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)和少数族裔地位的个人，包括美国最大的少数族裔群体西班牙裔美国人，不成比例地背负着慢性心血管和代谢疾病(如肥胖、糖尿病、高血压、心脏病)的负担。高水平的未得到满足的行为健康需求(例如，与心理健康、生活压力源、医疗保健服务相关) 人口对疾病流行率和结果的显著差异起到了作用。针对拉美裔人口的保健服务的数量和质量以及拉美裔人口所接受的保健服务的质量不同，是造成这些差异的原因之一。卫生保健获取和使用方面的不平等是几个因素相互作用的结果，例如与低社会保障水平有关的因素，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、具成本效益和可持续的慢性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。拟议的随机对照试验将测试Mi Puente(“我的桥”)与常规护理(UC；基于证据的最佳实践出院程序)的有效性，研究对象是560名拉美裔成年人，他们在加利福尼亚州圣地亚哥一家靠近美国/墨西哥边境的大型安全网医院住院，患有两种或两种以上心脏代谢疾病和行为健康问题(S)。MI Puente是一项跨学科计划，采用可持续的护士+志愿者团队方法，并建立在住院/“转诊”和门诊/“接受”护理环境之间的强大合作伙伴关系，以改善护理的连续性，并满足高危拉美裔的综合(即，身体和行为)健康需求。在社会生态模型、自我管理资源和支持模型以及行为改变的跨理论模型的指导下，Mi Puente包括行为健康护士的院内辅导访问(S)，以及出院后护士(第1周)和受过专门培训的志愿者同伴导师(第1-4周)的支持性电话，帮助患者克服导致医疗保健获取和使用不平等的多层障碍，进而永久保持心脏代谢和行为健康方面的差异。电子病历(EMR)将用于识别符合条件的患者，并在30天和180天内评估再次住院治疗，这是我们的主要结果。患者报告的身体症状、生活质量、医疗保健利用率、患者激活和慢性病管理支持资源的变化将在六个月内进行评估。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措施解决精神和身体的关键组成部分，Mi Puente旨在减少不断增长和老龄化的美国拉美裔人口的健康差距，并有望有效地扩展到其他疾病和服务不足的人口。

 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.