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佳，生活质量 (QoL) 下降，精神状态不佳 与医疗保健提供者的沟通，特别是在护理讨论目标 (GOCD) 方面。 姑息治疗与疾病管理一起提供时，可以改善症状控制、生活质量、 沟通、照护者满意度并减少照护者焦虑。由于受过专业训练的人有限 然而，姑息治疗劳动力中，患者及其护理人员往往无法获得这些福利，尤其是 在社区中。这些需求在晚期癌症和心力衰竭（心力衰竭的两个主要原因）中尤为迫切。 美国的死亡人数也模拟了最常见的疾病轨迹。这些疾病的动态性质 呈现出独特的症状模式和不断变化的功能状态，需要适应性的动态模型 姑息治疗服务。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/护理人员的需求，新模型 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 TIER-PALLIATIVE CARE (TIER-PC) 模式为适当的患者提供适当水平的护理 正确的时间。 TIER-PC 增加了经过专业培训的姑息治疗学科的数量和强度 随着症状恶化和功能下降，二人的护理团队开始接受治疗。在第一级，可以照顾的患者 且症状易于控制，接受社区卫生工作者 (CHW) 的支持 接受培训，以文化上合适的方式引发对疾病的理解。第 2 级，适用于功能较差的患者 和轻微症状时，一名接受过严重疾病沟通培训的社会工作者 (SW) 加入 CHW，以进一步 引发患者对疾病的理解和目标，并为护理人员提供支持。在第 3 层中，随着功能的减少 当症状加重时，高级执业护士 (APN) 会加入 CHW+SW 来管理复杂的症状。 在第 4 级，对于那些功能最差和症状最严重的患者，医学博士会加入来解决最严重的问题 复杂的需求（例如，临终治疗偏好和多方面的症状控制）。 CHW 如下 纵向跨所有层进行二元组，并根据不断变化的需求将它们重新分配到适当的层。 我们将在多中心、单盲、双臂、随机对照试验中评估 TIER-PC 的功效。患者 患有晚期癌症或心力衰竭的患者将接受 TIER-PC 团队的定期评估，以： 解决症状并 社会心理需求；提高对疾病/预后的了解；开药；并解决以下目标 关心。我们将招募并随机分组 400 名心力衰竭或癌症患者及其家庭护理人员接受 TIER- PC 或增强控制。我们将跟踪二组 12 个月，以确定 TIER-PC 是否：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；减少 照顾者的焦虑和创伤后压力；并降低患者的医疗保健利用率和成本。经过 我们的可扩展模型能够满足稀缺劳动力的需求，可以改善对癌症或心力衰竭患者的护理。