促进循证癌症筛查
- 批准号:
9079436 - 财政年份:2013
- 资助金额:
$ 39.45万 - 项目类别:
Implementing Personal Health Records to Promote Evidence-Based Cancer Screening
实施个人健康记录以促进循证癌症筛查
- 批准号:
8730100 - 财政年份:2013
- 资助金额:
$ 39.45万 - 项目类别:
Implementing Personal Health Records to Promote Evidence-Based Cancer Screening
实施个人健康记录以促进循证癌症筛查
- 批准号:
8883419 - 财政年份:2013
- 资助金额:
$ 39.45万 - 项目类别:
Implementing Personal Health Records to Promote Evidence-Based Cancer Screening
实施个人健康记录以促进循证癌症筛查
- 批准号:
8506457 - 财政年份:2013
- 资助金额:
$ 39.45万 - 项目类别:
Promoting Use of an Integrated Personal Health Record for Prevention
促进使用综合个人健康记录进行预防
- 批准号:
8090378 - 财政年份:2010
- 资助金额:
$ 39.45万 - 项目类别:
Promoting Use of an Integrated Personal Health Record for Prevention
促进使用综合个人健康记录进行预防
- 批准号:
7873921 - 财政年份:2010
- 资助金额:
$ 39.45万 - 项目类别:
An Interactive Preventive Health Record (IPHR) to Promote Patient-Centered Care
交互式预防性健康记录 (IPHR) 促进以患者为中心的护理
- 批准号:
7490945 - 财政年份:2007
- 资助金额:
$ 39.45万 - 项目类别:
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