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Brown MC, Harris JR, Hammerback K, Kohn MJ, Parrish AT, Chan GK, Ornelas IJ, Helfrich CD, Hannon PA. Development of a Wellness Committee Implementation Index for Workplace Health Promotion Programs in Small Businesses. Am J Health Promot 2020; 34:614-621. [PMID: 32077300 PMCID: PMC7305966 DOI: 10.1177/0890117120906967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To construct a wellness committee (WC) implementation index and determine whether this index was associated with evidence-based intervention implementation in a workplace health promotion program. DESIGN Secondary data analysis of the HealthLinks randomized controlled trial. SETTING Small businesses assigned to the HealthLinks plus WC study arm. SAMPLE Small businesses (20-200 employees, n = 23) from 6 low-wage industries in King County, Washington. MEASURES Wellness committee implementation index (0%-100%) and evidence-based intervention implementation (0%-100%). ANALYSIS We used descriptive and bivariate statistics to describe worksites' organizational characteristics. For the primary analyses, we used generalized estimating equations with robust standard errors to assess the association between WC implementation index and evidence-based intervention implementation over time. RESULTS Average WC implementation index scores were 60% at 15 months and 38% at 24 months. Evidence-based intervention scores among worksites with WCs were 27% points higher at 15 months (64% vs 37%, P < .001) and 36% points higher at 24 months (55% vs 18%, P < .001). Higher WC implementation index scores were positively associated with evidence-based intervention implementation scores over time (P < .001). CONCLUSION Wellness committees may play an essential role in supporting evidence-based intervention implementation among small businesses. Furthermore, the degree to which these WCs are engaged and have leadership support, a set plan or goals, and multilevel participation may influence evidence-based intervention implementation and maintenance over time.
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Gamble-George JC, Longenecker CT, Webel AR, Au DH, Brown AF, Bosworth H, Crothers K, Cunningham WE, Fiscella KA, Hamilton AB, Helfrich CD, Ladapo JA, Luque A, Tobin JN, Wyatt GE. ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research. Prog Cardiovasc Dis 2020; 63:79-91. [PMID: 32199901 PMCID: PMC7237329 DOI: 10.1016/j.pcad.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 02/08/2023]
Abstract
Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.
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Sanchez A, Pijoan JI, Pablo S, Mediavilla M, de Rozas RS, Lekue I, Gonzalez-Larragan S, Lantaron G, Argote J, García-Álvarez A, Latorre PM, Helfrich CD, Grandes G. Addressing low-value pharmacological prescribing in primary prevention of CVD through a structured evidence-based and theory-informed process for the design and testing of de-implementation strategies: the DE-imFAR study. Implement Sci 2020; 15:8. [PMID: 31969175 PMCID: PMC6977270 DOI: 10.1186/s13012-020-0966-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND De-implementation or abandonment of ineffective or low-value healthcare is becoming a priority research field globally due to the growing empirical evidence of the high prevalence of such care and its impact in terms of patient safety and social inefficiency. Little is known, however, about the factors, barriers, and facilitators involved or about interventions that are effective in promoting and accelerating the de-implementation of low-value healthcare. The De-imFAR study seeks to carry out a structured, evidence-based, and theory-informed process involving the main stakeholders (clinicians, managers, patients, and researchers) for the design, deployment, and assessment of de-implementation strategies for reducing low-value pharmacological prescribing. METHODS A phase I formative study using a systematic and comprehensive framework based on theory and evidence for the design of implementation strategies-specifically, the Behavior Change Wheel (BCW)-will be conducted to design and model de-implementation strategies to favor reductions in low-value pharmacological prescribing of statins in primary prevention of cardiovascular disease (CVD) by main stakeholders (clinicians, managers, patients, and researchers) in a collegiate way. Subsequently, a phase II comparative hybrid trial will be conducted to assess the feasibility and potential effectiveness of at least one active de-implementation strategy to reduce low-value pharmacological prescribing of statins in primary prevention of CVD compared to the usual procedures for dissemination of clinical practice guidelines ("what-not-to-do" recommendations). A mixed-methods evaluation will be used: quantitative for the results of the implementation at the professional level (e.g., adoption, reach and implementation or execution of the recommended clinical practice); and qualitative to determine the feasibility and perceived impact of the de-implementation strategies from the clinicians' perspective, and patients' experiences related to the clinical care received. DISCUSSION The DE-imFAR study aims to generate valid scientific knowledge about the design and development of de-implementation strategies using theory- and evidence-based methodologies suggested by implementation science. It will explore the effectiveness of these strategies and their acceptability among clinicians, policymakers, and patients. Its ultimate goal is to maximize the quality and efficiency of our health system by abandoning low-value pharmacological prescribing. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04022850. Registered 17 July 2019.
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Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne ST, Wiener RS, Feemster L, Udris E, Au DH, Helfrich CD. De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives. J Gen Intern Med 2020; 35:51-56. [PMID: 31396814 PMCID: PMC6957635 DOI: 10.1007/s11606-019-05193-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/21/2018] [Accepted: 05/23/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. OBJECTIVE We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. DESIGN We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. PARTICIPANTS We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. MAIN MEASURES Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. KEY RESULTS Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. CONCLUSIONS Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers' lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.
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Hannon PA, Hammerback K, Kohn MJ, Kava CM, Gary Chan KC, Parrish AT, Allen C, Helfrich CD, Mayotte C, Beresford SA, Harris JR. Disseminating Evidence-Based Interventions in Small, Low-Wage Worksites: A Randomized Controlled Trial in King County, Washington (2014-2017). Am J Public Health 2019; 109:1739-1746. [PMID: 31622155 DOI: 10.2105/ajph.2019.305313] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To determine whether (1) participating in HealthLinks, and (2) adding wellness committees to HealthLinks increases worksites' evidence-based intervention (EBI) implementation.Methods. We developed HealthLinks to disseminate EBIs to small, low-wage worksites. From 2014 to 2017, we conducted a site-randomized trial in King County, Washington, with 68 small worksites (20-200 employees). We assigned worksites to 1 of 3 arms: HealthLinks, HealthLinks plus wellness committee (HealthLinks+), or delayed control. At baseline, 15 months, and 24 months, we assessed worksites' EBI implementation on a 0% to 100% scale and employees' perceived support for their health behaviors.Results. Postintervention EBI scores in both intervention arms (HealthLinks and HealthLinks+) were significantly higher than in the control arm at 15 months (51%, 51%, and 23%, respectively) and at 24 months (33%, 37%, and 24%, respectively; P < .001). Employees in the intervention arms perceived greater support for their health at 15 and 24 months than did employees in control worksites.Conclusions. HealthLinks is an effective strategy for disseminating EBIs to small worksites in low-wage industries.Public Health Implications. Future research should focus on scaling up HealthLinks, improving EBI maintenance, and measuring impact of these on health behavior.
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Parikh TJ, Helfrich CD, Quiñones AR, Marshall-Fabien GL, Makaroun LK, Black MA, Thielke SM. Cost-related delay in filling prescriptions and health care ratings among medicare advantage recipients. Medicine (Baltimore) 2019; 98:e16469. [PMID: 31374008 PMCID: PMC6708951 DOI: 10.1097/md.0000000000016469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Despite higher health care needs, older adults often have limited and fixed income. Approximately a quarter of them report not filling or delaying prescription medications due to cost (cost-related prescription delay, CRPD). To ascertain the association between CRPD and satisfaction with health care, secondary analysis of the 2012 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Advantage Survey was performed.Regression models quantified the association between CRPD and rating of personal doctor, specialist, and overall health care. Models were adjusted for demographic, health-related, and socioeconomic characteristics. 274,996 Medicare Advantage enrollees were mailed the CAHPS survey, of which 101,910 (36.8%) returned a survey that had responses to all the items we analyzed. CRPD was assessed by self-report of delay in filling prescriptions due to cost. Health care ratings were on a 0-10 scale. A score ≤ 5 was considered a poor rating of care.In unadjusted models, CRPD more than doubled the relative risk (RR) for poor ratings of personal doctor (RR 2.34), specialist (RR 2.14), and overall health care (RR 2.40). Adjusting for demographics and health status slightly reduced the RRs to 1.9, but adjusting for low-income subsidy and lack of insurance for medications did not make a difference.CRPD is independently associated with poor ratings of medical care, regardless of health, financial or insurance status. Providers might reduce patients' financial stress and improve patient satisfaction by explicitly discussing prescription cost and incorporating patient priorities when recommending treatments.
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Helfrich CD, Hartmann CW, Parikh TJ, Au DH. Promoting Health Equity through De-Implementation Research. Ethn Dis 2019; 29:93-96. [PMID: 30906155 DOI: 10.18865/ed.29.s1.93] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias.
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Whittington MD, Ho PM, Helfrich CD. Recommendations for the Use of Audit and Feedback to De-Implement Low-Value Care. Am J Med Qual 2019; 34:409-411. [PMID: 30654620 DOI: 10.1177/1062860618824153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Helfrich CD, Kohn MJ, Stapleton A, Allen CL, Hammerback KE, Chan KCG, Parrish AT, Ryan DE, Weiner BJ, Harris JR, Hannon PA. Readiness to Change Over Time: Change Commitment and Change Efficacy in a Workplace Health-Promotion Trial. Front Public Health 2018; 6:110. [PMID: 29740572 PMCID: PMC5925216 DOI: 10.3389/fpubh.2018.00110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction Organizational readiness to change may be a key determinant of implementation success and a mediator of the effectiveness of implementation interventions. If organizational readiness can be reliably and validly assessed at the outset of a change initiative, it could be used to assess the effectiveness of implementation-support activities by measuring changes in readiness factors over time. Methods We analyzed two waves of readiness-to-change survey data collected as part of a three-arm, randomized controlled trial to implement evidence-based health promotion practices in small worksites in low-wage industries. We measured five readiness factors: context (favorable broader conditions); change valence (valuing health promotion); information assessment (demands and resources to implement health promotion); change commitment (an intention to implement health promotion); and change efficacy (a belief in shared ability to implement health promotion). We expected commitment and efficacy to increase at intervention sites along with their self-reported effort to implement health promotion practices, termed wellness-program effort. We compared means between baseline and 15 months, and between intervention and control sites. We used linear regression to test whether intervention and control sites differed in their change-readiness scores over time. Results Only context and change commitment met reliability thresholds. Change commitment declined significantly for both control (-0.39) and interventions sites (-0.29) from baseline to 15 months, while context did not change for either. Only wellness program effort at 15 months, but not at baseline, differed significantly between control and intervention sites (1.20 controls, 2.02 intervention). Regression analyses resulted in two significant differences between intervention and control sites in changes from baseline to 15 months: (1) intervention sites exhibited significantly smaller change in context scores relative to control sites over time and (2) intervention sites exhibited significantly higher changes in wellness program effort relative to control sites. Discussion Contrary to our hypothesis, change commitment declined significantly at both Healthlinks and control sites, even as wellness-program effort increased significantly at HealthLinks sites. Regression to the mean may explain the decline in change commitment. Future research needs to assess whether baseline commitment is an independent predictor of wellness-program effort or an effect modifier of the HealthLinks intervention.
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Helfrich CD, Rose AJ, Hartmann CW, van Bodegom-Vos L, Graham ID, Wood SJ, Majerczyk BR, Good CB, Pogach LM, Ball SL, Au DH, Aron DC. How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution. J Eval Clin Pract 2018; 24:198-205. [PMID: 29314508 PMCID: PMC5900912 DOI: 10.1111/jep.12855] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. RESULTS We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. CONCLUSIONS By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.
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Fishleder S, Petrescu-Prahova M, Harris JR, Steinman L, Kohn M, Bennett K, Helfrich CD. Bridging the Gap After Physical Therapy: Clinical-Community Linkages With Older Adult Physical Activity Programs. Innov Aging 2018; 2:igy006. [PMID: 30480131 PMCID: PMC6177034 DOI: 10.1093/geroni/igy006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many barriers exist to older adult participation in physical activity, despite known benefits. Referrals from physical therapists (PTs) through clinical-community linkages offer novel, promising opportunities to increase older adult engagement in appropriate community-based physical activity programs. We assessed the capacity of PTs to participate in such linkages. RESEARCH DESIGN AND METHODS We collected qualitative data using semistructured phone interviews (n = 30) with PTs across 14 states. We conducted thematic analysis using a priori themes based on the 2008 Bridging Model of Etz and colleagues: capacity to assess patient risk, ability to provide brief counseling, capacity and ability to refer, and awareness of community resources. RESULTS Risk assessment and counseling were already part of routine practice for our respondents, but counseling could be further facilitated if PTs had more skills to engage less-motivated patients. PTs expressed a desire to refer their patients to community programs; however, barriers to referrals included lack of knowledge of and trust in community programs, and limited infrastructure for communicating with potential partners. DISCUSSION AND IMPLICATIONS PTs have the capacity to develop patient referral linkages with community-based physical activity programs. PT session length and content facilitates patient risk assessment and behavioral counseling. Integrating motivational techniques can help PTs engage less-motivated patients in physical activity. Systemic improvements should include innovations in communication infrastructure, identifying clinic-level champions, and in-person outreach initiated by organizations that deliver community physical activity programs.
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Kim LY, Rose DE, Soban LM, Stockdale SE, Meredith LS, Edwards ST, Helfrich CD, Rubenstein LV. Primary Care Tasks Associated with Provider Burnout: Findings from a Veterans Health Administration Survey. J Gen Intern Med 2018; 33:50-56. [PMID: 28948450 PMCID: PMC5756167 DOI: 10.1007/s11606-017-4188-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/30/2017] [Accepted: 09/07/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout. OBJECTIVE To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout. DESIGN Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods. PARTICIPANTS 327 providers from 23 VA primary care practices within one VHA regional network. MAIN MEASURES The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables. KEY RESULTS In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03). CONCLUSIONS Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.
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Wang V, Maciejewski ML, Helfrich CD, Weiner BJ. Working smarter not harder: Coupling implementation to de-implementation. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:104-107. [PMID: 29279297 DOI: 10.1016/j.hjdsi.2017.12.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/09/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
In this paper, we discuss de-implementation as an implicit part of implementation and organizational change, and consider its underlying processes of unlearning to discontinue or deviate from ineffective practice and learning to applying newer, more effective practices. We describe a typology of de-implementation that represents four types of change: partial reduction, complete reversal, substitution with related replacement and substitution with unrelated replacement of existing practice. We also explicate how learning and unlearning needed for effective change vary in these four types of de-implementation. Last, we propose coupling de-implementation and implementation efforts, which serve conceptual and logistical goals of organizational change.
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Helfrich CD, Simonetti JA, Clinton WL, Wood GB, Taylor L, Schectman G, Stark R, Rubenstein LV, Fihn SD, Nelson KM. The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members. J Gen Intern Med 2017; 32:760-766. [PMID: 28233221 PMCID: PMC5481228 DOI: 10.1007/s11606-017-4011-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/11/2017] [Accepted: 02/02/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Work-related burnout is common in primary care and is associated with worse patient safety, patient satisfaction, and employee mental health. Workload, staffing stability, and team completeness may be drivers of burnout. However, few studies have assessed these associations at the team level, and fewer still include members of the team beyond physicians. OBJECTIVE To study the associations of burnout among primary care providers (PCPs), nurse care managers, clinical associates (MAs, LPNs), and administrative clerks with the staffing and workload on their teams. DESIGN We conducted an individual-level cross-sectional analysis of survey and administrative data in 2014. PARTICIPANTS Primary care personnel at VA clinics responding to a national survey. MAIN MEASURES Burnout was measured with a validated single-item survey measure dichotomized to indicate the presence of burnout. The independent variables were survey measures of team staffing (having a fully staffed team, serving on multiple teams, and turnover on the team), and workload both from survey items (working extended hours), and administrative data (patient panel overcapacity and average panel comorbidity). KEY RESULTS There were 4610 respondents (estimated response rate of 20.9%). The overall prevalence of burnout was 41%. In adjusted analyses, the strongest associations with burnout were having a fully staffed team (odds ratio [OR] = 0.55, 95% CI 0.47-0.65), having turnover on the team (OR = 1.67, 95% CI 1.43-1.94), and having patient panel overcapacity (OR = 1.19, 95% CI 1.01-1.40). The observed burnout prevalence was 30.1% lower (28.5% vs. 58.6%) for respondents working on fully staffed teams with no turnover and caring for a panel within capacity, relative to respondents in the inverse condition. CONCLUSIONS Complete team staffing, turnover among team members, and panel overcapacity had strong, cumulative associations with burnout. Further research is needed to understand whether improvements in these factors would lower burnout.
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Winchester DE, Schmalfuss C, Helfrich CD, Beyth RJ. A specialty-specific, multimodality educational quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging. Open Heart 2017; 4:e000589. [PMID: 28674630 PMCID: PMC5471866 DOI: 10.1136/openhrt-2017-000589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/06/2017] [Accepted: 04/11/2017] [Indexed: 01/03/2023] Open
Abstract
Objective Investigations of Appropriate Use Criteria (AUC) education have shown a mixed effect on changing provider behaviour. At our facility, rarely appropriate myocardial perfusion imaging (MPI) differs by specialty; awareness of AUC is low. Our objective is to investigate if specialty-specific, multimodality education could reduce rarely appropriate MPI. Methods We designed education focused on the rarely appropriate MPI ordered most often by each specialty. We tracked appropriateness of MPI in three cohorts: pre, post (immediately after) and late-post (4 months after) intervention. Results A total of 889 MPI were evaluated (n=287 pre, n=313 post, n=289 late-post), 95.3% were men. Chest pain was the most common symptom (n=530, 59.6%), while 14.1% (n=125) had no symptoms. Rarely appropriate testing decreased from 4.9% to 1.3% and remained at 1.4% in the late-post cohort (p<0.0001). In logistic regression, lack of symptoms (OR 31.3, 95% CI 10.3 to 94.8, p≤0.0001) and being in the post or late-post cohorts (OR 0.27, 95% CI 0.11 to 0.68, p=0.006) were associated with rarely appropriate MPI. Preoperative MPI in patients with good exercise capacity was a common rarely appropriate indication. Ischaemia was not observed among patients with rarely appropriate indication for MPI. Conclusions In certain clinical settings, education may be an effective approach for deimplementing rarely appropriate MPI. The effect of education may be enhanced when focused on improving patient care, delivered by a peer, and needs assessment indicates low awareness of guidelines. Lack of symptoms and preoperative MPI continue to be the predominant rarely appropriate MPI ordered.
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Winchester DE, Schmalfuss C, Wymer DC, Helfrich CD, Beyth RJ. Abstract 017: Feasibility of Audit and Feedback for Reducing Rarely Appropriate Nuclear Myocardial Perfusion Imaging Among Veterans. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Appropriate Use Criteria (AUC) are complex documents which provide great detail on which patients are likely to benefit from a test. For providers who order a low volume of cardiac tests, regular application and navigation through the AUC may be difficult. Audit and feedback (A&F) has been proposed as an effective method for encouraging de-implementation of unnecessary testing. We hypothesized that the volume of myocardial perfusion imaging (MPI) ordered by most providers would make A&F ineffective.
Methods:
We performed a secondary analysis of data gathered for the evaluation of a program to reduce rarely appropriate MPI. Patients who underwent nuclear myocardial perfusion imaging (MPI) were rated using the AUC. Appropriateness rating was performed retrospectively by a nurse trained in application of the AUC. We extracted data on both the patient and the ordering provider from the medical record which accompanied the visit where the MPI was ordered. Patients were compared in two cohorts: those with rarely appropriate indications for MPI, and all others. We performed logistic regression to determine which patient and provider characteristics were associated with rarely appropriate MPI. We ranked the most common indications for rarely appropriate testing and calculated the mean number of MPI ordered by our providers.
Results:
A total of 889 cases over six months were included; 22 MPI (2.5%) were rated as rarely appropriate. A minority of patients had a prior myocardial infarction (n=127, 143%) or coronary revascularization (n=291, 32.7%). Chest pain was more common among appropriate or maybe appropriate MPI (n=528, 61.1% vs. n=1, 4.5%, P<0.0001) while lack of symptoms was more common among rarely appropriate MPI (n=18, 81.8% vs. 107, 12.4%, P<0.0001). In logistic regression, lack of symptoms was retained in association with rarely appropriate testing (odds ratio 31.6, 95% confidence interval 10.5-95.2, P<0.0001). The majority (59.1%) of rarely appropriate tests were accounted for with only 3 indications (#8, #71, and #67). A total of 219 providers ordered MPI during the study period, with an average of 4.1 MPI per provider, less than one MPI per provider per month. The greatest number of rarely appropriate tests from any single provider was 3.
Conclusions:
Within the setting of an educational program to reduce rarely appropriate MPI, the number of rarely appropriate MPI per provider was low. Lack of symptoms and indications including preoperative testing and screening in low risk patients were common drivers of rarely appropriate MPI. These data raise doubt about efficacy of a broadly applied program which provides individualized A&F. Efforts to increase awareness of common reasons for rarely appropriate testing may have greater impact.
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Rose AJ, Park A, Gillespie C, Van Deusen Lukas C, Ozonoff A, Petrakis BA, Reisman JI, Borzecki AM, Benedict AJ, Lukesh WN, Schmoke TJ, Jones EA, Morreale AP, Ourth HL, Schlosser JE, Mayo-Smith MF, Allen AL, Witt DM, Helfrich CD, McCullough MB. Results of a Regional Effort to Improve Warfarin Management. Ann Pharmacother 2016; 51:373-379. [PMID: 28367699 DOI: 10.1177/1060028016681030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.
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Hannon PA, Helfrich CD, Chan KG, Allen CL, Hammerback K, Kohn MJ, Parrish AT, Weiner BJ, Harris JR. Development and Pilot Test of the Workplace Readiness Questionnaire, a Theory-Based Instrument to Measure Small Workplaces' Readiness to Implement Wellness Programs. Am J Health Promot 2016; 31:67-75. [PMID: 26389975 DOI: 10.4278/ajhp.141204-quan-604] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To develop a theory-based questionnaire to assess readiness for change in small workplaces adopting wellness programs. DESIGN In developing our scale, we first tested items via "think-aloud" interviews. We tested the revised items in a cross-sectional quantitative telephone survey. SETTING The study setting comprised small workplaces (20-250 employees) in low-wage industries. SUBJECTS Decision-makers representing small workplaces in King County, Washington (think-aloud interviews, n = 9), and the United States (telephone survey, n = 201) served as study subjects. MEASURES We generated items for each construct in Weiner's theory of organizational readiness for change. We also measured workplace characteristics and current implementation of workplace wellness programs. ANALYSIS We assessed reliability by coefficient alpha for each of the readiness questionnaire subscales. We tested the association of all subscales with employers' current implementation of wellness policies, programs, and communications, and conducted a path analysis to test the associations in the theory of organizational readiness to change. RESULTS Each of the readiness subscales exhibited acceptable internal reliability (coefficient alpha range, .75-.88) and was positively associated with wellness program implementation ( p < .05). The path analysis was consistent with the theory of organizational readiness to change, except change efficacy did not predict change-related effort. CONCLUSION We developed a new questionnaire to assess small workplaces' readiness to adopt and implement evidence-based wellness programs. Our findings also provide empirical validation of Weiner's theory of readiness for change.
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Schopfer DW, Takemoto S, Allsup K, Helfrich CD, Ho PM, Forman DE, Whooley MA. Notice of Retraction and Replacement. Schopfer DW, et al. Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease. JAMA Intern Med. 2014;174(10):1687-1689. JAMA Intern Med 2016; 176:1726-1727. [PMID: 27723859 DOI: 10.1001/jamainternmed.2016.5831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Helfrich CD, Sylling PW, Gale RC, Mohr DC, Stockdale SE, Joos S, Brown EJ, Grembowski D, Asch SM, Fihn SD, Nelson KM, Meredith LS. The facilitators and barriers associated with implementation of a patient-centered medical home in VHA. Implement Sci 2016; 11:24. [PMID: 26911135 PMCID: PMC4766632 DOI: 10.1186/s13012-016-0386-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/17/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)). METHODS We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness. RESULTS The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction. CONCLUSIONS A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.
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Haverhals LM, Sayre G, Helfrich CD, Battaglia C, Aron D, Stevenson LD, Kirsh S, Ho M, Lowery J. E-consult implementation: lessons learned using consolidated framework for implementation research. THE AMERICAN JOURNAL OF MANAGED CARE 2015; 21:e640-e647. [PMID: 26760426 PMCID: PMC4717483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES In 2011, the Veterans Health Administration (VHA) implemented electronic consults (e-consults) as an alternative to in-person specialty visits to improve access and reduce travel for veterans. We conducted an evaluation to understand variation in the use of the new e-consult mechanism and the causes of variable implementation, guided by the Consolidated Framework for Implementation Research (CFIR). STUDY DESIGN Qualitative case studies of 3 high- and 5 low-implementation e-consult pilot sites. Participants included e-consult site leaders, primary care providers, specialists, and support staff identified using a modified snowball sample. METHODS We used a 3-step approach, with a structured survey of e-consult site leaders to identify key constructs, based on the CFIR. We then conducted open-ended interviews, focused on key constructs, with all participants. Finally, we produced structured, site-level ratings of CFIR constructs and compared them between high- and low-implementation sites. RESULTS Site leaders identified 14 initial constructs. We conducted 37 interviews, from which 4 CFIR constructs distinguished high implementation e-consult sites: compatibility, networks and communications, training, and access to knowledge and information. For example, illustrating compatibility, a specialist at a high-implementation site reported that the site changed the order of consult options so that all specialties listed e-consults first to maintain consistency. High-implementation sites also exhibited greater agreement on constructs. CONCLUSIONS By using the CFIR to analyze results, we facilitate future synthesis with other findings, and we better identify common patterns of implementation determinants common across settings.
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Battaglia C, Lambert-Kerzner A, Aron DC, Sayre GG, Ho PM, Haverhals L, Stevenson L, Kirsh S, Au DH, Helfrich CD. Evaluation of E-Consults in the VHA: Provider Perspectives. Fed Pract 2015; 32:42-48. [PMID: 30766078 PMCID: PMC6363293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
As VHA expands the use of e-consults, this study suggests that they often are more timely than are face-to-face consultations.
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Dolan ED, Mohr D, Lempa M, Joos S, Fihn SD, Nelson KM, Helfrich CD. Using a single item to measure burnout in primary care staff: a psychometric evaluation. J Gen Intern Med 2015; 30:582-7. [PMID: 25451989 PMCID: PMC4395610 DOI: 10.1007/s11606-014-3112-6] [Citation(s) in RCA: 316] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/25/2014] [Accepted: 11/07/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Burnout affects nearly half of all U.S. nurses and physicians, and has been linked to poor outcomes such as worse patient safety. The most common measure of burnout is the well-validated Maslach Burnout Inventory (MBI). However, the MBI is proprietary and carries licensing fees, posing challenges to routine or repeated assessment. OBJECTIVE To compare a non-proprietary, single-item burnout measure to a single item from the MBI Emotional Exhaustion (MBI:EE) subscale that has been validated as a standalone burnout measure. DESIGN Cross-sectional online survey. PARTICIPANTS A sample of primary care providers (PCPs), registered nurses, clinical associates (e.g., licensed practical nurses (LPNs), medical technicians), and administrative clerks in the Veterans Health Administration surveyed in 2012. MAIN METHODS We compared a validated one-item version of the MBI:EE and a non-proprietary single-item burnout measure used in the Physician Work Life Study. We calculated kappa statistics, sensitivity and specificity, positive predictive (PPV) and negative predictive values (NPV), and area under the receiver operator curve (AUC). We conducted analyses stratified by occupation to determine the stability of the correlation between the two measures. KEY RESULTS We analyzed responses from 5,404 participants, including 1,769 providers and 1,380 registered nurses. The prevalence of burnout was 36.7% as measured on the single MBI:EE item and 38.5% as measured on the non-proprietary single-item measure. Relative to the MBI:EE, the non-proprietary single-item measure had a correlation of 0.79, sensitivity of 83.2%, specificity of 87.4%, and AUC of 0.93 (se = 0.004). Results were similar when stratified by respondent occupation. CONCLUSIONS A non-proprietary single-item measure served as a reliable substitute for the MBI:EE across occupations. Because it is non-proprietary and easy to interpret, it has logistical advantages over the one-item MBI.
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Gale RC, Asch SM, Taylor T, Nelson KM, Luck J, Meredith LS, Helfrich CD. The most used and most helpful facilitators for patient-centered medical home implementation. Implement Sci 2015; 10:52. [PMID: 25924611 PMCID: PMC4414441 DOI: 10.1186/s13012-015-0246-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/13/2015] [Indexed: 12/03/2022] Open
Abstract
Background Like other transformative healthcare initiatives, patient-centered medical home (PCMH) implementation requires substantial investments of time and resources. Even though PCMH and PCMH-like models are being implemented by multiple provider practices and health systems, little is known about what facilitates their implementation. The purpose of this study was to assess which PCMH-implementation resources are most widely used, by whom, and which resources primary care personnel find most helpful. Methods This study is an analysis of data from a cross-sectional survey of primary care personnel in the Veterans Health Administration in 2012, in which respondents were asked to rate whether they were aware of and accessed PCMH-implementation resources, and to rate their helpfulness. Logistic regression was used to produce odds ratios for the outcomes (1) resource use and (2) resource helpfulness. Respondents were nested within clinics, nested, in turn, within 135 parent hospitals. Results Teamlet huddles were the most widely accessed (80.4% accessed) and most helpful (90.4% rated helpful) resource; quality-improvement methods to conduct small tests of change were the least frequently accessed (42.4% accessed) resource though two-thirds (66.7%) of users reported as helpful. Supervisors were significantly more likely (ORs, 1.46 to 1.86) to use resources than non-supervisors but were less likely to rate the majority (8 out of 10) of resources as “somewhat/very helpful” than non-supervisors (ORs, 0.72 to 0.84). Longer-tenured employees tended to rate resources as more helpful. Conclusions These findings are the first in the PCMH literature that we are aware of that systematically assesses primary care staff’s access to and the helpfulness of PCMH implementation resources. Supervisors generally reported greater access to resources, relative to non-supervisors, but rated resources as less helpful, suggesting that information about them may not have been optimally disseminated. Knowing what resources primary care staff use and find helpful can inform administrators’ and policymakers’ investments in PCMH-implementation resources. The implications of our model extend beyond just PCMH implementation but also to considerations when providing implementation resources for other complex quality-improvement initiatives. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0246-9) contains supplementary material, which is available to authorized users.
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Helfrich CD, Dolan ED, Fihn SD, Rodriguez HP, Meredith LS, Rosland AM, Lempa M, Wakefield BJ, Joos S, Lawler LH, Harvey HB, Stark R, Schectman G, Nelson KM. Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2014; 2:238-44. [PMID: 26250630 DOI: 10.1016/j.hjdsi.2014.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 08/22/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. MATERIAL AND METHODS We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. RESULTS 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001). CONCLUSIONS Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. IMPLICATIONS Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.
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