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.

抽象的 患有严重疾病的人症状控制不良，生活质量降低（QOL）和差 与他们的医疗保健提供者进行沟通，特别是在护理讨论的目标方面（GOCD）。 姑息治疗与疾病管理一起提供时，可以改善症状控制，QOL， 沟通，护理人员满意度和减少护理人员焦虑。由于专业训练有限 但是，姑息治疗员工的患者及其护理人员通常无法获得这些好处，尤其是 在社区。这些需求在晚期癌症和HF中特别急切，这是两个主要原因 在美国的死亡，这也模拟了最常见的疾病轨迹。这些疾病的动态性质 呈现不同的症状模式和功能状态的变化，需要自适应的动态模型 姑息治疗。但是，劳动力短缺可以阻止现有基于社区的专业的扩展 姑息治疗模型。以有限的劳动力，新型号，满足患者/护理人员的二元组的需求 需要根据患者的疾病轨迹和不断变化的需求来部署姑息治疗临床医生。这 创新的层 - - 帕利亚治疗（TIER-PC）模型为正确的患者提供了适当的护理 正确的时间。 Tier-PC增加了添加到专业训练的姑息治疗学科的数量和强度 二元组的护理团队随着症状恶化，功能会下降。在第1级，可以照顾的患者 自己并且容易管理症状，得到社区卫生工作者（CHW）的支持 经过培训，以文化能力的方式引起疾病的理解。在第2层中，功能较差的患者 经过严重疾病交流的社会工作者（SW）和轻度症状，加入了CHW，以进一步 引起患者的疾病理解和目标，并提供护理人员的支持。在第3层中，功能降低 症状增加，一名预先执业护士（APN）加入了CHW+SW，以管理复杂的症状。 在第4层中，对于那些功能最差和最严重症状的患者，MD加入了最多的问题 复杂的需求（例如，临终治疗偏好和多方面的症状控制）。 CHW跟随 二元组在所有层次上纵向，并根据其不断发展的需求将它们重新分配到适当的层。 我们将评估Tier-PC在多站点，单盲，两个ARM，随机对照试验中的功效。患者 使用晚期癌症或HF，TIER-PC团队将定期评估：解决症状和 社会心理需求；改善疾病/预后理解；开药；并解决目标 关心。我们将注册和随机分配400名HF或癌症患者及其家庭护理人员接受层 PC或增强控制。我们将跟随二元组12个月，以确定层-PC是否可以改善患者的' 症状控制和QOL（主要结果），患者报告的GOCD和护理人员满意度；还原 护理人员焦虑和创伤后压力；并降低患者的医疗保健利用和成本。经过 与稀缺的劳动力相匹配的需求，我们的可扩展模型可以改善对癌症或HF患者的护理。