Integrated Online Assessment and Intervention Targeting Health Disparities

说明(由申请人提供)：社会经济和其他因素，如种族、民族、收入、教育和居住地，与获得更少和质量更差的医疗保健有关。为弱势人群服务的临床医生经常超负荷工作，几乎没有机会收集对患者的全面生物医学和心理社会(生物心理社会，BPS)评估。这种情况是不幸的，因为许多身体症状是医学上无法解释的，反映了一种高度症状报告或潜在的心理社会问题的模式，如抑郁、创伤或难以忍受的压力。对于来自弱势人群的患者来说，这些BPS因素尤其成问题。最后，严重的、医学上无法解释的症状、心理社会问题和糟糕的生活质量(QOL)共同出现在高危个体(ARI)的子集中，这一子集约占典型临床人群的20%。ARI面临因不适当的护理而产生不良结果和高昂费用的风险，这一问题在弱势群体和少数群体中更加严重，在这些人群中，获得初级保健的机会有限，紧急护理比预防性护理更普遍。解决方案：我们的目标是部署临床方法和基础设施，以确保向少数族裔和弱势患者提供以患者为中心的护理。我们的工作建立在名为CarePrep的在线患者自我评估系统的基础上，该系统现已投入临床使用。CarePrep允许患者在家中或诊所通过互联网轻松输入和跟踪BPS和QOL数据。然而，例如，仅仅将抑郁症的诊断交给临床医生并不能改变结果。因此，我们还将部署综合干预措施来支持BPS护理。方法：1)我们将适应、增强文化敏感性，在初级保健环境中部署、改进和初步验证CarePrep。我们的目标是满足患者和临床医生加强沟通和以患者为中心的护理的需求，确保BPS问题被发现。患者将被要求在临床前做好护理准备。我们将评估CarePrep的有效性、可行性以及CarePrep根据严重症状、心理社会问题、生活质量受损或药物滥用等发现准确识别需要额外关注(ARI)的患者的能力。2)我们将分析和制定一项计划，使用自动化CarePrep功能、培训和支持护理经理或现有诊所工作人员提供简单、简短的BPS干预和远程医疗支持的某种组合，来支持具有文化能力的BPS护理。影响来自1)创建一个对患者、临床医生和管理人员产生足够价值的系统，以保证常规使用；2)创建简化的分支评估，最大限度地减少冗余和最大化相关性，从而支持收集全面的相关数据并提供与背景相关的教育和指导；3)使用这种技术和临床方法来跨越照顾少数群体和弱势群体的障碍；4)识别、描述并针对这类人群中最需要和最高利用率的患者进行护理，从而促进有限的医疗资金的经济高效地使用。 公共卫生相关性：这项工作采用了目前在临床上运行的在线患者自我评估系统，以支持为少数族裔和弱势患者提供以患者为中心的护理。我们专注于帮助临床医生护理患有多种严重身体症状、心理和健康行为问题的患者，这些问题干扰了他们的生活质量和功能能力，因为这些患者现在的结果最差，消耗的资源比例不成比例。在弱势群体和少数群体中，这些结果可能会更糟，因为他们获得初级保健的机会有限，紧急护理比预防性护理更为普遍。我们的在线系统收集全面的评估并提供数据，以便临床医生能够快速确定最重要的问题。然而，仅仅提供这些信息是不够的；我们还建议通过组合在线系统来支持护理，卸载临床医生的任务，培训和支持护理经理或临床医生帮助评估和治疗，以及在需要的地方提供远程医疗支持。

DESCRIPTION (provided by applicant): Socioeconomic and other factors such as race, ethnicity, income, education, and place of residence are associated with reduced access to and poorer quality healthcare. Clinicians serving disadvantaged populations are often overloaded, and have little chance to gather a comprehensive biomedical and psychosocial (biopsychosocial, BPS) evaluation of patients. This situation is unfortunate because many physical symptoms are medically unexplained, reflecting a pattern of high symptom reporting or underlying psychosocial issues, such as depression, trauma, or poorly-tolerated stress. These BPS factors are particularly problematic for patients from disadvantaged populations. Lastly, severe, medically unexplained symptoms, psychosocial issues, and poor quality of life (QOL) occur together in a subset of at-risk individuals (ARI), which comprises about 20% of typical clinic populations. ARI are at risk for poor outcomes and high costs from inappropriate care, a problem that is compounded in disadvantaged and minority populations where access to primary care is limited and urgent care is more prevalent than preventive care. SOLUTION: Our objective is to deploy a clinical methodology and infrastructure to ensure delivery of patient-centered care to minority and disadvantaged patients. Our work builds on an online, patient self-assessment system called CarePrep, now operational in clinic. CarePrep allows patients to easily enter and track BPS and QOL data over the Internet from home or clinic. However, just handing a diagnosis of depression, for example, to a clinician does not change outcomes. Therefore, we will also deploy an integrated intervention to support BPS care. APPROACH: 1) We will adapt, enhance cultural sensitivity, deploy, refine, and initially validate CarePrep in a primary care setting. Our goals are to meet the needs of patients and clinicians for enhancing communication and patient- centered care, ensuring that BPS issues are uncovered. Patients will be asked to do CarePrep before clinic. We will assess validity, feasibility, and CarePrep's ability to accurately identify patients who warrant extra attention (ARI) by findings such as severe symptoms, psychosocial issues, impaired QOL, or substance abuse. 2) We will analyze and develop a plan for supporting culturally competent, BPS care using some combination of automated CarePrep functionality, training and supporting care managers or existing clinic staff in delivering simple, brief BPS interventions, and telehealth support. IMPACT stems from 1) creating a system that generates sufficient value to patients, clinicians, and administrators to warrant routine use; 2) creating a streamlined, branching assessment that minimizes redundancy and maximizes relevance, thereby supporting collection of the full spectrum of relevant data and delivery of context-relevant education and guidance; 3) using this technology and clinical methodology to transcend barriers to care for minorities and disadvantaged populations, and 4) identifying, characterizing, and targeting care to the patients with the greatest need and highest utilization within such populations, thereby facilitating cost-effective use of limited healthcare dollars. PUBLIC HEALTH RELEVANCE: This work adapts an online, patient self-assessment system now in operation in clinic to support delivery of patient-centered care for minority and disadvantaged patients. We focus on helping clinicians care for patients with multiple, severe physical symptoms, psychosocial, and health behavioral issues that interfere with their quality of life and ability to function, because these patients now have the poorest outcomes and consume a disproportionate share of resources. These outcomes are likely to be worse in disadvantaged and minority populations where access to primary care is limited and urgent care more prevalent than preventive care. Our online system gathers a comprehensive assessment and presents the data so that clinicians can rapidly identify the most important issues. However, simply delivering this information is not enough; we also propose to support care by a combination of the online system offloading clinician tasks, training and supporting care managers or clinicians to help in assessment and treatment, and delivering telehealth support where needed.