The ICAN Discussion Aid to Optimize Treatment for People Living with Multiple Chronic Conditions

项目总结 多发性慢性病(MCC)影响着四分之一的美国人，四分之三的65岁及以上人口， 这代表着一个不断增长的群体，医疗保健必须为他们找到有效护理的方法。对于这一组 就个人而言，仅基于疾病具体指导方针的护理规划是不够的。任务出线 根据患者的情况，可能会导致不可持续的自我管理策略，最终导致不遵守。 我们的研究团队设计了一个交流工具，ICAN讨论助手，以带来患者的概念 直接进入患者-临床医生会面的背景，在那里讨论和决定治疗计划。 然而，需要额外的开发工作来为卫生专业人员提供指导，指导他们如何 将这些背景信息转化为MCC患者的有效护理计划。 我们在此提案中的目标是使用以用户为中心的设计来创建ICAN实施工具包，该工具包可指导 广泛的卫生专业人员，包括医生、护士、护理协调员、社会工作者、社区 卫生工作者和卫生教练，如何有效地将ICAN对话转化为治疗计划。 以用户为中心的设计过程遵循SPARC框架。我们将看到当前的最佳实践领先 通过对当前ICAN用户的观察来制定治疗计划，计划实施工具包组件 帮助ICAN的未来用户创建行动计划，通过在新用户中测试实施工具包 当前合作者的社交网络，根据反馈修改工具包，并与工具包的 通过我们的网站和社交媒体平台发布。 这项拟议的研究将满足护理MCC患者的医疗保健专业人员的迫切需求。ICAN 通过其支持的实现工具包，他们可以进行描述患者背景的对话 和护理目标，并将这些对话转化为有效的护理计划。最终，这些护理计划 应该促成更令患者和护理人员满意的对话 他们的护理计划允许患者更好地获得和使用医疗保健，并制定自我护理，因为他们的 环境，最终更好的患者结果-重要的结果，如生活质量。虽然这些假设是 在这项发展研究的范围之外，拟议的工作将建立实施机会和 未来在这一领域的研究测试。

PROJECT SUMMARY Multiple chronic conditions (MCC) affects one of four Americans, three of four in the population 65 and older, representing a growing group for which healthcare must find ways to effectively care. For this group of individuals, care planning that is based upon disease specific guidelines alone is insufficient. Tasks out of line with patient's context may lead to unsustainable self-management strategies and ultimately, non-adherence. Our research team has designed a communication tool, the ICAN Discussion Aid, to bring concepts of patient context directly into the patient-clinician encounter, where treatment plans are discussed and decided upon. Yet, additional development work is required to provide guidance for health professionals regarding how to translate this contextual information into effective care plans for patients with MCC. Our aim in this proposal is to use user-centered design to create an ICAN Implementation Toolkit that guides a wide array of health professionals, including physicians, nurses, care coordinators, social workers, community health workers, and health coaches, how to effectively translate ICAN conversations into treatment plans. The process of user-centered design follows the SPARC framework. We will See current best practices leading to treatment plans through observations of current ICAN users, Plan implementation toolkit components that help future users of ICAN create action plans, Act by testing the implementation toolkit with new users in the social network of current collaborators, Revise the toolkit based on feedback, and Communicate the toolkit's release through our website and social media platforms. The proposed study will meet a critical need for healthcare professionals caring for patients with MCC. ICAN with its supporting implementation toolkit will allow them to have conversations that draw out patients' context and goals of care and translate these conversations into effective care plans. Ultimately, these care plans should lead to conversations that are more satisfying for patients and the health professionals who care for them, care plans that allow patients to better access and use healthcare and enact self-care given their context, and ultimately better patient-important outcomes such as quality of life. While these hypotheses are outside the scope of this developmental study, the proposed work will set up implementation opportunities and future testing in this area of research.