Implementing a Clinical-Community Partnered Intervention to Address Food Insecurity Among High-Risk Veterans

据估计，近25%的退伍军人处于粮食不安全状态（FI）， 获得营养充足和安全的食物。FI与广泛的不良健康状况有关 结果以及增加的医疗保健成本和利用率。但事实上，常常是在-- 在包括VHA在内的临床环境中得到认可。先前的研究表明，临床医生和其他护理团队 成员们往往感到，即使一旦查明，也没有能力处理金融机构问题。因此，迫切需要 确定如何最有效地将FI退伍军人与相关服务和社区资源联系起来， 以解决退伍军人金融机构及其下游后果。 解决的差距（知识和实践）：2017年10月，VA启动了一项全国性的FI临床 提醒旨在筛选所有在VHA接受护理的退伍军人。在筛查的前24个月， 提醒确定超过77，000退伍军人在全国各地报告FI。然而，人们对 VA研究中心之间筛查的差异;当退伍军人FI筛查呈阳性时，研究中心如何反应;或者 积极筛选后的VHA做法最能改善退伍军人的粮食安全状况， 护理和健康结果。这一拟议的应用将填补这些知识空白。 创新性：尽管VHA已经开始更广泛地解决健康的社会决定因素， 地址FI仍处于初始状态。这一建议以及它将促进的未来研究领域是创新的 因为它寻求发展新的VA-社区伙伴关系，解决健康的关键社会决定因素， 导致不良的健康后果。该提案通过强调多层次， 利益相关者的参与，包括退伍军人的参与，并寻求以退伍军人为中心的方法， 解决粮食不安全问题。 具体目标：我的长期职业目标是成为开发、评估和 实施有效的干预措施，以解决退伍军人金融中介机构和其他健康的社会决定因素。通过 在CDA-2申请中，我将在家庭医学和卫生服务研究方面的培训基础上， 获得先进的技能，在实施科学，干预设计和混合方法评价。我 提出以下研究目标：目标1：检查全国VA地点在实施过程中的差异 FI临床提醒和描述实施经验和社区转诊流程;目的 2：了解退伍军人的经验，以及他们与退伍军人事务部和社区资源的互动， 阳性FI筛查;目标3：开发和试点测试干预模式，以优化筛查和转诊 将FI退伍军人与相关VA和社区资源联系起来的流程。 方法：本提案采用了多阶段混合方法框架， 目标。 下一步：完成后，这项拟议的工作将评估目前的退伍军人FI方法，并确定 和试点战略，将VHA社区合作干预措施纳入临床实践，以解决FI问题。 研究结果将为未来的IIR进行干预模型的多地点试验奠定基础。此夕h 拟议的研究和培训将有助于启动我的职业生涯，作为一个独立的医生，调查承诺 为减少退伍军人FI和健康的相关社会决定因素提供严格的科学依据， 以退伍军人为中心，最大限度地提高患者自主权，并优化健康结果。

Background: Nearly 25% of Veterans are estimated to be food insecure (FI), experiencing limited or uncertain access to nutritionally adequate and safe foods. FI has been associated with a wide range of adverse health outcomes as well as increased healthcare costs and utilization. Concerningly, FI is frequently under- recognized in clinical settings including VHA. Prior research has shown that clinicians and other care team members often feel ill equipped to address FI even once identified. As such, there is a critical need to determine how to most effectively connect FI Veterans with relevant services and community resources in order to address Veteran FI and its downstream consequences. Gaps Addressed (Knowledge and Practice): In October 2017 the VA launched a national FI clinical reminder intended to screen all Veterans receiving care in the VHA. In the first 24 months of screening, the reminder identified over 77,000 Veterans across the country that reported FI. Little is known, however, about the variation in screening across VA sites; how sites respond when a Veteran screens positive for FI; or what VHA practices following a positive screen best improve Veteran food security status, Veteran experiences of care, and health outcomes. This proposed application would address these knowledge gaps. Innovativeness: Although VHA has begun to address social determinants of health more broadly, efforts to address FI are still in their nascency. This proposal, and the future area of research it will foster, is innovative because it seeks to develop novel VA-community partnerships that address key social determinants of health contributing to adverse health outcomes. This proposal further innovates through its emphasis on multi-level stakeholder engagement including strong Veteran engagement, and seeking Veteran-centered approaches to addressing food insecurity. Specific Aims: My long-term career goal is to become national leader in developing, evaluating, and implementing effective interventions to address Veteran FI and other social determinants of health. Through this CDA-2 application, I will build upon my prior training in family medicine and health services research to acquire advanced skills in implementation science, intervention design, and mixed methods evaluation. I propose the following research aims: Aim 1: Examine variation across VA sites nationally in implementation of the FI clinical reminder and characterize implementation experiences and community referral processes; Aim 2: Understand Veteran experiences of FI and their interactions with VA and community resources following a positive FI screen; Aim 3: Develop and pilot test an intervention model to optimize screening and referral processes for connecting FI Veterans to relevant VA and community resources. Methodology: This proposal employs a multistage mixed methods framework with integrated analyses across aims. Next Steps: When completed, this proposed work will evaluate current approaches to Veteran FI and identify and pilot strategies to integrate VHA-community partnered interventions to address FI into clinical practice. Findings will lay the foundation for a future IIR to conduct a multi-site trial of an intervention model. Further, the proposed research and training will help launch my career as an independent physician-investigator committed to providing a rigorous, scientific basis for reducing Veteran FI and related social determinants of health in a way that is Veteran-centered, maximizes patient autonomy, and optimizes health outcomes.