Effect of Patient Priorities Care Implementation in Older Veterans With Multiple Chronic Conditions

VA Office of Research and Development437 enrolled

Overview

The investigators will conduct a randomized control trial enrolling 420 older Veterans with multiple chronic conditions receiving primary care at the Michael E. DeBakey VA Medical Center and VA Connecticut Medical Center to determine if Patient Priorities Care reduces treatment burden, increases priorities-aligned home and community services, and sets shared health outcome goals compared with usual care. The investigators will randomize at the patient level rather than clinic or clinician level to evaluate the effect of identifying patient priorities on clinician decision making and alignment of care with identified priorities.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

SINGLE

Enrollment

437

Conditions

Multiple Chronic Conditions Decision Making, Shared

Interventions

A facilitator will schedule a PPC facilitation encounter 2-3 weeks before an upcoming PCP visit. The facilitator conducts a structured assessment using a written conversation guide that begins with general questions establishing what is most important to Veterans about their health and moves toward establishing specific goals (actionable outcomes), and what patients are willing/not willing to do to achieve these goals (care preferences). The result is a structured patient priorities report delivered to PCPs designed to facilitate changes in the patient's care plan to align it with his/her priorities. In the subsequent visit, the PCP will use one or more of the established PPC decisional strategies to align care with patients' priorities. Education for PCPs about the facilitation process, the patient priorities report, and the decisional strategies occurs prior to the PCP seeing any intervention patients. The PCP will document changes in care made to achieve the identified priorities.

Usual CareOTHER

PCPs will not be alerted when an encounter involves a UC group participant. UC participant visits will appear the same as all other unenrolled patient encounters. PCPs will be trained to address the needs of UC participants based on their typical approach without the use of a facilitator or explicit process for identifying patient priorities. UC participants will not receive any additional preparation

Eligibility

Sex: ALLMin age: 65 Years

Medical Language ↔ Plain English

Inclusion Criteria: * 2 encounters in prior 18 months * 3 active health problems on active problem list or prescribed 10 medications Exclusion Criteria: * nursing home resident * end stage renal disease on dialysis * active serious mental illness (psychosis, schizophrenia, etc) * active substance use disorder * complete hearing loss * dementia * Non-English speaker (translator required) * 4 or more no-show appointments in the last 6 months * the investigators will present a list of eligible patients to PCPs prior to chart review to identify patients who the PCP: * a) believes cannot participate independently or provide informed consent due to cognitive impairment * b) "would not be surprised if the patient passed away within the next 12 months?"

Locations (2)

VA Connecticut Healthcare System West Haven Campus, West Haven, CT

West Haven, Connecticut, United States

Michael E. DeBakey VA Medical Center, Houston, TX

Houston, Texas, United States

Outcomes

Primary Outcomes

Patient Reported Treatment Burden

Measured by the validated Treatment Burden Questionnaire, treatment burden measures perceptions of burdensomeness of overall care and treatment burden (e.g., medication taking, self-monitoring, visits to the provider, tests, tasks to access and coordinate care) imposed by healthcare as assessed with 15 items; possible range, 0-150; Cronbach = 0.90; higher scores indicate greater perceived burden.

Time frame: 4 month follow-up

Number of Participants Reporting Home and Community Services Use

Home and community based services includes care that supports independence and the ability to stay in one's own home. They are defined by the VA Geriatrics and Extended Care Data Analysis Center (GEC-DAC) as VA Long Term Services and Supports: adult day health care, home based primary care, homemaker and home health aide, hospice care, palliative care, respite care, skilled home health care, home telehealth, and home care services. For Home and community based services delivered by the VA, GEC-DAC has created a composite measure. Due to Department of Veterans Affairs policy changes after 2018, a significant proportion of VA home and community services and supports were delivered and paid by the Community Care Reimbursement System. As a result the Integrated Veteran Care Consolidation Data Sets (IVC-CDS) become a primary source for VA community care data. For the current study, we drew from both data sources: GEC-DAC and IVC-CDS.

Time frame: 4 month follow-up

Secondary Outcomes

Shared Decision Making

Measured using the CollaboRATE scale (3 items; possible range for each item 0-9; total range 0-27; Cronbach = 0.89; higher score indicates greater perceived shared decision-making and goal ascertainment).

Time frame: 4 month follow-up

Patients' Goal Setting

Will measure patients' perceptions of whether health care decisions were collaborative and focused on their goals using the Older Patient Assessment of Chronic Illness Care (OPACIC) score (10 items; range, 1-5; total range 10-50; Cronbach = 0.87; higher scores indicate better perceived chronic disease care).

Time frame: 4 month follow-up

Ambulatory Care Utilization - Change in Care

Medications added or stopped and diagnostic tests, referrals, and procedures ordered or avoided. Measured using a structured chart review tool using our validated process to guide uniform abstraction and classification to document if specific changes in care (i.e., medications, referrals, testing, self-management) are made.

Time frame: 4 month follow-up

Ambulatory Care Utilization - Type of Change

Medications added or stopped and tests, referrals, and self-management tasks ordered or avoided. Measured using a structured chart review tool using our validated process to guide uniform abstraction and classification to identify changes based on adding, discontinuing, or avoiding treatment actions across all care types (i.e. medication, testing, referrals, self-management).

Time frame: 4 month follow-up