Improving Communication Between Primary Care Providers and Their Trauma Patients

摘要创伤，尤其是人际暴力，与各种情绪抱怨、焦虑和抑郁障碍、人际问题以及医疗发病率的增加、预防保健的减少和医疗保健系统成本的增加有关。然而，与创伤有关的问题在培训提供者或初级保健机构中没有得到足够的重视，提供者感到没有准备好与这些患者一起工作。拟议的研究利用R34机制来适应和试点测试一种基于理论的实践方法，以有效地与创伤幸存者一起工作，即风险连接课程，适用于为低收入和少数族裔患者服务的初级保健提供者（pcp）。提出以下目标：1)调整现有的创伤幸存者治疗工作手册和培训课程，使其适合初级保健提供者。risk Connection （RC）是一种基于理论的实践方法，用于教授服务提供者如何在各种环境中与创伤幸存者一起工作，重点是促进成长和治愈关系。适应过程包括根据专家小组的经验进行多次修改，pcp的广泛投入，以及对患者的课程进行审查。2)评估课程和相关材料的初步可接受性。这一目标包括在早期试用16个pcp的培训课程，并对其可行性和可接受性进行定性调查。它还侧重于澄清课程可能影响提供者行为和患者评估和结果的理论相关领域。3)对区域安全网临床站点的pcp适应性培训进行对照研究。四组每组8名pcp将随机分配到培训或等待名单（延迟）条件；等待名单组将在延误后重新评估后进行培训。训练组和对照组的结果将在基线和训练后进行评估，延迟组将在训练后再次进行评估。主要结果将包括独立评分者的代码，这些代码基于标准化/模拟患者（SPs）在理论上与RC培训相关的地区对pcp的录音访问。次要结果包括干预对提供者的可接受性和可行性，提供者对所学技能的自我评估，SPs在访问后对提供者的技能进行评级，使用话语分析对访问子集进行评级，以及对pcp实际患者子集的短期影响。对一些提供者长达18个月的随访将探索目标行为持续获益的程度。该研究项目的长期目标是通过为pcp提供多种策略来解决患者的身心健康问题，并对可持续性和患者结果进行后续研究，从而支持他们。这项研究将补充我们的创伤和社区中心正在为低收入患者、他们的提供者和他们接受治疗的护理安全网系统开发的其他干预措施。拟议的研究计划旨在为初级保健提供者（pcp）调整和试点测试课程，以帮助他们更有效地与创伤幸存者一起工作。我们计划：(1)调整现有的创伤幸存者治疗手册和培训课程，使其适合pcp，(2)评估提供者和患者对课程和材料的初步接受程度；(3)对适应培训进行对照研究，重点关注为低收入人群服务的提供者。为pcp提供多种策略，以解决患者的身心健康投诉，将改善弱势群体的初级保健。

DESCRIPTION (provided by applicant): Improving Communication between Primary Care Providers and their Trauma Patients Abstract Trauma, especially interpersonal violence, is associated with a variety of emotional complaints, anxiety and depressive disorders, and interpersonal problems, as well as increased medical morbidity, decreased preventive care, and increased costs to the health care system. Yet trauma-related problems have not received sufficient attention in training of providers or in primary care settings, and providers feel unprepared to work with these patients. The proposed research utilizes the R34 mechanism to adapt and pilot test a theory- based practical approach to working productively with trauma survivors, the Risking Connection curriculum, to be appropriate for primary care providers (PCPs) serving low-income and minority patients. The following aims are proposed: 1) To adapt an existing manual and training curriculum on working therapeutically with trauma survivors to be appropriate for primary care providers. Risking Connection (RC) is a theory-based practical approach to teaching service providers how to work with trauma survivors in a variety of settings, with a focus on growth-promoting and healing relationships. The process of adaptation includes multiple modifications informed by the expert team's experiences, extensive input of PCPs, and the vetting of the curriculum to patients. 2) To evaluate initial acceptability of the curriculum and associated materials. This aim includes the early piloting of the training curriculum with 16 PCPs, and qualitative investigations of its feasibility and acceptability. It also focuses on clarifying the theory-linked areas in which the curriculum is likely to affect provider behavior and patient evaluations and outcomes. 3) To implement a controlled study of the adapted training in PCPs in regional safety-net clinical sites. Four groups of eight PCPs each will be randomized to training or wait-list (delay) conditions; the waitlist groups will be trained after reassessment following delay. Outcomes will be assessed at baseline and after training for trained and control groups, and the delay group will be assessed again after training. The primary outcomes will consist of codes of independent raters, based on taped visits to the PCPs by standardized/simulated patients (SPs) in areas that link theoretically with the RC training. Secondary outcomes include acceptability and feasibility of the intervention to the providers, provider self-assessments of learned skills, ratings of the providers' skills by the SPs after their visit, ratings of a subset of the visits using discourse analysis, and the short-term impact on a subset of PCPs' actual patients. Follow-up of some providers for as long as 18 months will explore the extent of sustained gains in the target behaviors. The long-term goal of the research program is to support PCPs by providing them with multiple strategies to address the physical and mental health complaints of their patients, with follow-on research addressed to sustainability and patient outcomes. The research will complement other interventions that our Center for Trauma and the Community is developing for low-income patients, their providers, and the safety-net systems of care in which they are treated. The proposed research program aims to adapt and pilot test a curriculum for primary care providers (PCPs) to help them work more productively with trauma survivors. We plan to: (1) adapt an existing manual and training curriculum on working therapeutically with trauma survivors to be appropriate for PCPs, (2) evaluate initial acceptability of the curriculum and material to providers and patients; and (3) conduct a controlled study of the adapted training, all with a focus on providers serving low-income populations. Providing PCPs with multiple strategies to address the physical and mental health complaints of their patients will improve primary care for vulnerable populations.