Empowering Formerly Homeless Older Adults to Engage in Advance Care Planning in Permanent Supportive Housing (ACP-PSH): An RCT

项目总结/摘要 背景：无家可归的人口正在老龄化，50岁以上的人越来越多， 经历加速老化，高死亡率，以及高风险的不尊重他们的愿望， 生命的终结高级护理计划（ACP）旨在引起患者的医疗偏好;然而，无家可归的老年人 ACP的发生率低。重大的政策关注集中在将长期无家可归的人重新安置到 永久性支助性住房（PSH），提供自愿支助服务的补贴永久性住房。我们 先前的研究表明PSH可能是启动ACP的理想环境;然而，没有研究表明 在机场核心计划内雇用了前无家可归的公屋居民。我们的团队为您的护理创建了 （AEE）-一个易于使用的，以证据为基础的，在线ACP计划与视频故事。该程序包括 易于阅读的预先指示、非加太集团参观指南和非加太一对一便利指南。通过 在之前的R34中，我们建立了社区咨询委员会（CAB），并共同确定了初步的适应性调整 为PSH设置提供支持。该项目需要一个最终的共同开发过程， 无家可归的老年PSH居民和工作人员以及我们的CAB。该提案的目的是共同开发 准备PSH，并在以前的患者中比较促进组与一对一访视的有效性 长期无家可归的老年人。目的：我们将（1）与PSH居民共同开发PREPARE-PSH， 工作人员和我们的CAB;（2）进行混合（NIH第三阶段疗效/有效性），1型，双臂，集群 比较PREPARE-PSH程序的两种递送策略的有效性的随机试验（即， ACP电影和易于阅读的广告）-促进小组与一对一的访问;以及（3）探索实施- 与ACP参与和ACP在PSH中的可持续性相关的相关因素。方法：在目标1中， 通过与20名PSH进行深入访谈和焦点小组讨论，参与严格的共同开发过程 居民和CAB。我们将使用一个理论知情的框架（即，行为改变轮（BCW））和 定性内容分析，共同创建一个PREPARE-PSH计划。关于目标2，咨询委员会指出， 与一对一的访问相比，规模化可能更可行，并要求我们按研究中心随机分配，这样居民就不会 感觉被“排除”在替代干预之外。因此，我们将进行混合（NIH阶段III） 疗效/有效性），比较PREPARE-PSH给药与 使用混合效应模型的促进组与一对一访问。随机化将在研究中心水平进行， 按网站大小平衡。在目标3中，我们将有目的地对目标2的参与者进行深入访谈（n=40-50）， 与PSH工作人员（n=40）进行焦点小组讨论，并从CAB成员（总共n=15）获得意见。我们将探讨 （a）非加太集团参与程度和可持续性的高低 使用《生物多样性公约》和《实施研究综合框架》模型编制《生物多样性和海洋环境保护方案》。 与NIH和公共卫生的相关性：PREPARE-PSH可能会减少ACP患者的健康差异 长期无家可归的老年人

PROJECT SUMMARY/ABSTRACT Background: The homeless population is aging, with an increasing proportion of individuals over age 50 who experience accelerated aging, high rates of mortality, and a high risk of not having their wishes honored at the end of life. Advance care planning (ACP) aims to elicit patients’ medical preferences; yet older homeless adults have low rates of ACP. Significant policy attention has focused on rehousing chronically homeless people into Permanent Supportive Housing (PSH), subsidized permanent housing with voluntary supportive services. Our previous research indicates that PSH may be the ideal setting to initiate ACP; however, no studies have engaged formerly homeless PSH residents in ACP. Our team has created PREPARE for Your Care (PREPARE) – an easy-to-use, evidence-based, online ACP program with video stories. This program includes easy-to-read advance directives, an ACP group visit guide, and an ACP one-on-one facilitation guide. Through a prior R34, we developed a Community Advisory Board (CAB) and together identified preliminary adaptations to PREPARE for the PSH setting. The project requires a final co-development process with formerly chronically homeless older PSH residents and staff and our CAB. The objective of this proposal is to co-develop PREPARE-PSH and compare the effectiveness of facilitated group versus one-on-one visits among formerly chronically homeless older adults in PSH. Aims: We will (1) co-develop PREPARE-PSH with PSH residents, staff, and our CAB; (2) conduct a Hybrid (NIH Stage III efficacy/effectiveness), Type 1, two-arm, cluster randomized trial comparing the effectiveness of two delivery strategies of the PREPARE-PSH program (i.e., ACP movies and easy-to-read ADs) – facilitated group vs. one-on-one visits; and (3) explore implementation- relevant factors associated with ACP engagement and sustainability of ACP in PSH. Methods: In Aim 1 we will engage in a rigorous co-development process through in-depth interviews and focus groups with 20 PSH residents and the CAB. We will use a theory-informed framework (i.e., Behavior Change Wheel (BCW)) and qualitative content analysis to co-create a PREPARE-PSH program. For Aim 2, the CAB noted that groups may be more feasible to scale vs. one-on-one visits and asked us to randomize by site so residents would not feel “left out” of the alternate intervention. Therefore, we will conduct a Hybrid (NIH Stage III efficacy/effectiveness), Type 1 cluster randomized trial comparing delivery of PREPARE-PSH through facilitated groups vs. one-on-one visits using mixed effects models. Randomization will be at the site level, balanced by site size. In Aim 3 we will purposively sample Aim 2 participants for in-depth interviews (n=40-50), conduct focus groups with PSH staff (n=40), and obtain input from CAB members (total n=15). We will explore implementation-relevant factors associated with: (a) high and low ACP engagement and sustainability of PREPARE-PSH using the BCW and the Consolidated Framework for Implementation Research (CFIR) model. Relevance to NIH and public health: PREPARE-PSH may reduce health disparities in ACP among formerly chronically homeless older adults.