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 严重疾病患者的症状控制不佳，生活质量下降，生活质量差 与他们的医疗保健提供者进行沟通，特别是在护理讨论目标(GOCD)方面。 姑息治疗与疾病治疗一起提供时，可以改善症状控制、生活质量、 沟通、照顾者满意度和降低照顾者焦虑。由于受过专业训练的有限 然而，姑息治疗工作人员、患者和他们的照顾者往往无法获得这些福利，特别是 在社区里。这些需求在晚期癌症和心力衰竭中尤为严重，这两种疾病是 美国的死亡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不断变化的功能状态，需要自适应、动态的 临终关怀服务。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。为了用有限的劳动力满足患者/护理者双方的需求，新的模式 需要根据患者的病情轨迹和不断变化的需求部署姑息治疗临床医生。这个 创新的一级姑息治疗(TIER-PC)模式为合适的患者提供适当级别的护理 恰逢其时。Tier-PC增加了受过专业训练的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，他们的护理团队。在Tier 1，可以照顾的患者 他们自己有容易控制的症状，接受社区卫生工作者(CHW)的支持 经过培训，以文化上称职的方式引起对疾病的理解。在Tier 2，适用于功能较差的患者 一名接受过严重疾病沟通训练的社工，加入社工中心，进一步 了解患者对疾病的理解和目标，并提供照顾者支持。在第3层中，AS功能减少 和症状增加，一名高级实践护士(APN)加入CHW+SW来管理复杂的症状。 在Tier 4中，对于那些功能最差和症状最严重的患者，MD将加入到解决最 复杂的需求(例如临终治疗偏好和多方面的症状控制)。以下是CHW DYAD纵向跨所有层，并根据其不断变化的需求将其重新分配到适当的层。 我们将在多点、单盲、双臂、随机对照试验中评估Tier-PC的疗效。病人 患有晚期癌症或心衰的患者将接受Tier-PC团队的定期评估，以：解决症状和 心理社会需求；改善对疾病/预后的了解；开出药物；解决 关心。我们将登记400名心力衰竭或癌症患者及其家庭照顾者并将其随机分配到以下级别- PC或增强型控制。我们将对DYADS进行12个月的跟踪调查，以确定Tier-PC：是否改善了患者的 症状控制和QOL(主要结果)、患者报告的GOCDs和照顾者满意度；降低 照顾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 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心力衰竭患者的护理。