TIER-PALLIATIVE CARE: A population-based care delivery model to match evolving patient needs and palliative care services for community-based patients with heart failure or cancer

分级姑息治疗：基于人群的护理提供模式，以满足不断变化的患者需求，并为社区心力衰竭或癌症患者提供姑息治疗服务

• 批准号: 10880994
• 负责人: Laura Pilar Gelfman
• 金额: $ 16.89万
• 依托单位: ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-08-18 至 2025-07-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10880994
• 关键词: 2 arm randomized control trial; Accounting; Acute; Address; Advanced Malignant Neoplasm; Advanced Practice Nurse; Anxiety; COVID-19; Caregiver support; Caregivers; Caring; Categories; Cause of Death; Cessation of life; Chaplain; Clinical; Communication; Communities; Community Health Aides; Community Trial; Complex; Data; Deterioration; Discipline; Disease; Disease Management; Drug Prescriptions; Emergency department visit; Enrollment; Ensure; Family Caregiver; Future; Goals; Growth; Health Care Costs; Health Personnel; Health system; Heart failure; Hospitalization; Hospitals; Individual; Inpatients; Intervention; Karnofsky Performance Status; Length of Stay; Malignant Neoplasms; Medicare; Modeling; Nature; Outcome; Palliative Care; Patient Care; Patient Self-Report; Patient-Focused Outcomes; Patients; Pattern; Persons; Physicians; Population; Quality of life; Randomized; Recovery; Reporting; Resources; Service delivery model; Services; Single-Blind Study; Site; Social Workers; Symptoms; Time; Training; anxiety reduction; arm; care costs; care delivery; care systems; community based care; community based service; cost; cultural competence; efficacy evaluation; end of life; experience; functional decline; functional status; health care service utilization; hospice environment; improved; innovation; medical specialties; member; novel; participant enrollment; population based; post-traumatic stress; post-traumatic symptoms; preference; prevent; primary outcome; prognostic; programs; psychosocial; randomized trial; satisfaction; symptom management; symptomatic improvement

ABSTRACT Persons with serious illness suffer from poor symptom control, decreased quality of life (QoL) and poor communication with their healthcare providers, especially in terms of goals of care discussions (GOCD). Palliative care, when offered alongside disease management, offers improved symptom control, QoL, communication, caregiver satisfaction and reduced caregiver anxiety. Due to a limited specialty-trained palliative care workforce, however, patients and their caregivers often cannot access these benefits, especially in the community. These needs are particularly acute in advanced cancer and HF, the two leading causes of death in the US which also model the most common illness trajectories. The dynamic nature of these illnesses presents distinct symptom patterns and changing functional status that require an adaptive, dynamic model of palliative care delivery. Yet, workforce shortages prevent scaling of existing community-based specialty palliative care models. To meet patient/caregiver dyads' needs with a limited workforce, new models that deploy palliative care clinicians based on patient's illness trajectory and changing needs are required. The innovative TIER-PALLIATIVE CARE (TIER-PC) model provides the right level of care to the right patients at the right time. TIER-PC increases the number and intensity of specialty trained palliative care disciplines added to the dyad's care team as their symptoms worsen and function declines. In Tier 1, patients who can care for themselves and have easily managed symptoms, receive support from a community health worker (CHW) trained to elicit illness understanding in a culturally competent way. In Tier 2, for patients with poorer function and mild symptoms, a social worker (SW), trained in serious illness communication, joins the CHW to further elicit patients' illness understanding and goals, and provide caregiver support. In Tier 3, as function decreases and symptoms increase, an advance practice nurse (APN) joins the CHW+SW to manage complex symptoms. In Tier 4, for those patients with the poorest function and worst symptoms, an MD joins to address the most complex needs (e.g., end-of-life treatment preferences and multifaceted symptom control). The CHW follows dyads longitudinally across all tiers and re-allocates them to the appropriate tier based on their evolving needs. We will evaluate TIER-PC's efficacy in a multi-site, single blinded, two arm, randomized controlled trial. Patients with advanced cancer or HF will receive regular assessments by the TIER-PC team to: address symptom and psychosocial needs; improve illness/prognostic understanding; prescribe medications; and address goals of care. We will enroll and randomize 400 patients with HF or cancer and their family caregivers to receive TIER- PC or an augmented control. We will follow dyads for 12 months to determine if TIER-PC: improves patients' symptom control and QoL (primary outcomes), patient-reported GOCDs and caregiver satisfaction; reduces caregiver anxiety and post-traumatic stress; and decreases patients' healthcare utilization and cost. By matching demand to the scarce workforce, our scalable model can improve care for patients with cancer or HF.

摘要 患有严重疾病的人症状控制差，生活质量下降（QoL）， 与他们的医疗保健提供者的沟通，特别是在护理讨论的目标（GOCD）方面。 姑息治疗与疾病管理一起提供时，可改善症状控制、生活质量， 沟通，照顾者满意度和减少照顾者焦虑。由于有限的专业训练 然而，姑息治疗工作人员，患者及其护理人员往往无法获得这些福利，特别是 在社区这些需求在晚期癌症和HF中特别迫切，这是两种主要的癌症病因。 这也是最常见的疾病轨迹模型。这些疾病的动态本质 呈现出不同的症状模式和不断变化的功能状态，这需要一个自适应的动态模型， 提供姑息治疗。然而，劳动力短缺阻碍了现有社区专业的扩展 姑息治疗模式为了在有限的劳动力条件下满足患者/护理人员的需求， 需要根据病人的病情发展和不断变化的需求部署姑息治疗临床医生。的 创新的TIER-PALLIATIVE CARE（TIER-PC）模式为合适的患者提供合适的护理水平， 正是时候TIER-PC增加了专业培训姑息治疗学科的数量和强度， 当他们的症状恶化和功能下降时，在第1层，可以照顾的患者 自己和容易管理的症状，接受社区卫生工作者（CHW）的支持 接受过以文化上胜任的方式引出疾病理解的培训。在第2层中，对于功能较差的患者 和轻微症状，一名受过严重疾病沟通培训的社会工作者（SW）加入CHW， 引导病人对疾病的理解和目标，并提供照顾者的支持。在第3层中，随着功能的减少 和症状增加，高级实践护士（APN）加入CHW+SW管理复杂的症状。 在第4层，对于那些功能最差和症状最严重的患者，医学博士加入，以解决最 复杂的需求（例如，临终治疗偏好和多方面的症状控制）。CHW如下 在所有层中纵向地划分成对单元，并根据其不断变化的需求将其重新分配到适当的层。 我们将在一项多中心、单盲、两组、随机对照试验中评估TIER-PC的疗效。患者 晚期癌症或HF患者将接受TIER-PC团队的定期评估，以：解决症状， 社会心理需求;改善对疾病/预后的理解;开药;并解决 在乎我们将入组并随机分配400例HF或癌症患者及其家庭护理人员接受TIER- PC或增强控制。我们将随访12个月，以确定TIER-PC：是否改善患者的 症状控制和QoL（主要结局）、患者报告的GOCD和护理人员满意度;降低 护理者焦虑和创伤后应激;并降低患者的医疗保健利用率和成本。通过 通过将需求与稀缺的劳动力相匹配，我们的可扩展模式可以改善对癌症或HF患者的护理。