Maintaining Preventive Care during Public Health Emergencies through Effective Coordination

背景筛查是预防保健的核心。然而，COVID-19严重扰乱了 常规筛查工作，导致非直接归因于COVID-19的退伍军人死亡率过高。筛选 COVID期间VA的发生率因设施和临床条件而显著不同。这在癌症中得到了说明 和心理健康筛查;每一个都存在跨机构的变异性，这表明能力上的兼容性。 以及筛选和转诊程序的工作流程。为了更好地理解这些义务， 新的做法，以减轻中断护理，我们提出了一个定性研究比较设施，表现出 大流行前和大流行期间筛查率表现分别为高、低和高度可变。 意义预防性筛查的中断导致退伍军人死亡率过高。因此，照顾 退伍军人的常规初级保健（PC）的需要，同时履行我们的第四个使命（应急准备） 需要所有临床人员的顶级协调和灵活的团队合作。我们的研究将确定 初级和专科护理之间的系统战略和协调模式， 成功的设施从挣扎的。我们的发现将有助于设计新的或调整现有的工作流程， 协调干预措施，塑造如何在期间和之后提供筛查和预防护理 新冠肺炎。我们的研究直接涉及：a）本次征集的目标; B）HSR & D的临床优先事项; c）VA的 高度可靠护理的战略规划目标;以及d）ORD现实世界研究影响优先事项。 具体目标。以癌症和精神健康筛查率为例，我们建议（1）比较 来自不同筛查性能模式（高，低，改善，恢复， 在COVID-19大流行期间，（a）作为一个团队协调开展筛查服务，以及（B）与 专科护理团队在他们的设施进行筛选服务;和（2）比较团队，设施和系统- 基于COVID-19大流行期间继续筛查服务的障碍、促进因素和策略 在此期间，来自VHA设施的不同筛查性能模式的PACTs之间。 法设计与参与者本研究采用多方法研究，包括访谈的定性分析， 与10个VA医疗中心（VAMCs）的初级保健人员、领导和患者的焦点小组。 选址。我们将根据研究中心的乡村性、COVID-19、 大流行开始时的病例量，以及五项门诊临床绩效指标的绩效 癌症和心理健康筛查的重要性。研究中心将被分类为五个筛选性能之一 分组：高绩效者、低绩效者、改进者、铅垂测量者和高度可变者。 procedure.使用PI先前研究的数据，我们将为每个性能创建流程图 这一措施旨在建立一个基线，以便与自大流行开始以来所使用的程序进行比较。我们将采访 每个站点的初级保健ACOS更新地图，以反映当前使用的流程。我们将 与PC和相关专科护理临床医生进行焦点小组讨论，以引出临床医生 协调模式（例如，COVID期间筛查的障碍/促进因素（目标1- 3）。我们亦会与病人会面，以了解他们在这段期间的检查经验， 上下文 数据分析：所有访谈和焦点小组都将进行录音、转录，并通过现场笔记进行增强。 我们将分析临床医生焦点小组的成绩单和现场笔记使用迭代，快速分析。患者半- 结构化面试将使用归纳/演绎内容分析进行分析。 下一步/执行。我们将在当地分享我们的调查结果，包括针对具体地点的建议 与参与地点的主要利益相关者以及全国范围内的初级保健心理健康办公室合作 整合计划和VA国家妇女退伍军人肿瘤学卓越系统。

BACKGROUND. Screening lies at the heart of preventive care. However, COVID-19 has dramatically disrupted routine screening efforts, resulting in excess veteran mortality not directly attributable to COVID-19. Screening rates at VA during COVID have varied markedly by facility and clinical condition. This is illustrated in cancer and mental health screening; cross-facility variability exists for each, suggesting susceptibilities in the capacity and workflow of the screening and referral process. To better understand these susceptibilities and identify new practices to mitigate interrupted care, we propose a qualitative study comparing facilities that exhibited high, low, and highly variable performance (respectively) in screening rates before and during the pandemic. SIGNIFICANCE. Disruptions to preventive screening lead to excess veteran mortality. Therefore, caring for veterans’ regular primary care (PC) needs while fulfilling our Fourth Mission (emergency preparedness) requires top-notch coordination and nimble teamwork from all clinical personnel. Our study will identify the systematic strategies and coordination patterns between primary and specialty care that differentiate successful facilities from struggling ones. Our findings will help design new or adapt existing workflows and interventions for coordination, shaping how screening and preventive care is delivered during and beyond COVID-19. Our study directly addresses: a) this solicitation’s goals; b) HSR&D’s clinical priorities; c) VA’s strategic plan goals for highly reliable care; and d) ORD real-world research impact priorities. SPECIFIC AIMS. Using cancer and mental health screening rates as exemplars, we propose to (1) Compare how PACTs from VHA facilities of varying screening performance patterns (high, low, improving, plummeting, variable) during the COVID-19 pandemic coordinated (a) as a team to conduct screening services, and (b) with specialty care teams at their facility to conduct screening services; and (2) Compare team, facility, and system- based barriers, facilitators, and strategies for continuing screening services during the COVID-19 pandemic amongst PACTs from VHA facilities of varying screening performance patterns during that period. METHOD. Design and Participants. This multi-method study consists of qualitative analysis of interviews and focus groups with primary care personnel, leadership, and patients at 10 VA Medical Centers (VAMCs). Site Selection. We will select study sites using a purposive stratified approach based on site rurality, COVID-19 caseload at the beginning of the pandemic, and performance on five outpatient clinical performance indicators of cancer and mental health screening. Sites will be categorized into one of five screening performance groups: high performers, low performers, improvers, plummeters, and highly variable. Procedure. Using data from prior research by the PI, we will create process maps for each performance measure to create a baseline for comparison to the process used since the pandemic began. We will interview the ACOS for primary care at each site to update the map to reflect the currently used process. We will conduct focus groups with PC and relevant specialty care clinicians to elicit themes regarding clinician coordination patterns (e.g., handoffs), strategies, and barriers/facilitators to screening during COVID (Aims 1- 3). We will also conduct patient interviews to examine their screening experience during this period, for context. Data Analysis: All interview and focus groups will be audio-recorded, transcribed, and enhanced by field notes. We will analyze clinician focus group transcripts and field notes using iterative, rapid analysis. Patient semi- structured interviews will be analyzed using inductive/deductive content analysis. NEXT STEPS/IMPLEMENTATION. We will share our findings, including site-specific recommendations, locally with key stakeholders at participating sites, and nationally through the Office of Primary Care-Mental Health Integration program and the VA National Women Veterans Oncology System of Excellence.