Identifying Modifiable Factors that Affect Veterans At-Risk due to Social Determinants of Health and Psychological Distress Access to Care Within Integrated Primary Care Settings

背景：退伍军人更有可能报告心理困扰，这也增加了他们的风险。 健康的某些社会决定因素，如未得到满足的社会需求（例如，住房不稳定）。为切入点 对于大多数退伍军人进入护理，多学科成员的存在对综合病人对齐护理 初级保健小组，如社会工作者和初级保健心理健康一体化小组 提供者通过提供更多的机会来帮助解决这些退伍军人的整体需求， 已经发现可以改善患者预后的资源。重要性：然而，先前的研究表明， 这些综合的PACTs在满足退伍军人的需求方面继续表现出显著的差异 心理困扰和未满足的社会需求（即使新的技术为PACT带来了技能） （三）有机会改善准入。由于合并症的负面影响， 心理困扰和未满足的社会需求对退伍军人的健康，确定如何优化 在这些综合的PACTs内获得护理是一个接触广泛退伍军人的机会。创新 和影响：拟议的研究是创新的，通过其关注的一个欠发达地区的 医疗保健结构、PACT综合特征及其与获取的关系。由先前的PACT告知 关于患者导航、集成PACT特征的实施文献和概念框架 包括：结构行为、特定于提供者行为和团队行为。我们的目标是寻求使用混合方法来提供 从多个角度全面了解PACT特征，预测改善 访问并确定相关流程，以便在这一高需求范围内实现综合PACTs内的访问 人口这些结果将为VHA提供基于证据的类型的直接指导 可以利用的干预措施，并实行可能支持这些干预措施的变革， 为社会需求未得到满足和心理困扰的退伍军人提供护理。目标：目标1 确定PACT的综合特征（供应商、结构和团队行为）， 预测在社会需求和心理需求未得到满足的退伍军人中， 痛苦假设：整合PACT结构，如人员配置，和团队行为，如团队会议 将是退伍军人参与护理的最强预测因素。目标2将确定最佳做法， 高绩效综合PACTs内成员和管理人员的观点， 优化重要的综合PACT特征，支持这些领域的高水平参与 老兵目的3将测试一个模型的假设关系之间的综合PACT的特点， 通过退伍军人对护理的感知（感知可及性）、护理质量评级以及 参与护理。方法：目标1将结合来自两个数据来源的联合收割机数据（行政数据混合 与综合PACT（n=160）调查），以确定哪些综合PACT特征显着预测 初步参与，将被定义为接受心理健康或社会资源护理。合格退伍军人 最近在初级保健中看到，报告目前的心理困扰和至少一个 未满足的社会需求将符合资格。目标2将使用定性访谈提供更深入的信息， 从高绩效的一体化PACT成员和管理员那里确定最佳做法和观点 （n=30）。目标3将使用目标1的数据和退伍军人调查（n=2000）来检查退伍军人的看法 在综合PACT特征和 使用结构方程模型进行护理参与。步骤/实施：将通过以下方式分享结果 传统的出版物，但也直接与主要利益相关者在初级保健，谁将利用这些结果， 指导质量改进项目。例如，结果可以帮助告知PCMHI能力 在培训新的PCMHI供应商时，就PACT的各种特点进行培训。

Background: Veterans are more likely to report psychological distress, which also elevates their risk for certain social determinants of health, such as unmet social needs (e.g., housing instability). As the entry point for most Veterans into care, the presence of multidisciplinary members on integrated Patient Aligned Care Teams (PACTs) in primary care, such as social workers and Primary Care Mental Health Integration (PCMHI) providers helps to address the wholistic needs of these Veterans by providing increased access to additional resources that have found to improve patient outcomes. Significance: However, prior research has showed that these integrated PACTs continue to demonstrate significant variation in meeting the needs of Veterans with psychological distress and unmet social needs (even with the skillsets brought to the PACT by the new members) leaving opportunities to improve access. Due to the negative impact of the comorbid experience of psychological distress and unmet social needs on Veteran’s health on health, identifying ways to optimize access to care within these integrated PACTs is an opportunity to reach a broad array of Veterans. Innovation and Impact: The proposed research is innovative through its attention to an underdeveloped area of the healthcare structure, integrated PACT characteristics, and its relationship with access. Informed by prior PACT implementation literature and a conceptual framework on patient navigation, integrated PACT characteristics include: structural, provider-specific, and team behaviors. Our aims seek to use mixed methods to provide a comprehensive understanding from multiple perspectives on PACT characteristics predictive of improved access and identify associated processes to achieve access within integrated PACTs within this high need population. These results will provide immediate guidance to VHA on the types of evidence-based interventions that can be utilized and practice changes that may support those interventions in achieving access to care for Veterans with unmet social needs and psychological distress. Specific Aims: Aim 1 will identify integrated PACT characteristics (provider, structural, and team behaviors) that significantly predict initial engagement to care among Veterans with unmet social needs and psychological distress. Hypothesis: Integrated PACT structural, such as staffing, and team behaviors, such as team meetings will be the strongest predictors of initial Veteran engagement in care. Aim 2 will identify best practices and perspectives from members and administrators within high performing integrated PACTs on ways to achieve optimization of significant integrated PACT characteristics supporting high levels of engagement among these Veterans. Aim 3 will test a model of hypothesized relationships between integrated PACT characteris tics and access as measured by Veterans’ perceptions of care (perceived access), ratings of quality of care, and engagement in care. Methodology: Aim 1 will combine data from two data sources (administrative data mixed with integrated PACT (n=160) surveys) to identify which integrated PACT characteristics significantly predict initial engagement, which will be defined as receipt of mental health or social resource care. Eligible Veterans have recently been seen in primary care, report current psychological distress and the presence of at least one unmet social need will be eligible. Aim 2 will use qualitative interviews to provide more in-depth information to identify best practices and perspectives from high-performing integrated PACT members and administrators (n=30). Aim 3 will use Aim 1 data and Veteran surveys (n=2000) to examine the role that Veterans’ perceptions of care and quality of care play within the relationship between integrated PACT characteristics and engagement in care using structural equation modeling. Steps/Implementation: Results will be shared via traditional publications, but also directly with key stakeholders in primary care, who will utilize these results to guide quality improvement projects. For instance, the results could help inform the PCMHI Competency training efforts on various PACT characteristics when training new PCMHI providers.