Patient-Centered Health Reform: Designing Engagement Interventions for ACOs

描述(由申请人提供)：责任护理组织(ACO)是最近的一项医疗改革，旨在以更低的成本提供更高质量的医疗服务。自2012年开始以来，Medicare ACO已经覆盖了500多万名患者。在ACOS中，临床医生和/或医院与付款人签订合同，分担对患者健康结果和支出的责任。有效地让患者参与ACOS将是他们成功的关键。利用以患者为中心的结果研究(PCOR)参与框架，该项目提出了一种新的系统级患者参与调查，定义为将患者的偏好、价值观和优先事项整合到医疗保健组织的设计和治理中。医疗保险条例要求在ACO领导委员会中有一名“受益代表”，作为系统级参与的一部分。目前尚不清楚这是否能有效地代表所有ACO患者，而且ACOs可以灵活地开发新的方法。这项建议结合定性和定量研究，以引出患者对系统水平参与的偏好，以填补这一知识空白，并设计一种新的患者参与干预。在学术医疗中心领导的联邦医疗保险ACO内工作，它将实现四个目标：AIM1将定义ACO使用的现有参与战略的分类，并从ACO领导人那里收集关于这些战略的丰富定性数据(例如，关于成功和挑战)。AIM2将引起受益代表对系统级参与的看法。从AIMS1-2获得的信息将被传播，以帮助ACOS不断开发系统级的参与方法。它还将向AIM3提供信息，这将引起患者对系统级参与的表达偏好，并通过对5个城市ACO的深入研究评估他们对ACO的知识和态度。来自AIMS1-3的信息将被用来设计一种新的系统级参与战略，并评估其在AIM4中的可行性。候选人是约翰霍普金斯大学普通内科(GIM)和伯曼生物伦理学研究所的助理教授。他的长期职业目标是成为一名独立的临床医生调查员，其创新的PCOR通过合乎道德的设计和有意义的患者参与来增强患者的护理体验，改善健康结果，并降低成本。作为一名接受哲学博士培训的执业内科医生，他有着独特的背景，并于2013年完成了GIM、生物伦理和卫生政策方面的联合奖学金。在短期内，他寻求为PCOR提供必要的额外培训，重点是先进的定性方法、调查设计以及患者参与的理论和实践。他的职业发展计划通过约翰霍普金斯大学彭博公共卫生学院的授课课程、实践研究经验和强大的多学科指导团队来满足他独特的培训需求，该团队由PCOR、患者参与、医疗体系改革和ACO方面的专业知识组成。导师团队包括Jeremy Sugarman博士、Albert Wu博士、Ruth Faden博士、Gerard Anderson博士和Scott Berkowitz博士。该项目的机构环境包括约翰霍普金斯大学的几个研究所和中心。首先是约翰霍普金斯大学伯曼生物伦理学研究所(BI)，它是国际公认的医学、公共卫生和卫生政策伦理实证研究的领先者。BI最近的研究重点包括以患者为中心的结果研究所(PCORI)资助的对利益相关者对比较有效性研究(CER)的看法的评估，以及在国家卫生研究院(NIH)医疗保健系统研究合作实验室(Jeremy Sugarman)内引发利益相关者观点的研究(都是在Ruth Faden的领导下)，以及努力让利益相关者参与到学习卫生系统的行动中。第二个是GIM分部，为90多名具有不同研究兴趣的教职员工提供支持。GIM是一个异常活跃的部门，在成功培训初级教员方面有着良好的记录。它包括一个GIM方法核心，提供研究咨询服务，如研究设计和统计分析。第三是约翰霍普金斯大学彭博公共卫生学院(JHBSPH)，它是公共卫生研究和教育的国际领先者。JHBSPH是卫生服务和结果研究中心(CHSOR)的所在地，由阿尔伯特·吴领导。CHSOR致力于研究卫生服务的组织和筹资，包括其对护理质量和成本的影响，最近的重点是PCOR、CER和患者参与。JHBSPH也是医院财务和管理中心(由Gerard Anderson领导)的所在地，该中心专门从事与政策相关的研究，涉及支付改革和其他降低医疗成本的方法。机构环境的最后一个关键部分是约翰·霍普金斯患者医学联盟 约翰霍普金斯医疗保险ACO(JMAP)，于2013年12月获得批准。与JMAP及其执行董事Scott Berkowitz合作，提供了实时研究ACOS参与度的机会，并确保该项目解决ACO实施所关注的问题。该项目协同整合了这些机构组成部分，并将其应用于一种新的卫生保健系统改革背景：系统级患者参与ACOs。它的发现--尽管ACO重点关注--将与卫生系统改革总体相关，并为未来的PCOR研究提供坚实的基础，以检验不同系统层面参与战略在健康结果、患者满意度和成本方面的比较有效性。

DESCRIPTION (provided by applicant): Accountable care organizations (ACOs) are a recent health reform that seeks to provide higher quality care at lower cost. Since starting in 2012, Medicare ACOs already cover more than 5 million patients. In ACOs, clinicians and/or hospitals contract with payers to share accountability for patients' health outcomes and expenditures. Effectively engaging patients in ACOs will be critical to their success. Using a patient centered outcomes research (PCOR) engagement framework, this project proposes a novel investigation of system- level patient engagement, defined as integrating patients' preferences, values, and priorities into the design and governance of health care organizations. Medicare regulations require a "beneficiary representative" on ACO leadership boards as part of system-level engagement. Whether this effectively represents all ACO patients remains unknown, and ACOs have flexibility to develop novel methods. This proposal integrates qualitative and quantitative research to elicit patient preferences about system-level engagement in order to fill this knowledge gap and design a new patient engagement intervention. Working within Medicare ACOs led by academic medical centers, it will accomplish four aims: AIM1 will define a taxonomy of existing engagement strategies in use by ACOs and collect rich qualitative data about these strategies (e.g., regarding successes and challenges) from ACO leaders. AIM2 will elicit beneficiary representatives' perceptions of system-level engagement. The information gained from AIMS1-2 will be disseminated to assist ACOs' ongoing development of system-level engagement methods. It will also inform AIM3, which will elicit patients' expressed preferences regarding system-level engagement and assess their knowledge and attitudes toward ACOs via an in-depth study of 5 urban ACOs. Information from AIMS1-3 will be used to design a novel system-level engagement strategy and evaluate its feasibility in AIM4. The candidate is an Assistant Professor at Johns Hopkins in the Division of General Internal Medicine (GIM) and the Berman Institute of Bioethics. His long-term career goal is to become an independent clinician investigator whose innovative PCOR enhances patients' experiences of care, improves health outcomes, and lowers costs through ethically-designed, meaningful patient engagement. He has a unique background as a practicing internist with PhD training in philosophy who in 2013 completed a joint fellowship in GIM and bioethics and health policy. In the short-term, he seeks additional training necessary for PCOR, focusing on advanced qualitative methods, survey design, and the theory and practice of patient engagement. His career development plan meets his unique training needs via didactic courses at the Johns Hopkins Bloomberg School of Public Health, practical research experience, and a strong multi-disciplinary mentorship team comprising expertise in PCOR, patient engagement, health system reform, and ACOs. The mentorship team includes Drs. Jeremy Sugarman, Albert Wu, Ruth Faden, Gerard Anderson, and Scott Berkowitz. The institutional environment for the project includes several institutes and centers at Johns Hopkins. First is the Johns Hopkins Berman Institute of Bioethics (BI), an internationally recognized leader in empirical research on the ethics of medicine, public health, and health policy. Recent emphases of BI research include a Patient-Centered Outcomes Research Institute (PCORI) funded evaluation of stakeholder views of comparative effectiveness research (CER) and an effort at engaging stakeholders in the move toward Learning Health Systems (both under Ruth Faden), as well as research eliciting stakeholder views within the National Institutes of Health (NIH) Health Care Systems Research Collaboratory (under Jeremy Sugarman). Second is the Division of GIM, which supports over 90 faculty members with diverse research interests. GIM is an exceptionally active division with a track record of successfully training junior faculty. It includes a GIM Methods Core that provides research consulting services, such as study design and statistical analysis. Third is the Johns Hopkins Bloomberg School of Public Health (JHBSPH), an international leader in public health research and education. JHBSPH is home to the Center for Health Services and Outcomes Research (CHSOR, directed by Albert Wu). CHSOR is devoted to research on the organization and financing of health services, including their impact on care quality and costs, with a recent focus on PCOR, CER, and patient engagement. JHBSPH is also home to the Center for Hospital Finance and Management (directed by Gerard Anderson), which specializes in policy-relevant research on payment reform and other approaches to reducing health care costs. A final key part of the institutional environment is the Johns Hopkins Medicine Alliance for Patients (JMAP), the Johns Hopkins Medicare ACO, which was approved in December 2013. Collaborating with JMAP and its executive director, Scott Berkowitz, affords the opportunity to study engagement in ACOs real-time and to ensure the project addresses issues of concern to ACO implementation. This project synergistically integrates these institutional components and applies them to a novel health care system reform context: system-level patient engagement in ACOs. Its findings - though ACO focused - will be relevant to health system reform generally and provide a strong foundation for future PCOR studies examining the comparative effectiveness of different system-level engagement strategies in terms of health outcomes, patient satisfaction, and costs.