Maintaining Preventive Care during Public Health Emergencies through Effective Coordination

背景资料。筛查是预防保健的核心。然而，新冠肺炎已经戏剧性地颠覆了 常规筛查工作，导致退伍军人死亡率过高，与新冠肺炎没有直接关系。筛选 COVID期间VA的发生率因设备和临床条件的不同而有显著差异。这一点在癌症中得到了说明 和心理健康筛查；每一个都存在跨设施的差异性，这表明能力上的易感性 以及筛选和推荐过程的工作流程。为了更好地了解这些易感性并确定 为了减少中断的护理，我们提出了一项定性研究，对展示的设施进行比较 大流行前和大流行期间筛查率(分别为高、低和高度可变)。 意义重大。对预防性筛查的干扰会导致退伍军人死亡率过高。因此，关爱 退伍军人在履行第四使命(应急准备)时的常规初级保健(PC)需求 需要所有临床人员的一流协调和灵活的团队合作。我们的研究将确定 区分初级和专科护理的系统战略和协调模式 成功的设施来自苦苦挣扎的设施。我们的发现将有助于设计新的或调整现有的工作流程 协调的干预措施，决定筛查和预防护理在期间和之后的提供方式 新冠肺炎。我们的研究直接涉及：a)本次征集的目标；b)HSR&D的临床优先事项；c)退伍军人事务部 高度可靠的保健的战略计划目标；和d)或现实世界研究影响的优先事项。 明确的目标。以癌症和精神健康筛查率为样本，我们建议(1)比较 VHA设施的不同筛选性能模式(高、低、改善、暴跌、 变量)在新冠肺炎大流行期间协调(A)作为一个团队进行筛查服务，(B)与 专科护理团队在其设施中进行筛查服务；以及(2)比较团队、设施和系统- 新冠肺炎大流行期间持续筛查服务的障碍、促进者和战略 在此期间，来自VHA设施的不同筛查性能模式的协议中。 方法。设计和参与者。这项多方法研究包括定性分析的访谈和 由10个退伍军人医疗中心(VAMC)的初级保健人员、领导层和患者组成的焦点小组。 选址。我们将使用基于场地乡村性的有目的的分层方法来选择研究场地，新冠肺炎 大流行初期的工作量，以及五项门诊临床表现指标的表现 癌症和心理健康筛查。网站将被归类为五种放映表演之一 分组：高绩效、低绩效、改进型、垂直型和高度变化型。 程序。使用PI之前研究的数据，我们将为每项绩效创建流程图 制定基线措施，以便与大流行开始以来使用的进程进行比较。我们将采访 每个地点的初级保健ACO更新地图以反映当前使用的流程。我们会 与PC和相关的专业护理临床医生组成焦点小组，以引出有关临床医生的主题 COVID期间的协调模式(例如，移交)、战略和筛查障碍/促进者(目标1- 3)。我们亦会与病人面谈，以了解他们在这段期间的筛查经验。 背景。 数据分析：所有访谈和焦点小组都将被录音、转录，并通过实地笔记进行增强。 我们将使用迭代、快速分析来分析临床医生焦点小组记录和现场笔记。患者半- 结构化面试将使用归纳/演绎内容分析进行分析。 后续步骤/实施。我们将在当地分享我们的发现，包括针对特定站点的建议 在参与地点与主要利益攸关方合作，并在全国范围内通过初级保健-精神卫生办公室 整合计划和退伍军人全国女性肿瘤系统的卓越。

BACKGROUND. Screening lies at the heart of preventive care. However, COVID-19 has dramatically disrupted routine screening efforts, resulting in excess veteran mortality not directly attributable to COVID-19. Screening rates at VA during COVID have varied markedly by facility and clinical condition. This is illustrated in cancer and mental health screening; cross-facility variability exists for each, suggesting susceptibilities in the capacity and workflow of the screening and referral process. To better understand these susceptibilities and identify new practices to mitigate interrupted care, we propose a qualitative study comparing facilities that exhibited high, low, and highly variable performance (respectively) in screening rates before and during the pandemic. SIGNIFICANCE. Disruptions to preventive screening lead to excess veteran mortality. Therefore, caring for veterans’ regular primary care (PC) needs while fulfilling our Fourth Mission (emergency preparedness) requires top-notch coordination and nimble teamwork from all clinical personnel. Our study will identify the systematic strategies and coordination patterns between primary and specialty care that differentiate successful facilities from struggling ones. Our findings will help design new or adapt existing workflows and interventions for coordination, shaping how screening and preventive care is delivered during and beyond COVID-19. Our study directly addresses: a) this solicitation’s goals; b) HSR&D’s clinical priorities; c) VA’s strategic plan goals for highly reliable care; and d) ORD real-world research impact priorities. SPECIFIC AIMS. Using cancer and mental health screening rates as exemplars, we propose to (1) Compare how PACTs from VHA facilities of varying screening performance patterns (high, low, improving, plummeting, variable) during the COVID-19 pandemic coordinated (a) as a team to conduct screening services, and (b) with specialty care teams at their facility to conduct screening services; and (2) Compare team, facility, and system- based barriers, facilitators, and strategies for continuing screening services during the COVID-19 pandemic amongst PACTs from VHA facilities of varying screening performance patterns during that period. METHOD. Design and Participants. This multi-method study consists of qualitative analysis of interviews and focus groups with primary care personnel, leadership, and patients at 10 VA Medical Centers (VAMCs). Site Selection. We will select study sites using a purposive stratified approach based on site rurality, COVID-19 caseload at the beginning of the pandemic, and performance on five outpatient clinical performance indicators of cancer and mental health screening. Sites will be categorized into one of five screening performance groups: high performers, low performers, improvers, plummeters, and highly variable. Procedure. Using data from prior research by the PI, we will create process maps for each performance measure to create a baseline for comparison to the process used since the pandemic began. We will interview the ACOS for primary care at each site to update the map to reflect the currently used process. We will conduct focus groups with PC and relevant specialty care clinicians to elicit themes regarding clinician coordination patterns (e.g., handoffs), strategies, and barriers/facilitators to screening during COVID (Aims 1- 3). We will also conduct patient interviews to examine their screening experience during this period, for context. Data Analysis: All interview and focus groups will be audio-recorded, transcribed, and enhanced by field notes. We will analyze clinician focus group transcripts and field notes using iterative, rapid analysis. Patient semi- structured interviews will be analyzed using inductive/deductive content analysis. NEXT STEPS/IMPLEMENTATION. We will share our findings, including site-specific recommendations, locally with key stakeholders at participating sites, and nationally through the Office of Primary Care-Mental Health Integration program and the VA National Women Veterans Oncology System of Excellence.