Using Data Analytics and Targeted Whole Health Coaching to Reduce Frequent Utilization of Acute Care among Homeless Veterans

背景：10%的患者承担了高达70%的急性护理费用。在这些“超级利用者”中 对于患者来说，无家可归是急性护理利用的一个强有力的社会决定因素。通过基于字段的 控制面板和临床辅助工具，热点分析计划帮助患者对齐的护理团队(PACT) 针对最需要的无家可归退伍军人进行针对性护理。然而，许多退伍军人被确认为 分析不参与降低急性护理利用风险的支持性服务。同行专家(PS) 是一支高价值的劳动力队伍，可以促进退伍军人参与护理。然而，有必要加强 PS角色具有结构化的方法，可以利用已知的护理参与促进者 无家可归的退伍军人。整体健康指导(WHC)就是这样一种方法。通过关注患者的价值观和 目标而不是针对特定疾病的治疗，WHC减少了患者对其护理需求的耻辱 并增加患者的活跃度和幸福感，这可以增加对支持性服务的参与度。 意义：通过以患者为中心的护理方法培训高价值的劳动力，从而促进 参与支持服务，我们建议的研究可以减少无家可归的退伍军人对急性 护理服务，从而最大限度地减少这些患者对护理系统造成的经济负担。这项建议 对退伍军人事务部HSR&D研究的几个优先事项做出回应，包括心理健康、医疗价值、初级保健 实践、医疗信息学和整体健康，以及退伍军人事务部相关的立法优先事项(使命法)。 创新和影响：这项研究的一个关键创新是使用数据驱动的流程(热点 分析)，以更好地针对VHA的高需求、无家可归的退伍军人并为其量身定做护理。我们建议的研究是 同样具有创新性的是，它寻求将分析与员工(PS)和护理方法(WHC)相集成 在退伍军人事务部范围内的初级保健服务方面正在迅速扩大。我们目标干预的这些特点是 符合美国国家医学研究院对高需求人群提供高质量护理的建议 病人。最后，通过专注于制定与患者的个人健康目标相一致的个人健康目标 在优先事项和价值方面，WHC是一项关键创新，将添加到现有的VHA服务，为无家可归的退伍军人。 具体目标：该项目的目标是将HotSpotter Analytics的使用与培训的同行专家相结合 在整体健康指导(PS-WHC)中，并评估这种方法是否会减少无家可归的退伍军人 经常使用急诊护理。目标1：进行RCT以测试是否收到PS-WHC(与增强的平时 护理；EUC)预测(1a)更低的急性护理利用率，(1b)更好的健康相关结果，以及(1c) PS-WHC对1a和1b的影响是通过增加(I)患者的活跃度和幸福感，以及(Ii) 获得支持性服务。目标2：进行流程评估，告知退伍军人管理局潜在的广泛性 热聚焦分析+PS-WHC在PACTS上的实施。目标3：进行预算影响分析(BIA) 确定实施PS-WHC对退伍军人管理局护理总成本的影响。 方法：在帕洛阿尔托和贝德福德VAS使用混合类型1设计，220名退伍军人参加PACT小组 谁是(I)在退伍军人事务部无家可归者登记处，和(Ii)持续的急性护理超级使用者将完成 基线访谈，随机分为EUC(常规契约护理+热点分析和文本提醒 预约)或EUC加上12周的PS-WHC会议，并在3、6和9重新面谈 月份。对于目标2，CFIR框架将指导与7名PACT工作人员/领导人和12名PACT工作人员/领导人的主要线人面谈 每个地点的病人。对于BIA，我们将只包括来自VA、费用基础护理和选择护理的VA成本。 从随机化开始，持续9个月，将估计每个患者的治疗费用。 下一步/实施：根据结果，我们将与我们的VACO合作伙伴在全国 退伍军人无家可归中心，以病人为中心的护理和文化转型办公室，以及 心理健康和自杀预防办公室进行了一项大型多地点实施试验。

Background: Ten percent of patients account for up to 70% of acute care costs. Among these “super-utilizer” patients, homelessness is a robust social determinant of acute care utilization. Through a field-based dashboard and clinical aids, the Hot Spotter Analytic program assists Patient Aligned Care Teams (PACT) with targeting and tailoring care for the highest-need homeless Veterans. However, many Veterans identified by the Analytics do not engage in supportive services that reduce risk for acute care utilization. Peer Specialists (PS) are a high-value workforce that can facilitate Veterans’ engagement in care. Yet, there is a need to enhance the PS role with a structured approach that can capitalize on known facilitators of care engagement among homeless Veterans. Whole Health Coaching (WHC) is one such approach. By focusing on patients’ values and goals rather than treatment of specific conditions, WHC reduces patients’ stigma regarding their care needs and increases patient activation and well-being, which can increase engagement in supportive services. Significance: By training a high-value workforce in a patient-centered approach to care that facilitates engagement in supportive services, our proposed research can reduce homeless Veterans’ reliance on acute care services, thereby minimizing the financial burden these patients exert on the care system. This proposal responds to several VA HSR&D Research Priorities including Mental Health, Healthcare Value, Primary Care Practice, Healthcare Informatics, and Whole Health, as well as VA-related Legislative Priorities (MISSION Act). Innovation and Impact: A critical innovation of this research is use of data-driven processes (Hot Spotter Analytics) to better target and tailor care for high-need, homeless Veterans in VHA. Our proposed research is also innovative in that it seeks to integrate the Analytics with a workforce (PS) and approach to care (WHC) that are rapidly expanding in primary care services VA-wide. These features of our target intervention are consistent with the National Academy of Medicine’s recommendations for high-quality care for high-need patients. Finally, by focusing on the development of personal health goals that are aligned with patients’ priorities and values, WHC is a key innovation to be added to existing VHA services for homeless Veterans. Specific Aims: The goal of this project is to integrate use of Hot Spotter Analytics with Peer Specialists trained in Whole Health Coaching (PS-WHC) and evaluate whether this approach reduces homeless Veterans’ frequent use of acute care. Aim 1: Conduct an RCT to test whether receipt of PS-WHC (vs. Enhanced Usual Care; EUC) predicts (1a) lower acute care utilization, (1b) better health-related outcomes, and whether (1c) the effects of PS-WHC on 1a and 1b are mediated by increased (i) patient activation and well-being, and (ii) access to supportive services. Aim 2: Conduct a process evaluation to inform VA's potential widespread implementation of Hot Spotter Analytics + PS-WHC on PACTs. Aim 3: Conduct a Budget Impact Analysis (BIA) to determine the impact on total costs of VA care due to implementing PS-WHC. Methodology: Using a Hybrid Type 1 design at the Palo Alto and Bedford VAs, 220 Veterans on PACT panels who are (i) on the VA Homeless Registry, and (ii) persistent super-utilizers of acute care will complete a baseline interview, be randomized to either EUC (usual PACT care + Hot Spotter Analytics and text reminders of appointments) or EUC plus 12 sessions of PS-WHC over 12 weeks, and be re-interviewed at 3, 6, and 9 months. For Aim 2, the CFIR framework will guide key informant interviews with 7 PACT staff/leaders and 12 patients from each site. For the BIA, we will include only VA costs from VA, Fee Basis care, and Choice care. Costs will be estimated per patient for all treatment beginning with randomization and continuing for 9 months. Next Steps/Implementation: Depending on the results, we will work with our VACO partners in the National Center for Homelessness Among Veterans, the Office of Patient Centered Care & Cultural Transformation, and the Office of Mental Health & Suicide Prevention to conduct a large multisite implementation trial.