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IIR 20-079 – HSR&D Study

IIR 20-079
Effect of Patient Priorities Care Implementation in Older Veterans with Multiple Chronic Conditions
Lilian N. Dindo, PhD
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: July 2021 - June 2025


Background: As Veterans age, they face an increasing number of chronic conditions and functional limitations. Multiple chronic conditions (MCC) in this population are inadequately treated by current approaches to healthcare, based on single-disease guidelines. These guidelines do not provide optimum care for patients with MCC for three key reasons: 1) single disease treatments in cases of MCC can often be conflicting and lead to adverse events because they do not take into account disease or drug interactions; 2) they do not take into account the priorities of older adult patients (what matters most) when offering treatment recommendations; 3) Guideline in this older population often lead to care that is burdensome. Significance/Impact: Patient Priorities Care (PPC) was designed with input from patients, caregivers and clinicians to address these concerns by promoting a shift in decision-making for MCC which will result in less burdensome care, fewer adverse events, and care which is focused on what matters most for patients (including increased use of long-term home and community-based services and support) for Veterans with MCC and their families. Innovation: The PPC approach elaborates specific patient priorities (i.e., values-based patient outcome goals and care preferences) and trains clinicians to recommend care that aligns with patient priorities rather than single-disease guidelines alone. Specific Aim 1: Using our primary care-research partnership, we will conduct a formative assessment of PPC implementation for Veterans with MCC and develop implementation tools. Aim 1 Methods: We will perform stakeholder interviews with leadership, clinician, and staff partners structured by a formative evaluation framework. The assessment will identify barriers to implementation of PPC within VA primary care, and inform our enablers of implementation (e.g., recruitment of clinical champions, training of interested primary care providers, note templates, and processes for identifying care that aligns with patient priorities within routine care). Specific Aim 2: Evaluate the effectiveness of PPC in a randomized controlled study at two VA primary care centers. Aim 2 Methods: We will conduct a randomized clinical trial with 366 Veterans at Houston DeBakey VA and West Haven, Connecticut VA primary care practices to determine if PPC results in care that reduces treatment burden and unnecessary medications, increases use of home and community services, and aligns care with patient priorities compared with usual care. We will determine if Veterans randomized to PPC have lower ratings on the treatment burden questionnaire, and increased number of home and community based services used compared to usual care at six months post intervention. Specific Aim 3: Conduct a summative assessment of implementation outcomes of PPC in VA primary care. Aim 3 Methods: Evaluate PPC implementation in primary care using Proctor’s implementation outcomes framework (i.e., acceptability, adoption, appropriateness, feasibility, fidelity, penetration, and activity cost accounting). Participants will complete pre and post surveys and post-implementation interviews to assess these implementation outcomes of the PPC intervention. Cost analysis will be performed to determine costs associated with PPC. Implementation/Next Step: Working with the VA Whole Health program and VA Office of Geriatrics and Extended Care, we to evaluate our effectiveness and implementation outcomes and develop an implementation toolkit and strategies for dissemination across VA.

External Links for this Project

NIH Reporter

Grant Number: I01HX003211-01A1

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Journal Articles

  1. Ouellet GM, Fried TR, Gilstrap LG, O'Leary JR, Austin AM, Skinner JS, Cohen AB. Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life. JAMA internal medicine. 2021 Aug 1; 181(8):1121-1123. [view]
  2. Cohen AB, Paiva AL, Redding CA, Fried TR. Characteristics of Older Adults Who Cannot Identify a Healthcare Agent. Journal of general internal medicine. 2022 Apr 1; 37(5):1313-1314. [view]
  3. Fried TR. Giving up on the objective of providing goal-concordant care: Advance care planning for improving caregiver outcomes. Journal of the American Geriatrics Society. 2022 Oct 1; 70(10):3006-3011. [view]
  4. Lee YK, Fried TR, Costello DM, Hajduk AM, O'Leary JR, Cohen AB. Perceived dementia risk and advance care planning among older adults. Journal of the American Geriatrics Society. 2022 May 1; 70(5):1481-1486. [view]
  5. Zang E, Shi Y, Wang X, Wu B, Fried TR. Trajectories of physical functioning among US adults with cognitive impairment. Age and ageing. 2022 Jun 1; 51(6). [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems, Other Conditions
DRE: Treatment - Efficacy/Effectiveness Clinical Trial, Treatment - Implementation, TRL - Applied/Translational
Keywords: Care Coordination, Dementia, Disability, Frailty
MeSH Terms: None at this time.

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