Leveraging Knowledge of Chronic Multisymptom Illness to Improve Care for Veterans

An estimated 10-50% of patients develop persistent, disabling, & poorly understood symptoms after COVID-19 (PASC). For many, PASC is phenomenologically like CMI (e.g., Gulf War Illness). A meta-synthesis found patients with PASC have poor experiences with care. Patients report that, at best, clinicians want to support

them but do not know how, and at worst, clinicians dismiss them as having a “mental health” disorder. Clinicians report poorly understood conditions, like PASC, are the most difficult conditions to manage. These descriptions of care for PASC are like those found in decades of research with CMI. Prior research has found

as many as 60% of patients with these conditions are dissatisfied with care, which results in low uptake of evidence-based treatments and poor health outcomes. A critical gap exists in our understanding of how to improve the experience of care for patients with poorly understood conditions, like PASC. Our team is well-

positioned to lead research to improve experiences with care for Veterans with PASC. We have led VA research efforts to understand and improve care for Veterans with CMI. This work has found 3 factors account for 40% of the variance in satisfaction with care for CMI. We have termed our approach, Concordant Care. The

evidence-based Concordant Care approach involves engaging in processes that: 1) validate the patient's experience, 2) develop a shared understanding of the condition, and 3) create a patient-centered, whole health-oriented action plan to manage the condition. This is consistent with published expert opinion that

Concordant Care underlies patients' (and clinicians') positive experiences of care for poorly understood conditions. Despite strong evidence supporting this care approach, there are no interventions to train clinicians on practices to provide Concordant Care for Veterans with poorly understood conditions. Our objective is to

adapt, optimize, then test if a Concordant Care training improves VA clinicians' engagement in recommended practices to achieve Concordant Care (i.e., validate, shared understanding, action plan) for Veterans with PASC. Achieving this objective is feasible as we have already developed and piloted a CMI Concordant Care

training for >300 VA clinicians, who rated it positively and reported it improved their practice. Our preliminary experiences suggests that our training is feasible, acceptable, and perceived as useful by VA clinicians and valued by VA program offices. Design: In Aim 1, we will adapt and optimize our Concordant Care training for

PASC. The Concordant Care clinician training will include didactics, tele-mentoring sessions, and a clinician pocket card. Veterans who are cared for by trained clinicians will get a prompt to raise PASC concerns with their clinician. In Aim 2, we will conduct a randomized parallel cluster clinical trial to determine if Concordant

Care training improves primary care clinicians' (n=60) provision of Concordant Care among Veterans with PASC (n=240), as compared to education packet control. Specific Aims: Aim 1. Adapt and refine Concordant Care training for PASC using an interactive, iterative, and user-centered design process informed by qualitative

interviews and focus groups to optimize clinician access, uptake, and utilization. Aim 2. Determine if Concordant Care training increases clinicians' engagement in recommended practices to provide Concordant Care. Exploratory Aim 3: Explore effectiveness of Concordant Care on Veterans' with PASC care outcomes

including satisfaction, adherence, and disability. Significance. Prior research with Gulf War Veterans showed the danger in waiting until we better understand the condition and best treatments before providing Concordant Care. This proposal aims to leverage our experiences with CMI to prevent another generation of Veterans from

leaving the VA, feeling betrayed, and not receptive to new treatments when they become available. It is also responsive to President Biden's April 5, 2022 executive order addressing the need to quickly improve care for PASC. Long-term we will use our findings to propose a randomized clinical trial to determine the effectiveness

of Concordant Care training on Veterans with PASC care outcomes.