Mi Puente: My Bridge to Better Cardiometabolic Health and Well-being

 描述（由申请人提供）：低社会经济（SES）和少数民族地位的个人，包括美国最大的少数民族群体西班牙裔，不成比例地受到慢性心血管和代谢疾病（“心脏代谢”，例如，肥胖、糖尿病、高血压、心脏病）。高水平的未满足的行为健康需求（例如，与心理健康、生活压力源、医疗保健获取有关）， 人口的差异造成了疾病流行率和结果的显著差异。针对西班牙裔人口成员的医疗保健的数量和质量的差异导致了这些差异。卫生保健获得和使用的不平等是由几个因素的相互作用造成的，例如与社会经济地位低有关的因素，以及文化、语言和/或沟通方式的差异。我们建立的学术-医疗-社区合作伙伴关系在开发和测试创新，具有成本效益和可持续的慢性病护理干预措施方面拥有独特的经验，以减少差距并改善服务不足社区的健康状况。拟定的随机对照试验将在560名西班牙裔成年人中测试Mi Puente（“My Bridge”）与Mental Care（UC;循证、最佳实践出院程序）相比的有效性，这些成年人因2种或2种以上心脏代谢疾病和行为健康问题在加利福尼亚州圣地亚哥美国/墨西哥边境附近的一家大型安全网医院住院。Mi Puente是一个跨学科的计划，采用可持续的护士+志愿者团队的方法，并建立在住院/“转诊”和门诊/“接受”护理环境之间强大的合作伙伴关系的基础上，以提高护理的连续性并解决综合（即，身体和行为）的健康需要的风险西班牙裔。根据社会生态模型、自我管理模型的资源和支持以及行为改变的跨理论模型，Mi Puente包括行为健康护士的住院指导访问，以及出院后护士（第1周）和经过专门培训的志愿同伴导师的支持电话（第1-4周），这将有助于患者在导航的多层次的障碍，有助于医疗保健的获取和使用的不平等，反过来，在心脏代谢和行为健康的差距永久化。电子病历（EMR）将用于识别合格的患者，并评估30天和180天时的再住院情况（我们的主要结局）。将在6个月内评价患者报告的身体症状、生活质量、医疗保健利用、患者激活和慢性病管理支持资源的变化。彻底的流程和成本效益分析将评估Mi Puente的可扩展性和可持续性潜力。通过利用现有的医院资源，并通过跨学科，文化定制和可持续的干预来解决身心的关键组成部分，Mi Puente旨在减少不断增长和老龄化的美国西班牙裔人口的健康差距，并有望有效扩展到其他条件和服务不足的人群。

 DESCRIPTION (provided by applicant): Individuals of low socioeconomic (SES) and ethnic minority status, including Hispanics, the largest U.S. ethnic minority group, are disproportionately burdened by chronic cardiovascular and metabolic conditions ("cardiometabolic" e.g., obesity, diabetes, hypertension, heart disease). High levels of unmet behavioral health needs (e.g., related to mental health, life stressors, healthcare access) in this population contribute to the striking disparities in disease prevalence and outcomes. Differences in the quantity and quality of health care targeted to and received by members of the Hispanic population contribute to these disparities. Inequities in health care access and use result from the interaction of several factors, such as those related to low SES, and cultural, language, and/or communication-style differences. Our established academic-healthcare-community partnership has unique experience in developing and testing innovative, cost-effective, and sustainable chronic care interventions to reduce disparities and improve health in underserved communities. The proposed randomized controlled trial will test the effectiveness of Mi Puente ("My Bridge") compared to Usual Care (UC; evidence-based, best practice discharge procedures) in 560 Hispanics adults, hospitalized with 2 or more cardiometabolic conditions and behavioral health concern(s) at a large safety net hospital near the US/Mexico border in San Diego, CA. Mi Puente is an interdisciplinary program that applies a sustainable nurse + volunteer team approach, and builds upon a strong collaborative partnership between inpatient/"referring" and outpatient/"receiving" care settings to improve continuity of care and address the integrated (i.e., physical and behavioral) health needs of at-risk Hispanics. Informed by the Social Ecological Model, Resources and Support for Self-Management Model, and Transtheoretical Model of behavior change, Mi Puente includes in-hospital coaching visit(s) from a Behavioral Health Nurse, and post-discharge supportive telephone calls from the nurse (week 1) and a specially-trained Volunteer Peer Mentor (weeks 1-4) that will assist patients in navigating the multi-level barriers that contribute to inequities in health care access and use, and in turn, perpetuate disparities in cardiometabolic and behavioral health. Electronic medical records (EMR) will be used to identify eligible patients and evaluate re-hospitalizations, our primary outcome, at 30- and 180-days. Changes in patient-reported physical symptoms, quality of life, healthcare utilization, patient activation, and support resources for chronic disease management will be evaluated across six months. Thorough process and cost- effectiveness analyses will evaluate the scalability and sustainability potential of Mi Puente. By capitalizing o existing hospital-based resources, and by addressing critical components of mind and body via an interdisciplinary, culturally-tailored, and sustainable intervention, Mi Puente aims to reduce health disparities in the growing and aging US Hispanic population, and holds promise for impactful expansion to other conditions and underserved populations.