Progressive Tinnitus Management: An Assessment of Readiness

耳鸣是退伍军人最普遍的服务相关残疾;它也与 创伤性脑损伤（TBI）和多发性创伤。退伍军人健康管理局（VHA）致力于 提供耳鸣服务，以改善患者在自我管理和健康结果方面的参与。 我们已经开发了渐进式精神病管理（PTM），一个跨学科（心理健康和 听力学）咨询/自我管理计划，已在对照研究中显示，以减少 耳鸣的症状和改善生活满意度。VA听力学和言语病理学（ASP） 服务认可PTM作为耳鸣的有效干预措施，并建议在VA使用 医疗中心（VAMC）。然而，PTM不是常规提供给退伍军人患有耳鸣.在 与退伍军人事务部项目办公室（心理健康服务和ASP服务）以及多发性创伤和爆炸- 相关伤害（PT/BRI）QUERI，我们计划检查造成这一差距的提供商和系统级因素 基于证据的VA建议和提供者实践之间的差异。 这项为期一年的混合方法研究将分三个阶段进行：（1）进行网上调查， 描述目前耳鸣管理实践中VA听力学和心理健康（MH）计划全国; (2)进行访谈，以确定在全国选定的VA诊所提供PTM的障碍和促进因素; 和（3）进行访谈，以确定VISN 20中的诊所是否准备好进行以下实施研究： PTM。目标是更好地了解与PTM实施相关的提供商和系统因素 在VA门诊听力学和MH诊所提供服务。感兴趣的是提供者的经验和背景 其中它们发生在既促进又阻碍实现PTM服务的能力的VA环境中。 该研究直接涉及PT/BRI QUERI的所有三个优先目标：（1）支持和加强实施 为TBI/多发伤患者提供循证、综合、以患者为中心的护理。(2)改善患者的 管理持续性TBI/多发性创伤相关症状、损伤和功能障碍的能力。（三） 优化退伍军人的支持系统，包括家庭，同龄人，VA和社区资源。 通过与VA计划办公室和PT/BRI QUERI的团队合作， 这些研究成果将得到推广。这项研究的数据结果将为制定一项 一项研究计划，将评估VA耳鸣管理的传播和实施 在全国范围内，以PTM为重点。在成功完成快速反应项目后，我们 我打算进行一项“护理点”研究，以评价在VISN 20中提供PTM的三种模式：（1）在 诊所;（2）在VA护理站点使用临床视频远程医疗;以及（3）为无法 否则访问VA耳鸣服务。我们目前正在完成两项随机临床研究， 提供PTM干预的三种模式中的两种：诊所内护理和家庭远程医疗。 定量和定性的初步分析表明，这两种模式都提供了有效的 干预（见附录1和2）。 长期，PTM的实施可以为退伍军人提供有效的耳鸣服务 到处这两种远程保健模式可由主要的VAMC和/或中央 位置.一个集中的程序可以直接为退伍军人提供耳鸣远程医疗服务， 支持VA临床医生努力为患者提供耳鸣服务。一个集中的耳鸣计划 将在全国范围内促进统一的耳鸣护理，并将导致新的效率标准， 耳鸣的危害有哪些？耳鸣的危害有哪些？

Tinnitus is the most prevalent service-connected disability for Veterans; it is also strongly associated with traumatic brain injury (TBI) and polytrauma. The Veterans Health Administration (VHA) is committed to providing access to tinnitus services to improve patient engagement in self management and health outcomes. We have developed Progressive Tinnitus Management (PTM), a cross-disciplinary (Mental Health and Audiology) counseling/self-management program that has been shown in controlled studies to reduce symptoms and improve life satisfaction for tinnitus sufferers. VA Audiology and Speech Pathology (ASP) Service has endorsed PTM as an effective intervention for tinnitus and has recommended its use at VA medical centers (VAMCs). However, PTM is not routinely offered to Veterans suffering from tinnitus. In partnership with VA Program Offices (Mental Health Services and ASP Service) and the Polytrauma and Blast- Related Injuries (PT/BRI) QUERI, we plan to examine provider- and systems-level contributors to this gap between evidence-based VA recommendations and provider practices. This 1-year mixed-methods study will be conducted in three phases: (1) conduct an online survey to describe current tinnitus management practices in VA Audiology and Mental Health (MH) programs nationwide; (2) conduct interviews to determine barriers and facilitators to providing PTM in selected VA clinics nationwide; and (3) conduct interviews to determine readiness of clinics in VISN 20 to conduct an implementation study of PTM. The goal is to better understand provider and systems factors associated with implementation of PTM services in VA outpatient Audiology and MH clinics. Of interest are both providers' experiences and the context in which they occur in VA environments that both facilitate and impede the ability to implement PTM services. The study directly addresses all three PT/BRI QUERI priority goals: (1) Support and enhance implementation of evidence-based, integrated, patient-centered care for patients with TBI/polytrauma. (2) Improve patients' ability to manage their persistent TBI/polytrauma-related symptoms, impairments, and functional difficulties. (3) Optimize Veterans' support systems, including family, peers, VA, and community resources. Through team collaboration with the VA Program Offices and the PT/BRI QUERI, the dissemination of these study results will be widespread. Data findings from this research will inform the development of a program of research that will evaluate the dissemination and implementation of VA tinnitus management programs nationally, with focus on PTM. Following successful completion of the Rapid Response Project, we intend to conduct a "point of care" study to evaluate three modalities for delivering PTM in VISN 20: (1) in the clinic; (2) using Clinical Video Telehealth at VA sites of care; and (3) Home Telehealth for Veterans who cannot otherwise access VA tinnitus services. We are currently completing two randomized clinical studies evaluating two of the three modalities for delivering the PTM intervention: In-Clinic Care and In-Home Telehealth. Preliminary analyses, both quantitative and qualitative, reveal that both modalities provide efficacious intervention (see Appendices 1 and 2). Long-term, implementation of PTM can provide access to effective tinnitus services for Veterans everywhere. The two telehealth modalities could be delivered from major VAMCs and/or from a centralized location. A centralized program could provide tinnitus telehealth services directly to Veterans, and could also support VA clinicians in their efforts to provide tinnitus services to their patients. A centralized tinnitus program would promote uniform tinnitus care on a national basis, and would result in a new standard of efficiency and improved outcomes for managing the needs of all Veterans suffering from tinnitus.