Randomized Trial of a Home-Advance Care Planning Video Intervention for Patients with Life-limiting Illness

项目概要/摘要 概述：本研究的目的是证明以家庭为基础的预先护理计划的有效性 (ACP)视频干预改善ACP对话，复苏偏好记录，临终关怀 利用率，并降低在家庭环境中接受护理的患有限制生命的疾病的患者的护理成本。 背景：患有严重慢性病并接受家庭护理的患者人数， 医疗保险的家庭呼叫提供者计划正在增加。通常，这些患者缺乏接触专业姑息治疗 护理和过于频繁地接受住院姑息治疗咨询的疾病轨迹后期。很大一部分 这些住院专科姑息治疗咨询的重点是专门支持ACP文件， 满足这一人群的临终关怀需求。医疗保健系统需要基于证据的ap- 在家里推广这些集中的姑息治疗服务，同时克服挑战， 姑息治疗的劳动力短缺。我们开发了一种视频辅助的、以家庭为基础的ACP干预（家庭- ACP），以改善患者与临床医生的沟通，增加ACP文件，并导致更多的患者中心， 在EOL时提供更安全、成本更低的护理。Home-ACP结合了两个循证特征，包括1）预测性 分析以识别患有晚期严重疾病的患者，预计预后为一年或更短;以及 2)ACP视频决策援助提供的护士作为三叶草健康的家庭呼叫提供者计划的一部分。我们 先前的工作已经在几个随机试验中显示了ACP视频的有效性，但还没有检查它们的效果 在家庭环境中。该视频以25种语言提供，并以低识字水平编写。 研究计划：我们建议进行一项随机临床试验，比较Home-ACP干预与常规干预 为500名患有限制生命的疾病、预后为一年或不到一年的病人提供家庭护理。我们 将评估家庭-ACP干预的有效性，以优先复苏，ACP文件- 和临终关怀利用。我们还将比较200例患者的患者报告结局，包括 ACP知识，对未来护理的信心，沟通满意度和决策确定性。最后，我们将 比较接受Home-ACP干预与常规干预的患者在生命最后一年的护理成本 在乎 环境：该项目将在三叶草健康之家呼叫提供商的支持下进行， gram拥有资源、基础设施和电子健康记录能力，可以确保 这次审判患者将从新泽西的17个县招募，这些县具有很大的种族和人种多样性。 调查研究团队拥有开发和测试视频决策辅助工具和姑息治疗的专业知识。 在大型多地点国家试验中进行护理干预。 研究的相关性：该项目将为未来的实施和传播奠定基础 这项务实的试验包括全国各地的上门服务提供者项目中的数万名患者。

PROJECT SUMMARY/ABSTRACT Overview: The goal of this study is to demonstrate the effectiveness of a home-based advance care planning (ACP) video intervention for improving ACP conversations, resuscitation preference documentation, hospice utilization, and reducing cost of care for patients with life-limiting illness receiving care in the home setting. Background: The number of patients living with serious chronic illness and receiving home-based care through Medicare's House Call Providers program is increasing. Often, these patients lack exposure to specialty palliative care and too frequently receive inpatient palliative care consultations late in the illness trajectory. A large portion of these inpatient specialty palliative care consults are focused exclusively to support ACP documentation, and addressing end-of-life (EOL) care needs for this population. Health care systems require evidence-based ap- proaches that promote these focused palliative care services at home while surmounting challenges such as palliative care workforce shortage. We have developed a video-assisted, home-based ACP intervention (Home- ACP) to improve patient-clinician communication, increase ACP documentation, and lead to more patient-cen- tered and less costly care at the EOL. Home-ACP combines two evidence-based features including 1) predictive analytics to identify patients with an advanced serious illness and a projected prognosis of one year or less; and 2) ACP video decision aid delivered by a nurse as part of Clover Health's House Call Provider program. Our prior work has shown the efficacy of ACP videos in several randomized trials, but have not examined their effect in the home setting. The video is available in 25 languages and scripted at a low literacy level. Research Plan: We propose to conduct a randomized clinical trial of the Home-ACP intervention versus usual care in 500 patients with life-limiting illness and a prognosis of one year or less, receiving home-based care. We will assess the effectiveness of the Home-ACP intervention for preferences for resuscitation, ACP documenta- tion, and hospice utilization. We will also compare patient-reported outcomes in a subset of 200 patients including ACP knowledge, confidence in future care, communication satisfaction, and decisional certainty. Lastly, we will compare the cost of care in the last year of life for patients receiving the Home-ACP intervention versus usual care. Environment: This project will be conducted with the support of the Clover Health House Call Providers pro- gram, which has the resources, infrastructure, and electronic health record capabilities to ensure the success of this trial. Patients will be recruited from 17 counties in New Jersey with substantial ethnic and racial diversity. The investigative research team has the expertise in developing and testing video decision aids and palliative care interventions in large multi-site national trials. Relevance of Research: This project will establish the foundation of a future implementation and dissemination pragmatic trial including tens of thousands of patients in House Call Provider programs across the country.