Progressive Tinnitus Management: An Assessment of Readiness

耳鸣是退伍军人最常见的与服务相关的残疾；它也与 创伤性脑损伤(TBI)和多发伤。退伍军人健康管理局(VHA)致力于 提供耳鸣服务，以提高患者对自我管理和健康结果的参与度。 我们已经开发了进行性耳鸣管理(PTM)，这是一种跨学科(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可减少 改善耳鸣患者的症状和生活满意度。退伍军人管理局听力学和言语病理学(ASP) 服务部门支持PTM作为耳鸣的有效干预手段，并建议在退伍军人管理局使用PTM 医疗中心(VAMC)。然而，PTM并不是常规提供给患有耳鸣的退伍军人。在……里面 与退伍军人事务部方案办公室(精神卫生服务和ASP服务)以及多发性创伤和冲击波- 相关伤害(PT/BRI)QUERI，我们计划检查导致这一差距的提供者和系统级别的因素 在基于证据的退伍军人管理局建议和服务提供者实践之间。 这项为期一年的混合方法研究将分三个阶段进行：(1)进行在线调查，以 描述目前在退伍军人管理局听力学和精神卫生(MH)项目中的耳鸣管理实践； (2)进行访谈，以确定在全国选定的退伍军人管理局诊所提供PTM的障碍和促进者； 以及(3)进行访谈以确定VISN 20中的诊所是否准备好进行 PTM。目标是更好地了解与实施PTM相关的提供商和系统因素 退伍军人事务部耳科门诊和MH诊所的服务。令人感兴趣的是提供商的经验和背景 它们发生在促进和阻碍实施PTM服务的能力的退伍军人管理局环境中。 该研究直接涉及PT/BRI QUERI的所有三个优先目标：(1)支持和加强执行 为脑外伤/多发伤患者提供基于证据的、综合的、以患者为中心的护理。(2)改善患者的生活质量 有能力处理持续的颅脑损伤/多发伤相关症状、损伤和功能障碍。(3) 优化退伍军人支持系统，包括家庭、同伴、退伍军人和社区资源。 通过与退伍军人事务部计划办公室和PT/BRI QUERI的团队协作，传播 这些研究成果将会广泛应用。这项研究的数据发现将为开发一种 评估VA耳鸣治疗传播和实施情况的研究方案 全国范围内的方案，重点是PTM。在成功完成快速应变计划后，我们 打算进行一项“护理点”研究，以评估在VISN 20中提供PTM的三种方式：(1)在 诊所；(2)在退伍军人护理地点使用临床视频远程保健；以及(3)为不能做到这一点的退伍军人提供家庭远程保健 否则可使用退伍军人管理局的耳鸣服务。我们目前正在完成两项随机临床研究，评估 提供PTM干预的三种方式中的两种：门诊护理和家庭远程保健。 定量和定性的初步分析表明，这两种方法都是有效的 干预(见附录1和2)。 从长远来看，PTM的实施可以为退伍军人提供有效的耳鸣服务 到处都是。这两种远程医疗模式可以从主要的VAMC和/或从中央 地点。一个集中的方案可以直接向退伍军人提供耳鸣远程保健服务，还可以 支持退伍军人管理局临床医生努力为患者提供耳鸣服务。集中式耳鸣方案 将在全国范围内促进统一的耳鸣护理，并将产生一个新的效率和 改善了管理所有患有耳鸣的退伍军人的需求的结果。

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.