Optimizing Patient-Centered Routine Care at a Distance for Veterans with Chronic Conditions

背景：由于新冠肺炎的推出，退伍军人管理局经历了相当大的转变，转向远程护理 以确保服务的安全交付。组件包括扩展的远程医疗、远程 在常规面对面访问和其他实践更改时采取措施。患有慢性病的退伍军人是如何 经常使用退伍军人管理局的医疗保健体验这些变化是未知的。这项为期18个月的试点研究评估了 混合方法描述对老年、慢性病退伍军人的远程护理，如何服务 退伍军人经历了变化，以及这些经历如何影响健康管理和结果。 意义/影响：新冠肺炎前所未有的影响为小说的发展提供了机会 以退伍军人为中心的混合方法，以了解大流行对退伍军人医疗保健的影响。调查 可以识别和测试以退伍军人为中心的系统改进，以支持为未来做好准备 紧急情况。这项研究与退伍军人管理局2018-2024财年的战略目标和目标保持一致，以促进客户 和HSR&D的科学优先事项，以提高远程医疗的有效性，并利用初级保健 优化复杂慢性病管理。它还与退伍军人正在进行的活动保持一致 体验处使用旅程图了解退伍军人在退伍军人护理方面的经验。创新： 建议的混合方法试点研究是跨学科的，在VA研究中使用新方法。通过借鉴 医学人类学和卫生服务研究的理论和方法，先导研究的定位是 提供关于新冠肺炎对退伍军人及其关怀的S影响的深入和可操作的知识。具体目标： 目标1：描述远距离护理的组成部分，以适应基于体验的旅程地图 模板，它将描述远程护理如何影响老年退伍军人的医疗体验 合并症及其健康后果。目标二：测试可行性和可接受性，并进行分析 在深入的定性访谈中嵌入基于体验的旅程映射，以描述 患有合并症的老年退伍军人及其常规护理提供者的距离。目标3：评估 检查服务变更、退伍军人经历和健康之间关系的混合方法技术 结果，纳入图表审查，作为比较和三角数据来源。方法：本研究 采用在纽约州布朗克斯的詹姆斯·J·彼得斯VA和弗吉尼亚州哈德逊谷健康中心进行的顺序设计 纽约州北部的关爱中心。在目标1中，将对远程退伍军人管理局护理的变化进行文档分析 为完善组件、关键功能及其实现的清单而进行。库存将 通知经过调整的基于体验的旅行地图模板和面试主题指南，以及医疗表 分析。在目标2中，将招募40名65岁以上并有两个或两个以上合并症(1个)的退伍军人 患有艾滋病毒或糖尿病)，并有资格参加Geripact或HIV诊所。面试将使用 基于体验的调查地图模板，用于记录COVID之前的服务接触和体验- 19(2020年3月之前)、初始阶段(2020年3月至5月)和前进阶段(6月 2020年--学习时间)。后续访谈将讨论测绘的可行性和可接受性。12个提供商 将就远程护理的实施和退伍军人经历进行采访，以及 行程测绘的可行性。我们将对可行性和可接受性进行分析，并进行定性 主题分析和流程分析。在目标3中，将进行图表审查，以检查健康使用记录 将在图表和地图之间进行比较分析。实施/ 下一步：研究结果将被用于制定IIR研究方案，以：1)描述远程护理 对退伍军人医院的影响；以及2)测试和评估改善退伍军人护理的干预措施，特别是 那些因慢性健康状况而衰老的人。退伍军人体验办公室将合作开展这项研究， 将寻求持续的经验丰富的投入。

Background: As a result of COVID-19, the VA has undergone a sizable transition to Care at a Distance in order to ensure the safe delivery of services. Components encompass expanded telehealth, distancing measures at routine face to face visits, and other practice changes. How Veterans with chronic conditions who regularly use VA healthcare experience these changes is unknown. This 18-month pilot study assesses a mixed methods approach to describe Care at a Distance for older, chronically ill Veterans, how service changes are experienced by Veterans, and how the experiences affect health management and outcomes. Significance/Impact: The unprecedented impact of COVID-19 provides an opportunity to advance novel Veteran-centered mixed methods to understand the pandemic’s effects on Veteran healthcare. Investigations can identify and test out Veteran-centered system improvements that support preparedness for future emergencies. This study aligns with VA’s strategic goals and objectives for FY2018-2024 to promote ‘customer service,’ and HSR&D’s scientific priorities to improve telehealth’s effectiveness, and to use primary care to optimize complex chronic disease management. It also aligns with ongoing activities in the Veterans Experience Office using journey mapping to understand Veteran experiences of VA care. Innovation: The proposed mixed methods pilot study is interdisciplinary, using novel methods in VA studies. By drawing upon theories and methods of medical anthropology and health services research, the pilot study is positioned to produce deep and actionable knowledge about COVID-19’s impact on Veterans and their care. Specific Aims: Aim 1: Describe components of Care at a Distance, to inform adapting an experience-based journey mapping template, which will describe how Care at a Distance affects the healthcare experiences of older Veterans with comorbidities, and their health outcomes. Aim 2: Test the feasibility and acceptability, and conduct an analysis, of embedding experienced-based journey mapping within in-depth qualitative interviews to describe Care at a Distance for older Veterans with comorbidities, and their routine care providers. Aim 3: Assess the utility of the mixed methods techniques to examine relationships among service changes, Veteran experiences, and health outcomes, incorporating chart review as a comparative and triangulating data source. Methods: The study uses a sequential design carried out at the James J. Peters VA in Bronx, NY and VA Hudson Valley Health Care in upstate, New York. In Aim 1, a documents analysis of VA Care at a Distance changes will be conducted to refine an inventory of components, key features, and their implementation. The inventory will inform an adapted experience-based journey map template and interview topic guide, and a medical chart analysis. In Aim 2, 40 Veterans will be recruited who are 65+ years old with two or more comorbidities (one being HIV or diabetes) and eligible for enrollment in the GeriPact, or HIV clinic. Interviews will use the experience-based survey mapping template to document service encounters and experiences before COVID- 19 (prior to March 2020), in the initial phase (March-May 2020), and during the Moving Forward period (June 2020-time of study). A follow-up interview will discuss feasibility and acceptability of mapping. 12 provider interviews will be conducted about implementation and Veteran experiences of Care at a Distance, and the feasibility of journey mapping. We will analyze for feasibility and acceptability, and conduct a qualitative thematic and process analysis. In Aim 3, a chart review will be performed to examine the record of health use and outcomes, and a comparative analysis will be performed between charts and the maps. Implementation/ Next Steps: Findings will be used to develop an IIR research proposal to: 1) describe Care at a Distance impact across VA facilities; and 2) test out and evaluate interventions to improve care for Veterans, particularly those aging with chronic health conditions. The VA Veteran Experience Office will partner on this study, and continuous Veteran input will be sought.