Empowering Formerly Homeless Older Adults to Engage in Advance Care Planning in Permanent Supportive Housing (ACP-PSH): An RCT

项目摘要/摘要 背景：无家可归人口正在老龄化，50岁以上的人中 经历衰老加速，死亡率高，愿望得不到满足的高风险 生命的终结。高级护理计划(ACP)旨在吸引患者的医疗偏好；但年长的无家可归者 ACP发生率低。重大的政策关注集中在将长期无家可归的人重新安置到 永久性支持性住房(PSH)，提供自愿支持性服务的补贴永久性住房。我们的 先前的研究表明，PSH可能是启动ACP的理想环境；然而，还没有研究表明 在机场核心计划雇用以前无家可归的PSH居民。我们的团队已经创建了为您的关怀做准备 (准备)-一个易于使用的，以证据为基础的在线ACP计划，带有视频故事。该计划包括 易于阅读的高级指令、ACP小组访问指南和ACP一对一促进指南。穿过 在R34之前，我们开发了一个社区咨询委员会(CAB)，并共同确定了初步适应 为PSH设置做准备。该项目需要一个最终的共同开发过程，与以前的慢性 无家可归的老年PSH居民和工作人员以及我们的出租车。这项提议的目标是共同开发 准备-PSH并比较促进小组访问与以前的一对一访问的效果 PSH中长期无家可归的老年人。目标：(1)与PSH居民共同开发Prepare-PSH， 员工和我们的CAB；(2)进行混合(NIH第三阶段功效/有效性)、类型1、双臂、集群 比较准备-PSH计划的两种递送策略的有效性的随机试验(即， ACP电影和易于阅读的广告)促进的小组访问与一对一访问；以及(3)探索实施- PSH中ACP参与和ACP可持续性的相关因素。方法：在目标1中我们将 通过与20名PSH的深入访谈和焦点小组，参与严格的共同开发过程 居民和出租车。我们将使用基于理论的框架(即行为改变轮(BCW))和 定性内容分析，共同创建PSH准备计划。对于目标2，CAB注意到，小组 可能比一对一访问更可行，并要求我们按地点随机化，这样居民就不会 感觉自己被“排除在”交替干预之外。因此，我们将进行混合(NIH第三阶段 疗效/有效性)，类型1整群随机试验，比较Prepare-PSH通过 促进小组访问与使用混合效果模型的一对一访问。随机化将在场地层面上进行， 按站点大小进行平衡。在目标3中，我们将有目的地抽取目标2参与者进行深入访谈(n=40-50)， 与PSH工作人员(n=40)一起进行焦点小组，并从CAB成员那里获得意见(总共n=15)。我们将探索 与执行有关的因素与：(A)非加太项目参与度高和低以及可持续 准备-使用BCW和实施研究综合框架(CFIR)模式的PSH。 与美国国立卫生研究院和公共卫生的相关性：Prepare-PSH可能会减少老年人在ACP方面的健康差距 长期无家可归的老年人。

PROJECT SUMMARY/ABSTRACT Background: The homeless population is aging, with an increasing proportion of individuals over age 50 who experience accelerated aging, high rates of mortality, and a high risk of not having their wishes honored at the end of life. Advance care planning (ACP) aims to elicit patients’ medical preferences; yet older homeless adults have low rates of ACP. Significant policy attention has focused on rehousing chronically homeless people into Permanent Supportive Housing (PSH), subsidized permanent housing with voluntary supportive services. Our previous research indicates that PSH may be the ideal setting to initiate ACP; however, no studies have engaged formerly homeless PSH residents in ACP. Our team has created PREPARE for Your Care (PREPARE) – an easy-to-use, evidence-based, online ACP program with video stories. This program includes easy-to-read advance directives, an ACP group visit guide, and an ACP one-on-one facilitation guide. Through a prior R34, we developed a Community Advisory Board (CAB) and together identified preliminary adaptations to PREPARE for the PSH setting. The project requires a final co-development process with formerly chronically homeless older PSH residents and staff and our CAB. The objective of this proposal is to co-develop PREPARE-PSH and compare the effectiveness of facilitated group versus one-on-one visits among formerly chronically homeless older adults in PSH. Aims: We will (1) co-develop PREPARE-PSH with PSH residents, staff, and our CAB; (2) conduct a Hybrid (NIH Stage III efficacy/effectiveness), Type 1, two-arm, cluster randomized trial comparing the effectiveness of two delivery strategies of the PREPARE-PSH program (i.e., ACP movies and easy-to-read ADs) – facilitated group vs. one-on-one visits; and (3) explore implementation- relevant factors associated with ACP engagement and sustainability of ACP in PSH. Methods: In Aim 1 we will engage in a rigorous co-development process through in-depth interviews and focus groups with 20 PSH residents and the CAB. We will use a theory-informed framework (i.e., Behavior Change Wheel (BCW)) and qualitative content analysis to co-create a PREPARE-PSH program. For Aim 2, the CAB noted that groups may be more feasible to scale vs. one-on-one visits and asked us to randomize by site so residents would not feel “left out” of the alternate intervention. Therefore, we will conduct a Hybrid (NIH Stage III efficacy/effectiveness), Type 1 cluster randomized trial comparing delivery of PREPARE-PSH through facilitated groups vs. one-on-one visits using mixed effects models. Randomization will be at the site level, balanced by site size. In Aim 3 we will purposively sample Aim 2 participants for in-depth interviews (n=40-50), conduct focus groups with PSH staff (n=40), and obtain input from CAB members (total n=15). We will explore implementation-relevant factors associated with: (a) high and low ACP engagement and sustainability of PREPARE-PSH using the BCW and the Consolidated Framework for Implementation Research (CFIR) model. Relevance to NIH and public health: PREPARE-PSH may reduce health disparities in ACP among formerly chronically homeless older adults.