Optimizing Outcomes in Home-Based Primary Care

目标：这项提议是为了CDA-2指导培训计划，该计划将使塞缪尔·爱德华兹，医学博士， 公共卫生硕士成为一名独立的退伍军人健康服务研究员，他在设计、功能和 医疗和社会复杂退伍军人护理模式的评估。该计划的总体目标 研究计划是探索退伍军人家庭初级保健(HBPC)的哪些特点推动其成功地减少 对门诊护理敏感情况的住院治疗，并利用这些见解制定干预措施 推广HBPC的最佳做法。 研究计划：爱德华兹博士将使用混合方法进行三项研究。研究方法将 参考有关患者复杂性、初级护理的核心特征和慢性护理模式的文献。这个 拟议研究的具体目标是：1)描述以下方面的登记和提供护理的模式 HBPC，并确定可预防住院的临床和系统相关性，2)评估HBPC 提供者对适当的患者选择和护理提供模式的看法，HBPC的核心功能，以及 HBPC绩效的障碍和促进者，以及3)开发和测试试点干预措施，以促进最佳 在HBPC的实践。 方法：目标1和目标2将包括一项探查HBPC患者的解释性序贯混合方法研究 HBPC的选择、护理提供模式、核心功能。目标1，是一项由四项组成的定量研究 对全国VHA数据进行二次分析，以(1)确定登记参加HBPC的预测因素，(2)定义临床 HBPC患者的亚组，(3)描述HBPC内的护理提供模式，以及(4)确定 门诊护理敏感住院的患者亚群和护理提供模式。目标2是2 阶段定性研究。在第一阶段，我们将使用以下工具对我们的本地HBPC计划进行深入研究 访谈、焦点小组和结构化观察。第二，我们将对节目导演进行采访 在HBPC的其他项目中，以更广泛地了解网站之间的差异。在这两个阶段，我们都将 了解患者选择流程、适当的护理提供模式以及 HBPC的核心职能集中在5个拟议领域：1)牢固的提供者-患者关系，2)药物 管理3)处理健康的社会决定因素，4)整合姑息治疗，5)协调 关爱。我们还计划探索供应商对HBPC性能的障碍和促进者的观点。 最后，目标3将是制定一项试点干预措施，以促进从以下方面学习的HBPC的最佳做法 目标1和目标2，将在本地进行试验。我们将同时进行一次形成性评估 关于可接受性和可行性，并初步考察了有效性。预期的结果将是初步的 数据支持在多个HBPC站点测试精细化干预的多中心试验。 职业规划：爱德华兹博士是一名医生兼调查员，接受过医疗服务研究方法和 在初级保健重新设计、基于团队的护理和HBPC方面的专业知识。这一建议将深化他的理论 理解、内容专业知识和研究技能。具体的培训领域是：1)质量和 可应用于卫生服务研究的混合方法方法的高级量化技能；2) 患者复杂性和基于家庭的初级保健方面的内容专业知识；以及3)实施科学和 干预性发展。培训计划将由课程作业、研讨会和阅读材料组成，由 导师团队。最终，这些努力将有助于爱德华兹博士实现他成为一名国民 在针对医学和社会复杂的退伍军人进行研究和测试护理模式方面处于领先地位。

Objective: This proposal is for a CDA-2 mentored training program that will transition Samuel Edwards, MD, MPH into an independent VA health services researcher who has special expertise in the design, function and evaluation of care models for medically and socially complex Veterans. The overarching objective of the research plan is explore what features of VA Home Based Primary Care (HBPC) drive its success in reducing hospitalizations for ambulatory care sensitive conditions, and use these insights to develop an intervention to promote best practices in HBPC. Research Plan: Dr. Edwards will conduct three studies using mixed methods. The research approach will draw upon the literature on patient complexity, core features of primary care, and the chronic care model. The Specific Aims of the proposed research are to: 1) Characterize patterns of enrollment and care delivery within HBPC, and determine clinical and systems correlates of preventable hospitalizations, 2) Assess HBPC providers perceptions of appropriate patient selection and care delivery patterns, core functions of HBPC, and barriers and facilitators to HBPC performance, and 3) Develop and test a pilot intervention to promote best practices in HBPC. Methods: Aims 1 and 2 will consist of an explanatory sequential mixed methods study exploring HBPC patient selection, care delivery patterns, core functions of HBPC. Aim 1, is a quantitative study consisting of four secondary analyses of national VHA data to (1) determine predictors of enrollment in HBPC, (2) define clinical subgroups of HBPC patients, (3) describe care delivery patterns within HBPC, and (4) determine association of patient subgroups and care delivery patterns with ambulatory care sensitive hospitalizations. Aim 2 is a two phase qualitative study. In the first phase, we will perform an in depth study of our local HBPC program using interviews, focus groups and structured observation. Second, we will perform interviews with program directors at other HBPC programs to gain a broader understanding of differences between sites. In both phases we will explore perceptions of the patient selection process, appropriate care delivery patterns, and the importance of core HBPC functions focusing on 5 proposed domains: 1) strong provider-patient relationships, 2) medication management 3) addressing social determinants of health, 4) integration of palliative care, and 5) coordination of care. We also plan to explore provider perspectives on barriers and facilitators on HBPC performance. Finally, Aim 3 will be the development of a pilot intervention to promote best practices in HBPC learned from Aims 1 and 2, which will be tested locally in a trial. We will perform a formative evaluation concurrently focused on acceptability and feasibility, with a preliminary look at efficacy. The expected outcome will be preliminary data to support a multicenter trial of a refined intervention to be tested at multiple HBPC sites. Career Plan: Dr. Edwards is a physician-investigator with training in health services research methods and expertise in primary care redesign, team based care, and HBPC. This proposal will deepen his theoretical understanding, content expertise, and research skills. Specific areas for training are: 1) Qualitative and advanced quantitative skills that can be applied to mixed methods approaches in health services research; 2) Content expertise in patient complexity and home based primary care; and 3) Implementation science and intervention development. The training plan will consist of coursework, seminars, and readings guided by the mentorship team. Ultimately, these efforts will assist in Dr. Edwards reaching his goal of becoming a national leader in conducting research and testing care models directed at medically and socially complex Veterans.