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Sen A, Sinha AP. An ontological model of the practice transformation process. J Biomed Inform 2016; 61:298-318. [PMID: 27178475 DOI: 10.1016/j.jbi.2016.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 05/06/2016] [Accepted: 05/07/2016] [Indexed: 11/25/2022]
Abstract
Patient-centered medical home is defined as an approach for providing comprehensive primary care that facilitates partnerships between individual patients and their personal providers. The current state of the practice transformation process is ad hoc and no methodological basis exists for transforming a practice into a patient-centered medical home. Practices and hospitals somehow accomplish the transformation and send the transformation information to a certification agency, such as the National Committee for Quality Assurance, completely ignoring the development and maintenance of the processes that keep the medical home concept alive. Many recent studies point out that such a transformation is hard as it requires an ambitious whole-practice reengineering and redesign. As a result, the practices suffer change fatigue in getting the transformation done. In this paper, we focus on the complexities of the practice transformation process and present a robust ontological model for practice transformation. The objective of the model is to create an understanding of the practice transformation process in terms of key process areas and their activities. We describe how our ontology captures the knowledge of the practice transformation process, elicited from domain experts, and also discuss how, in the future, that knowledge could be diffused across stakeholders in a healthcare organization. Our research is the first effort in practice transformation process modeling. To build an ontological model for practice transformation, we adopt the Methontology approach. Based on the literature, we first identify the key process areas essential for a practice transformation process to achieve certification status. Next, we develop the practice transformation ontology by creating key activities and precedence relationships among the key process areas using process maturity concepts. At each step, we employ a panel of domain experts to verify the intermediate representations of the ontology. Finally, we implement a prototype of the practice transformation ontology using Protégé.
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Affiliation(s)
- Arun Sen
- Department of Information and Operations Management - Mays Business School, Texas A&M University and Texas A&M Regional Extension Center in RCHI-Texas A&M Health Sciences Center, College Station, TX 77843, USA.
| | - Atish P Sinha
- Lubar School of Business, University of Wisconsin-Milwaukee, Milwaukee, WI 53201-0742, USA.
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Hudson SV, Ohman-Strickland PA, Bator A, O'Malley D, Gundersen D, Lee HS, Crabtree BF, Miller SM. Breast and prostate cancer survivors' experiences of patient-centered cancer follow-up care from primary care physicians and oncologists. J Cancer Surviv 2016; 10:906-14. [PMID: 27034260 DOI: 10.1007/s11764-016-0537-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/14/2016] [Indexed: 01/21/2023]
Abstract
PURPOSE Patient-physician relationships impact health care seeking and preventive screening behaviors among patients. At the end of active treatment some cancer survivors report feeling disconnected from their care team. This study explores cancer survivors' experiences of patient-centered cancer follow-up care provided by primary care physicians (PCP) and oncologists (ONC). METHODS Three hundred five early stage, breast and prostate cancer survivors at least 2 years post treatment were surveyed from four community hospital oncology programs in New Jersey. Participants reported receipt of patient-centered care measured by care coordination, comprehensiveness of care, and personal relationship with PCPs and ONCs. RESULTS PCPs received higher ratings for coordination of care and comprehensive care than ONCs from all survivors (P < 0.01). However, prostate and breast cancer survivors rated strengths of their personal bonds with the physicians differently. While prostate cancer survivors rated PCPs significantly higher for all items (P < 0.028), breast cancer survivors rated ONCs significantly higher on four out of seven items including having been through a lot together, understanding what is important regarding health, knowing their medical history and taking their beliefs and wishes into account (P < 0.036). CONCLUSIONS Prostate and breast cancer survivors report different experiences with their PCPs and oncologists around the comprehensiveness and coordination of their cancer follow-up care in addition to the strength of their relationships with their physicians. IMPLICATIONS FOR CANCER SURVIVORS There are important differences in the experience of patient-centered care among cancer survivors that should be considered when planning care models and interventions for these different populations.
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Affiliation(s)
- Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA.
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, NJ, 08873, USA.
| | - Pamela A Ohman-Strickland
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Biometrics Division, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Alicja Bator
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Denalee O'Malley
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Daniel Gundersen
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Heather S Lee
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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Solimeo SL, Ono SS, Stewart KR, Lampman MA, Rosenthal GE, Stewart GL. Gatekeepers as Care Providers: The Care Work of Patient-centered Medical Home Clerical Staff. Med Anthropol Q 2016; 31:97-114. [DOI: 10.1111/maq.12281] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Samantha L. Solimeo
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System and Division of General Internal Medicine University of Iowa Carver College of Medicine
| | - Sarah S. Ono
- VISN 23 Patient Aligned Care Team Demonstration Lab, Department of Veterans Affairs; Iowa City VA Health Care System and Division of Family Medicine Oregon Health and Science University and CIVIC (Center to Improve Veteran Involvement in Care), Department of Veterans Affairs VA Portland Health Care System
| | - Kenda R. Stewart
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System
| | - Michelle A. Lampman
- VISN 23 Patient Aligned Care Team Demonstration Lab; Department of Veterans Affairs Iowa City VA Health Care System
| | - Gary E. Rosenthal
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System and Division of General Internal Medicine University of Iowa Carver College of Medicine
| | - Greg L. Stewart
- VISN 23 Patient Aligned Care Team Demonstration Lab and; CADRE, the Center for Comprehensive Access & Delivery Research and Evaluation Department of Veterans Affairs Iowa City VA Health Care System and Tippie College of Business, University of Iowa
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O'Donnell AJ, Bogner HR, Cronholm PF, Kellom K, Miller-Day M, McClintock HFDV, Kaye EM, Gabbay R. Stakeholder Perspectives on Changes in Hypertension Care Under the Patient-Centered Medical Home. Prev Chronic Dis 2016; 13:E28. [PMID: 26916899 PMCID: PMC4768875 DOI: 10.5888/pcd13.150383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Hypertension is a major modifiable risk factor for cardiovascular and kidney disease, yet the proportion of adults whose hypertension is controlled is low. The patient-centered medical home (PCMH) is a model for care delivery that emphasizes patient-centered and team-based care and focuses on quality and safety. Our goal was to investigate changes in hypertension care under PCMH implementation in a large multipayer PCMH demonstration project that may have led to improvements in hypertension control. METHODS The PCMH transformation initiative conducted 118 semistructured interviews at 17 primary care practices in southeastern Pennsylvania between January 2011 and January 2012. Clinicians (n = 47), medical assistants (n = 26), office administrators (n = 12), care managers (n = 11), front office staff (n = 7), patient educators (n = 4), nurses (n = 4), social workers (n = 4), and other administrators (n = 3) participated in interviews. Study personnel used thematic analysis to identify themes related to hypertension care. RESULTS Clinicians described difficulties in expanding services under PCMH to meet the needs of the growing number of patients with hypertension as well as how perceptions of hypertension control differed from actual performance. Staff and office administrators discussed achieving patient-centered hypertension care through patient education and self-management support with personalized care plans. They indicated that patient report cards were helpful tools. Participants across all groups discussed a team- and systems-based approach to hypertension care. CONCLUSION Practices undergoing PCMH transformation may consider stakeholder perspectives about patient-centered, team-based, and systems-based approaches as they work to optimize hypertension care.
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Affiliation(s)
- Alison J O'Donnell
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hillary R Bogner
- Associate Professor, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 9 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104.
| | - Peter F Cronholm
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine Kellom
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Miller-Day
- Department of Health and Strategic Communication, Chapman University, Orange, California
| | | | - Elise M Kaye
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Gabbay
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
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Holtz B, Annis AM, Morrish W, Davis Burns J, Krein SL. Characteristics of patients with diabetes who accept referrals for care management services. SAGE Open Med 2016; 4:2050312115626431. [PMID: 26835018 PMCID: PMC4724766 DOI: 10.1177/2050312115626431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 12/17/2015] [Indexed: 12/19/2022] Open
Abstract
Introduction: Patients with chronic conditions can improve their health through participation in self-care programs. However, awareness of and enrollment in these programs are generally low. Objective: We sought to identify factors influencing patients’ receptiveness to a referral for programs and services supporting chronic disease management. Methods: We analyzed data from 541 high-risk diabetic patients who completed an assessment between 2010 and 2013 from a computer-based, nurse-led Navigator referral program within a large primary care clinic. We compared patients who accepted a referral to those who declined. Results: A total of 318 patients (75%) accepted 583 referrals, of which 52% were for self-care programs. Patients who accepted a referral had more primary care visits in the previous year, were more likely to be enrolled in another program, expressed more interest in using the phone and family or friends for support, and were more likely to report recent pain than those who declined a referral. Discussion: Understanding what factors influence patients’ decisions to consider and participate in self-care programs has important implications for program design and development of strategies to connect patients to programs. This work informs outreach efforts to identify and engage patients who are likely to benefit from self-care activities.
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Affiliation(s)
- Bree Holtz
- Departments of Advertising and Public Relations and Media and Information, Michigan State University, East Lansing, MI, USA
| | - Ann M Annis
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Wendy Morrish
- Department of Ambulatory Care, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Davis Burns
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Sarah L Krein
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Abstract
BACKGROUND The National Committee for Quality Assurance patient-centered medical home recognition program provides practices an opportunity to implement medical home activities. Understanding the costs to apply for recognition may enable practices to plan their work. METHODS Practice coaches identified 5 exemplar practices (3 pediatric and 2 family medicine practices) that received level 3 recognition. This analysis focuses on 4 that received recognition in 2011. Clinical, informatics, and administrative staff participated in 2- to 3-hour interviews. We determined the time required to develop, implement, and maintain required activities. We categorized costs as (1) nonpersonnel, (2) developmental, (3) those used to implement activities, (4) those used to maintain activities, (5) those to document the work, and (6) consultant costs. Only incremental costs were included and are presented as costs per full-time equivalent (pFTE) provider. RESULTS Practice size ranged from 2.5 to 10.5 pFTE providers, and payer mixes ranged from 7% to 43% Medicaid. There was variation in the distribution of costs by activity by practice, but the costs to apply were remarkably similar ($11,453-15,977 pFTE provider). CONCLUSION The costs to apply for 2011 recognition were noteworthy. Work to enhance care coordination and close loops were highly valued. Financial incentives were key motivators. Future efforts to minimize the burden of low-value activities could benefit practices.
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McHugh M, Shi Y, Ramsay PP, Harvey JB, Casalino LP, Shortell SM, Alexander JA. Patient-Centered Medical Home Adoption: Results From Aligning Forces For Quality. Health Aff (Millwood) 2016; 35:141-9. [DOI: 10.1377/hlthaff.2015.0495] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Megan McHugh
- Megan McHugh ( ) is a research assistant professor in the Center for Healthcare Studies and Department of Emergency Medicine, Feinberg School of Medicine, at Northwestern University, in Chicago, Illinois
| | - Yunfeng Shi
- Yunfeng Shi is an assistant professor in the Department of Health Policy and Administration at Pennsylvania State University, in University Park
| | - Patricia P. Ramsay
- Patricia P. Ramsay is a policy analyst in the School of Public Health and administrative director of the Center for Healthcare Organizational and Innovation Research at the University of California, Berkeley
| | - Jillian B. Harvey
- Jillian B. Harvey is an assistant professor of healthcare leadership and management at the Medical University of South Carolina, in Charleston
| | - Lawrence P. Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor and chief of the Division of Health Policy and Research at Weill Cornell Medical College, in New York City
| | - Stephen M. Shortell
- Stephen M. Shortell is dean emeritus of the School of Public Health, the Blue Cross of California Distinguished Professor of Health Policy and Management in both the School of Public Health and the Haas School of Business, and faculty director of the Center for Healthcare Organizational and Innovation Research, all at the University of California, Berkeley
| | - Jeffrey A. Alexander
- Jeffrey A. Alexander is a professor emeritus of health management and policy at the University of Michigan, in Ann Arbor
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Ogunleye A, Osunlana A, Asselin J, Cave A, Sharma AM, Campbell-Scherer DL. The 5As team intervention: bridging the knowledge gap in obesity management among primary care practitioners. BMC Res Notes 2015; 8:810. [PMID: 26695407 PMCID: PMC4689048 DOI: 10.1186/s13104-015-1685-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/10/2015] [Indexed: 01/25/2023] Open
Abstract
Background Despite opportunities for didactic education on obesity management, we still observe low rates of weight management visits in our primary care setting. This paper describes the co-creation by front-line interdisciplinary health care providers and researchers of the 5As Team intervention to improve obesity prevention and management in primary care. Methods We describe the theoretical foundations, design, and core elements of the 5AsT intervention, and the process of eliciting practitioners’ self-identified knowledge gaps to inform the curricula for the 5AsT intervention. Themes and topics were identified through facilitated group discussion and a curriculum relevant to this group of practitioners was developed and delivered in a series of 12 workshops. Result The research question and approach were co-created with the clinical leadership of the PCN; the PCN committed internal resources and a practice facilitator to the effort. Practice facilitation and learning collaboratives were used in the intervention For the content, front-line providers identified 43 topics, related to 13 themes around obesity assessment and management for which they felt the need for further education and training. These needs included: cultural identity and body image, emotional and mental health, motivation, setting goals, managing expectations, weight-bias, caregiver fatigue, clinic dynamics and team-based care, greater understanding of physiology and the use of a systematic framework for obesity assessment (the “4Ms” of obesity). The content of the 12 intervention sessions were designed based on these themes. There was a strong innovation values fit with the 5AsT intervention, and providers were more comfortable with obesity management following the intervention. The 5AsT intervention, including videos, resources and tools, has been compiled for use by clinical teams and is available online at http://www.obesitynetwork.ca/5As_Team. Conclusions Primary care interdisciplinary practitioners perceive important knowledge gaps across a wide range of topics relevant to obesity assessment and management. This description of the intervention provides important information for trial replication. The 5AsT intervention may be a useful aid for primary care teams interested to improve their knowledge of obesity prevention and management. Clinical Trials.gov (NCT01967797)
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Affiliation(s)
- Ayodele Ogunleye
- Department of Medicine, Obesity Research and Management University of Alberta, Li Ka Shing Center for Health Research Innovation, Edmonton, AB, T6G 2E1, Canada. .,Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada.
| | - Adedayo Osunlana
- Department of Medicine, Obesity Research and Management University of Alberta, Li Ka Shing Center for Health Research Innovation, Edmonton, AB, T6G 2E1, Canada.
| | - Jodie Asselin
- Department of Medicine, Obesity Research and Management University of Alberta, Li Ka Shing Center for Health Research Innovation, Edmonton, AB, T6G 2E1, Canada. .,Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada.
| | - Andrew Cave
- Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada.
| | - Arya Mitra Sharma
- Department of Medicine, Obesity Research and Management University of Alberta, Li Ka Shing Center for Health Research Innovation, Edmonton, AB, T6G 2E1, Canada.
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El Rayess F, Goldman R, Furey C, Chandran R, Goldberg AR, Anandarajah G. Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step. J Grad Med Educ 2015; 7:580-8. [PMID: 26692970 PMCID: PMC4675415 DOI: 10.4300/jgme-d-14-00597.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 04/07/2015] [Accepted: 05/18/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The patient-centered medical home (PCMH) is an accepted framework for delivering high-quality primary care, prompting many residencies to transform their practices into PCMHs. Few studies have assessed the impact of these changes on residents' and faculty members' PCMH attitudes, knowledge, and skills. The family medicine program at Brown University achieved Level 3 PCMH accreditation in 2010, with training relying primarily on situated learning through immersion in PCMH practice, supplemented by didactics and a few focused clinical activities. OBJECTIVE To assess PCMH knowledge and attitudes after Level 3 PCMH accreditation and to identify additional educational needs. METHODS We used a qualitative approach, with semistructured, individual interviews with 12 of the program's 13 postgraduate year 3 residents and 17 of 19 core faculty. Questions assessed PCMH knowledge, attitudes, and preparedness for practicing, teaching, and leading within a PCMH. Interviews were analyzed using the immersion/crystallization method. RESULTS Residents and faculty generally had positive attitudes toward PCMH. However, many expressed concerns that they lacked specific PCMH knowledge, and felt inadequately prepared to implement PCMH principles into their future practice or teaching. Some exceptions were faculty and resident leaders who were actively involved in the PCMH transformation. Barriers included lack of time and central roles in PCMH activities. CONCLUSIONS Practicing in a certified PCMH training program, with passive PCMH roles and supplemental didactics, appears inadequate in preparing residents and faculty for practice or teaching in a PCMH. Purposeful curricular design and evaluation, with faculty development, may be needed to prepare the future leaders of primary care.
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Affiliation(s)
- Fadya El Rayess
- Corresponding author: Fadya El Rayess, MD, MPH, Memorial Hospital of Rhode Island, Department of Family Medicine, 111 Brewster Street, Pawtucket, RI 02860, 401.729.2235,
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Creating a 'reverse' integrated primary and mental healthcare clinic for those with serious mental illness. Prim Health Care Res Dev 2015; 17:421-7. [PMID: 26586369 DOI: 10.1017/s1463423615000523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Individuals with serious mental illness (SMI) are more likely to experience preventable medical health issues, such as diabetes, hyperlipidemia, obesity, and cardiovascular disease, than the general population. To further compound this issue, these individuals are less likely to seek preventative medical care. These factors result in higher usage of expensive emergency care, lower quality of care, and lower life expectancy. This manuscript presents literature that examines the health disparities this population experiences, and barriers to accessing primary care. Through the identification of these barriers, we recommend that the field of family medicine work in collaboration with the field of mental health to implement 'reverse' integrated care (RIC) systems, and provide primary care services in the mental health settings. By embedding primary care practitioners in mental health settings, where individuals with SMI are more likely to present for treatment, this population may receive treatment for somatic care by experts. This not only would improve the quality of care received by patients, but would also remove the burden of managing complex somatic care from providers trained in mental health. The rationale for this RIC system, as well as training and policy reforms, are discussed.
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Liddy C, Hogg W, Singh J, Taljaard M, Russell G, Deri Armstrong C, Akbari A, Dahrouge S, Grimshaw JM. A real-world stepped wedge cluster randomized trial of practice facilitation to improve cardiovascular care. Implement Sci 2015; 10:150. [PMID: 26510577 PMCID: PMC4625868 DOI: 10.1186/s13012-015-0341-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/19/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC's impact on adherence to processes of care delivery. METHODS A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada (ClinicalTrials.gov: NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention. RESULTS Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively. CONCLUSIONS IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT00574808.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada. .,Bruyère Research Institute, 43 Bruyère St, Annex E, Room 106, Ottawa, Ontario, K1N 5C8, Canada.
| | - William Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Jatinderpreet Singh
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. .,Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, Canada.
| | - Grant Russell
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Notting Hill, Victoria, Australia.
| | | | - Ayub Akbari
- The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Simone Dahrouge
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. .,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Hebert PL, Liu CF, Wong ES, Hernandez SE, Batten A, Lo S, Lemon JM, Conrad DA, Grembowski D, Nelson K, Fihn SD. Patient-centered medical home initiative produced modest economic results for Veterans Health Administration, 2010-12. Health Aff (Millwood) 2015; 33:980-7. [PMID: 24889947 DOI: 10.1377/hlthaff.2013.0893] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.
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Affiliation(s)
- Paul L Hebert
- Paul L. Hebert is an investigator in the Veterans Affairs (VA) Health Services Research and Development Center for Veteran-Centered, Value-Driven Health, VA Puget Sound Health Care System, and a research associate professor in the Department of Health Services, School of Public Health, University of Washington, both in Seattle
| | - Chuan-Fen Liu
- Chuan-Fen Liu is an investigator in the VA Health Services Research and Development Center for Veteran-Centered, Value-Driven Health and a research professor in the Department of Health Services, School of Public Health, University of Washington
| | - Edwin S Wong
- Edwin S. Wong is an investigator in the VA Health Services Research and Development Center for Veteran-Centered, Value-Driven Health
| | - Susan E Hernandez
- Susan E. Hernandez is a doctoral candidate in the Department of Health Services, School of Public Health, University of Washington
| | - Adam Batten
- Adam Batten is a statistician in the VA Health Services Research and Development Center for Veteran-Centered, Value-Driven Health
| | - Sophie Lo
- Sophie Lo is a program analyst in the Veterans Health Administration Office of Analytics and Business Intelligence, in Bedford, Massachusetts
| | - Jaclyn M Lemon
- Jaclyn M. Lemon is a medical student at the University of Washington School of Medicine
| | - Douglas A Conrad
- Douglas A. Conrad is a professor of health services at the School of Public Health, University of Washington
| | - David Grembowski
- David Grembowski is a professor of health services at the University of Washington
| | - Karin Nelson
- Karin Nelson is an investigator in the VA Health Services Research and Development Center for Veteran-Centered, Value-Driven Health and an associate professor in the Department of Medicine, School of Medicine, University of Washington
| | - Stephan D Fihn
- Stephan D. Fihn is director of the VHA Office of Analytics and Business Intelligence, VA Puget Sound Health Care System, and a professor in the Department of Medicine, School of Medicine, University of Washington
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Denton GD, Lo MC, Brandenburg S, Hingle S, Meade L, Chheda S, Fazio SB, Blanchard M, Hoellein A. Solutions to common problems in training learners in general internal medicine ambulatory settings. Am J Med 2015; 128:1152-7. [PMID: 26071822 DOI: 10.1016/j.amjmed.2015.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/29/2015] [Indexed: 11/25/2022]
Affiliation(s)
- G Dodd Denton
- Ochsner Clinical School, University of Queensland, New Orleans, La.
| | - Margaret C Lo
- University of Florida College of Medicine, Gainesville
| | | | - Susan Hingle
- Southern Illinois University School of Medicine, Springfield
| | - Lauren Meade
- Tufts University School of Medicine, Baystate Medical Center, Springfield, Mass
| | - Shobhina Chheda
- University of Wisconsin School of Medicine and Public Health, Madison
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Soones TN, O'Brien BC, Julian KA. Internal Medicine Residents' Perceptions of Team-Based Care and its Educational Value in the Continuity Clinic: A Qualitative Study. J Gen Intern Med 2015; 30:1279-85. [PMID: 26173512 PMCID: PMC4539326 DOI: 10.1007/s11606-015-3228-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In order to teach residents how to work in interprofessional teams, educators in graduate medical education are implementing team-based care models in resident continuity clinics. However, little is known about the impact of interprofessional teams on residents' education in the ambulatory setting. OBJECTIVE To identify factors affecting residents' experience of team-based care within continuity clinics and the impact of these teams on residents' education. DESIGN This was a qualitative study of focus groups with internal medicine residents. PARTICIPANTS Seventy-seven internal medicine residents at the University of California San Francisco at three continuity clinic sites participated in the study. APPROACH Qualitative interviews were audiotaped and transcribed. The authors used a general inductive approach with sensitizing concepts in four frames (structural, human resources, political and symbolic) to develop codes and identify themes. KEY RESULTS Residents believed that team-based care improves continuity and quality of care. Factors in four frames affected their ability to achieve these goals. Structural factors included communication through the electronic medical record, consistent schedules and regular team meetings. Human resources factors included the presence of stable teams and clear roles. Political and symbolic factors negatively impacted team-based care, and included low staffing ratios and a culture of ultimate resident responsibility, respectively. Regardless of the presence of these factors or resident perceptions of their teams, residents did not see the practice of interprofessional team-based care as intrinsically educational. CONCLUSIONS Residents' experiences practicing team-based care are influenced by many principles described in the interprofessional teamwork literature, including understanding team members' roles, good communication and sufficient staffing. However, these attributes are not correlated with residents' perceptions of the educational value of team-based care. Including residents in interprofessional teams in their clinic may not be sufficient to teach residents how team-based care can enhance their overall learning and future practice.
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Affiliation(s)
- Tacara N Soones
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, NY, USA,
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Sklar M, Aarons GA, O'Connell M, Davidson L, Groessl EJ. Mental Health Recovery in the Patient-Centered Medical Home. Am J Public Health 2015; 105:1926-34. [PMID: 26180945 DOI: 10.2105/ajph.2015.302683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the impact of transitioning clients from a mental health clinic to a patient-centered medical home (PCMH) on mental health recovery. METHODS We drew data from a large US County Behavioral Health Services administrative data set. We used propensity score analysis and multilevel modeling to assess the impact of the PCMH on mental health recovery by comparing PCMH participants (n = 215) to clients receiving service as usual (SAU; n = 22,394) from 2011 to 2013 in San Diego County, California. We repeatedly assessed mental health recovery over time (days since baseline assessment range = 0-1639; mean = 186) with the Illness Management and Recovery (IMR) scale and Recovery Markers Questionnaire. RESULTS For total IMR (log-likelihood ratio χ(2)[1] = 4696.97; P < .001) and IMR Factor 2 Management scores (log-likelihood ratio χ(2)[1] = 7.9; P = .005), increases in mental health recovery over time were greater for PCMH than SAU participants. Increases on all other measures over time were similar for PCMH and SAU participants. CONCLUSIONS Greater increases in mental health recovery over time can be expected when patients with severe mental illness are provided treatment through the PCMH. Evaluative efforts should be taken to inform more widespread adoption of the PCMH.
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Affiliation(s)
- Marisa Sklar
- Marisa Sklar is with San Diego State University-University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego. Gregory A. Aarons is with Department of Psychiatry, University of California San Diego, La Jolla. Maria O'Connell and Larry Davidson are with Department of Psychiatry, Yale School of Medicine, New Haven, CT. Erik J. Groessl is with Department of Family and Preventive Medicine, University of California San Diego
| | - Gregory A Aarons
- Marisa Sklar is with San Diego State University-University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego. Gregory A. Aarons is with Department of Psychiatry, University of California San Diego, La Jolla. Maria O'Connell and Larry Davidson are with Department of Psychiatry, Yale School of Medicine, New Haven, CT. Erik J. Groessl is with Department of Family and Preventive Medicine, University of California San Diego
| | - Maria O'Connell
- Marisa Sklar is with San Diego State University-University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego. Gregory A. Aarons is with Department of Psychiatry, University of California San Diego, La Jolla. Maria O'Connell and Larry Davidson are with Department of Psychiatry, Yale School of Medicine, New Haven, CT. Erik J. Groessl is with Department of Family and Preventive Medicine, University of California San Diego
| | - Larry Davidson
- Marisa Sklar is with San Diego State University-University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego. Gregory A. Aarons is with Department of Psychiatry, University of California San Diego, La Jolla. Maria O'Connell and Larry Davidson are with Department of Psychiatry, Yale School of Medicine, New Haven, CT. Erik J. Groessl is with Department of Family and Preventive Medicine, University of California San Diego
| | - Erik J Groessl
- Marisa Sklar is with San Diego State University-University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego. Gregory A. Aarons is with Department of Psychiatry, University of California San Diego, La Jolla. Maria O'Connell and Larry Davidson are with Department of Psychiatry, Yale School of Medicine, New Haven, CT. Erik J. Groessl is with Department of Family and Preventive Medicine, University of California San Diego
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David SP, Johnson SG, Berger AC, Feero WG, Terry SF, Green LA, Phillips RL, Ginsburg GS. Making Personalized Health Care Even More Personalized: Insights From Activities of the IOM Genomics Roundtable. Ann Fam Med 2015; 13:373-80. [PMID: 26195686 PMCID: PMC4508182 DOI: 10.1370/afm.1772] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 12/29/2014] [Accepted: 01/21/2015] [Indexed: 01/08/2023] Open
Abstract
Genomic research has generated much new knowledge into mechanisms of human disease, with the potential to catalyze novel drug discovery and development, prenatal and neonatal screening, clinical pharmacogenomics, more sensitive risk prediction, and enhanced diagnostics. Genomic medicine, however, has been limited by critical evidence gaps, especially those related to clinical utility and applicability to diverse populations. Genomic medicine may have the greatest impact on health care if it is integrated into primary care, where most health care is received and where evidence supports the value of personalized medicine grounded in continuous healing relationships. Redesigned primary care is the most relevant setting for clinically useful genomic medicine research. Taking insights gained from the activities of the Institute of Medicine (IOM) Roundtable on Translating Genomic-Based Research for Health, we apply lessons learned from the patient-centered medical home national experience to implement genomic medicine in a patient-centered, learning health care system.
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Affiliation(s)
- Sean P David
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California Roundtable on Translating Genomic-Based Research for Health, Institute of Medicine (IOM) of the National Academies
| | - Samuel G Johnson
- Roundtable on Translating Genomic-Based Research for Health, Institute of Medicine (IOM) of the National Academies Applied Pharmacogenomics, Kaiser-Permanente Colorado, Aurora, Colorado Department of Clinical Pharmacy, University of Colorado, Denver, Colorado
| | - Adam C Berger
- Applied Pharmacogenomics, Kaiser-Permanente Colorado, Aurora, Colorado
| | - W Gregory Feero
- Applied Pharmacogenomics, Kaiser-Permanente Colorado, Aurora, Colorado Maine-Dartmouth Family Medicine Residency Program, Augusta, Maine
| | - Sharon F Terry
- Roundtable on Translating Genomic-Based Research for Health, Institute of Medicine (IOM) of the National Academies Genetic Alliance, Washington, DC
| | - Larry A Green
- Department of Family Medicine, University of Colorado, Denver, Colorado
| | | | - Geoffrey S Ginsburg
- Roundtable on Translating Genomic-Based Research for Health, Institute of Medicine (IOM) of the National Academies Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
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Fontaine P, Whitebird R, Solberg LI, Tillema J, Smithson A, Crabtree BF. Minnesota's Early Experience with Medical Home Implementation: Viewpoints from the Front Lines. J Gen Intern Med 2015; 30:899-906. [PMID: 25500785 PMCID: PMC4471008 DOI: 10.1007/s11606-014-3136-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 10/16/2014] [Accepted: 11/14/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Evidence is evolving about the impact of patient-centered medical homes (PCMHs) on important outcomes in primary care. Minnesota has developed its own PCMH certification process, envisioned as an all-payer initiative with an emphasis on patient-centeredness, which may add unique experiences and outcomes to the national discussion. OBJECTIVE We aimed to identify the facilitators and barriers encountered by nine diverse primary care practices selected from the first 80 to achieve PCMH certification in Minnesota. DESIGN This was a qualitative analysis of semi-structured, in-person interviews. PARTICIPANTS Thirty-one administrative and clinical leaders, including clinic managers, physician champions, medical directors, nursing supervisors, and care coordinators participated in the study. KEY RESULTS Six factors emerged as most important to the efforts to become PMCHs: leadership support, organizational culture, finances, quality improvement (QI) experience, information technology (IT) resources, and patient involvement. Facilitators included committed leadership at local and higher levels, prior experience and ongoing support for QI initiatives, and adequate financial and IT resources. Reimbursement was a significant barrier due to perceived inadequacy and inconsistent participation by health plans. The unsuitability of electronic medical records (EMRs) to PCMH documentation requirements likewise presented ongoing challenges. Many interviewees described patient input as helpful to their clinics' PCMH-related changes and were enthusiastic about their "patient partners." The majority of interviewees felt that becoming a PCMH was right for patients and was personally worthwhile, even while acknowledging the tremendous effort involved and voicing skepticism about reimbursement over the short term. CONCLUSIONS The experience of participants in Minnesota's state-wide initiative to legislate PCMH transformation provides a broad view of facilitators and barriers. Unique facilitators included a requirement for patient involvement, which pushed practices to create patient-centered innovations, and new reimbursement models based on quality indicators for a population. Among barriers were the costs to practices and patients, and EMRs that failed to accommodate PCMH requirements.
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Affiliation(s)
- Patricia Fontaine
- HealthPartners Institute for Education and Research, PO Box 1524, MS 23301A, Minneapolis, MN, 55440-1524, USA,
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Reynolds PP, Klink K, Gilman S, Green LA, Phillips RS, Shipman S, Keahey D, Rugen K, Davis M. The Patient-Centered Medical Home: Preparation of the Workforce, More Questions than Answers. J Gen Intern Med 2015; 30:1013-7. [PMID: 25707941 PMCID: PMC4471027 DOI: 10.1007/s11606-015-3229-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 10/08/2014] [Accepted: 01/26/2015] [Indexed: 10/24/2022]
Abstract
As American medicine continues to undergo significant transformation, the patient-centered medical home (PCMH) is emerging as an interprofessional primary care model designed to deliver the right care for patients, by the right professional, at the right time, in the right setting, for the right cost. A review of local, state, regional and national initiatives to train professionals in delivering care within the PCMH model reveals some successes, but substantial challenges. Workforce policy recommendations designed to improve PCMH effectiveness and efficiency include 1) adoption of an expanded definition of primary care, 2) fundamental redesign of health professions education, 3) payment reform, 4) responsiveness to local needs assessments, and 5) systems improvement to emphasize quality, population health, and health disparities.
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Jenkins LS, Gunst C, Blitz J, Coetzee JF. What keeps health professionals working in rural district hospitals in South Africa? Afr J Prim Health Care Fam Med 2015; 7:805. [PMID: 26245623 PMCID: PMC4564845 DOI: 10.4102/phcfm.v7i1.805] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 02/24/2015] [Accepted: 01/15/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The theme of the 2014 Southern African Rural Health Conference was 'Building resilience in facing rural realities'. Retaining health professionals in South Africa is critical for sustainable health services. Only 12% of doctors and 19% of nurses have been retained in the rural areas. The aim of the workshop was to understand from health practitioners why they continued working in their rural settings. CONFERENCE WORKSHOP: The workshop consisted of 29 doctors, managers, academic family physicians, nurses and clinical associates from Southern Africa, with work experience from three weeks to 13 years, often in deep rural districts. Using the nominal group technique, the following question was explored, 'What is it that keeps you going to work every day?' Participants reflected on their work situation and listed and rated the important reasons for continuing to work. RESULTS Five main themes emerged. A shared purpose, emanating from a deep sense of meaning, was the strongest reason for staying and working in a rural setting. Working in a team was second most important, with teamwork being related to attitudes and relationships, support from visiting specialists and opportunities to implement individual clinical skills. A culture of support was third, followed by opportunities for growth and continuing professional development, including teaching by outreaching specialists. The fifth theme was a healthy work-life balance. CONCLUSION Health practitioners continue to work in rural settings for often deeper reasons relating to a sense of meaning, being part of a team that closely relate to each other and feeling supported.
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Affiliation(s)
- Louis S Jenkins
- Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University and Western Cape Department of Health.
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Kozakowski SM, Eiff MP, Green LA, Pugno PA, Waller E, Jones SM, Fetter G, Carney PA. Five Key Leadership Actions Needed to Redesign Family Medicine Residencies. J Grad Med Educ 2015. [PMID: 26221432 PMCID: PMC4512787 DOI: 10.4300/jgme-d-14-00214.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND New skills are needed to properly prepare the next generation of physicians and health professionals to practice in medical homes. Transforming residency training to address these new skills requires strong leadership. OBJECTIVE We sought to increase the understanding of leadership skills useful in residency programs that plan to undertake meaningful change. METHODS The Preparing the Personal Physician for Practice (P4) project (2007-2014) was a comparative case study of 14 family medicine residencies that engaged in innovative training redesign, including altering the scope, content, sequence, length, and location of training to align resident education with requirements of the patient-centered medical home. In 2012, each P4 residency team submitted a final summary report of innovations implemented, overall insights, and dissemination activities during the study. Six investigators conducted independent narrative analyses of these reports. A consensus meeting held in September 2012 was used to identify key leadership actions associated with successful educational redesign. RESULTS Five leadership actions were associated with successful implementation of innovations and residency transformation: (1) manage change; (2) develop financial acumen; (3) adapt best evidence educational strategies to the local environment; (4) create and sustain a vision that engages stakeholders; and (5) demonstrate courage and resilience. CONCLUSIONS Residency programs are expected to change to better prepare their graduates for a changing delivery system. Insights about effective leadership skills can provide guidance for faculty to develop the skills needed to face practical realities while guiding transformation.
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Taplin SH, Weaver S, Salas E, Chollette V, Edwards HM, Bruinooge SS, Kosty MP. Reviewing cancer care team effectiveness. J Oncol Pract 2015; 11:239-46. [PMID: 25873056 PMCID: PMC4438110 DOI: 10.1200/jop.2014.003350] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The management of cancer varies across its type, stage, and natural history. This necessitates involvement of a variety of individuals and groups across a number of provider types. Evidence from other fields suggests that a team-based approach helps organize and optimize tasks that involve individuals and groups, but team effectiveness has not been fully evaluated in oncology-related care. METHODS We undertook a systematic review of literature published between 2009 and 2014 to identify studies of all teams with clear membership, a comparator group, and patient-level metrics of cancer care. When those teams included two or more people with specialty training relevant to the care of patients with cancer, we called them multidisciplinary care teams (MDTs). After reviews and exclusions, 16 studies were thoroughly evaluated: two addressing screening and diagnosis, 11 addressing treatment, two addressing palliative care, and one addressing end-of-life care. The studies included a variety of end points (eg, adherence to quality indicators, patient satisfaction with care, mortality). RESULTS Teams for screening and its follow-up improved screening use and reduced time to follow-up colonoscopy after an abnormal screen. Discussion of cases within MDTs improved the planning of therapy, adherence to recommended preoperative assessment, pain control, and adherence to medications. We did not see convincing evidence that MDTs affect patient survival or cost of care, or studies of how or which MDT processes and structures were associated with success. CONCLUSION Further research should focus on the association between team processes and structures, efficiency in delivery of care, and mortality.
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Affiliation(s)
- Stephen H Taplin
- National Cancer Institute, Bethesda; Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD; University of Central Florida, Orlando, FL; American Society of Clinical Oncology, Alexandria, VA; and Scripps Clinic, La Jolla, Ca
| | - Sallie Weaver
- National Cancer Institute, Bethesda; Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD; University of Central Florida, Orlando, FL; American Society of Clinical Oncology, Alexandria, VA; and Scripps Clinic, La Jolla, Ca
| | - Eduardo Salas
- National Cancer Institute, Bethesda; Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD; University of Central Florida, Orlando, FL; American Society of Clinical Oncology, Alexandria, VA; and Scripps Clinic, La Jolla, Ca
| | - Veronica Chollette
- National Cancer Institute, Bethesda; Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD; University of Central Florida, Orlando, FL; American Society of Clinical Oncology, Alexandria, VA; and Scripps Clinic, La Jolla, Ca
| | - Heather M Edwards
- National Cancer Institute, Bethesda; Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD; University of Central Florida, Orlando, FL; American Society of Clinical Oncology, Alexandria, VA; and Scripps Clinic, La Jolla, Ca
| | - Suanna S Bruinooge
- National Cancer Institute, Bethesda; Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD; University of Central Florida, Orlando, FL; American Society of Clinical Oncology, Alexandria, VA; and Scripps Clinic, La Jolla, Ca
| | - Michael P Kosty
- National Cancer Institute, Bethesda; Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore; Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD; University of Central Florida, Orlando, FL; American Society of Clinical Oncology, Alexandria, VA; and Scripps Clinic, La Jolla, Ca
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Using a facilitation model to achieve patient-centered medical home recognition. Health Care Manag (Frederick) 2015; 34:93-105. [PMID: 25909396 DOI: 10.1097/hcm.0000000000000059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article describes how a facilitation model that included a partnership between a Community Care of North Carolina network and undergraduates at a regional university supported rural primary care practices in transforming their practices to become National Committee for Quality Assurance-recognized patient-centered medical homes. Health care management and preprofessional undergraduate students worked with 14 rural primary care practices to redesign practice processes and complete the patient-centered medical home application. Twelve of the practices participated in the evaluation of the student contribution. A semistructured interview guide containing questions about practice characteristics, student competencies, and the value of the student's contribution to their practice's achievement of patient-centered medical home recognition was used to interview practice managers or their designee. Analysis included item-descriptive statistics and qualitative analysis of narrative content. All 12 participating practices achieved 2011 National Committee for Quality Assurance patient-centered medical home recognition, with 4 practices achieving level 3, 5 practices achieving level 2, and 3 practices achieving level 1. The facilitation model using partnerships between health care agencies and universities might be an option for enhancing a practice's internal capacity for successful transformation and should be explored further.
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Alexander JA, Markovitz AR, Paustian ML, Wise CG, El Reda DK, Green LA, Fetters MD. Implementation of Patient-Centered Medical Homes in Adult Primary Care Practices. Med Care Res Rev 2015; 72:438-67. [PMID: 25861803 DOI: 10.1177/1077558715579862] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 03/07/2015] [Indexed: 11/17/2022]
Abstract
There has been relatively little empirical evidence about the effects of patient-centered medical home (PCMH) implementation on patient-related outcomes and costs. Using a longitudinal design and a large study group of 2,218 Michigan adult primary care practices, our study examined the following research questions: Is the level of, and change in, implementation of PCMH associated with medical surgical cost, preventive services utilization, and quality of care in the following year? Results indicated that both level and amount of change in practice implementation of PCMH are independently and positively associated with measures of quality of care and use of preventive services, after controlling for a variety of practice, patient cohort, and practice environmental characteristics. Results also indicate that lower overall medical and surgical costs are associated with higher levels of PCMH implementation, although change in PCMH implementation did not achieve statistical significance.
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Affiliation(s)
| | | | | | | | | | - Lee A Green
- University of Alberta, Edmonton, Alberta, Canada
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Etz RS, Keith RE, Maternick AM, Stein KL, Sabo RT, Hayes MS, Sevak P, Holland J, Crosson JC. Supporting Practices to Adopt Registry-Based Care (SPARC): protocol for a randomized controlled trial. Implement Sci 2015; 10:46. [PMID: 25885661 PMCID: PMC4399225 DOI: 10.1186/s13012-015-0232-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/11/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Diabetes is predicted to increase in incidence by 42% from 1995 to 2025. Although most adults with diabetes seek care from primary care practices, adherence to treatment guidelines in these settings is not optimal. Many practices lack the infrastructure to monitor patient adherence to recommended treatment and are slow to implement changes critical for effective management of patients with chronic conditions. Supporting Practices to Adopt Registry-Based Care (SPARC) will evaluate effectiveness and sustainability of a low-cost intervention designed to support work process change in primary care practices and enhance focus on population-based care through implementation of a diabetes registry. METHODS SPARC is a two-armed randomized controlled trial (RCT) of 30 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participating practices (including control groups) will be introduced to population health concepts and tools for work process redesign and registry adoption at a meeting of practice-level implementation champions. Practices randomized to the intervention will be assigned study peer mentors, receive a list of specific milestones, and have access to a physician informaticist. Peer mentors are clinicians who successfully implemented registries in their practices and will help champions in the intervention practices throughout the implementation process. During the first year, peer mentors will contact intervention practices monthly and visit them quarterly. Control group practices will not receive support or guidance for registry implementation. We will use a mixed-methods explanatory sequential design to guide collection of medical record, participant observation, and semistructured interview data in control and intervention practices at baseline, 12 months, and 24 months. We will use grounded theory and a template-guided approach using the Consolidated Framework for Implementation Research to analyze qualitative data on contextual factors related to registry adoption. We will assess intervention effectiveness by comparing changes in patient-level hemoglobin A1c scores from baseline to year 1 between intervention and control practices. DISCUSSION Findings will enhance our understanding of how to leverage existing practice resources to improve diabetes care in primary care practices by implementing and using a registry. SPARC has the potential to validate the effectiveness of low-cost implementation strategies that target practice change in primary care. TRIAL REGISTRATION NCT02318108.
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Affiliation(s)
- Rebecca S Etz
- Department of Family Medicine and Population Health, Virginia Commonwealth University, 830 East Main Street, Room 629, PO Box 980101, Richmond, VA, 23298-0101, USA.
| | | | - Anna M Maternick
- Department of Family Medicine and Population Health, Virginia Commonwealth University, 830 East Main Street, Room 629, PO Box 980101, Richmond, VA, 23298-0101, USA.
| | - Karen L Stein
- Department of Family Medicine and Population Health, Virginia Commonwealth University, 830 East Main Street, Room 629, PO Box 980101, Richmond, VA, 23298-0101, USA.
| | - Roy T Sabo
- Department of Family Medicine and Population Health, Virginia Commonwealth University, 830 East Main Street, Room 629, PO Box 980101, Richmond, VA, 23298-0101, USA.
| | - Melissa S Hayes
- Department of Family Medicine and Population Health, Virginia Commonwealth University, 830 East Main Street, Room 629, PO Box 980101, Richmond, VA, 23298-0101, USA.
| | - Purvi Sevak
- Mathematica Policy Research, Princeton, NJ, USA.
| | - John Holland
- Mathematica Policy Research, Princeton, NJ, USA.
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Adaptive leadership framework for chronic illness: framing a research agenda for transforming care delivery. ANS Adv Nurs Sci 2015; 38:83-95. [PMID: 25647829 PMCID: PMC4417005 DOI: 10.1097/ans.0000000000000063] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We propose the Adaptive Leadership Framework for Chronic Illness as a novel framework for conceptualizing, studying, and providing care. This framework is an application of the Adaptive Leadership Framework developed by Heifetz and colleagues for business. Our framework views health care as a complex adaptive system and addresses the intersection at which people with chronic illness interface with the care system. We shift focus from symptoms to symptoms and the challenges they pose for patients/families. We describe how providers and patients/families might collaborate to create shared meaning of symptoms and challenges to coproduce appropriate approaches to care.
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Zickafoose JS, DeCamp LR, Prosser LA. Parents' preferences for enhanced access in the pediatric medical home: a discrete choice experiment. JAMA Pediatr 2015; 169:358-64. [PMID: 25643000 PMCID: PMC4545238 DOI: 10.1001/jamapediatrics.2014.3534] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Efforts to transform primary care through the medical home model may have limited effectiveness if they do not incorporate families' preferences for different primary care services. OBJECTIVE To assess parents' relative preferences for different categories of enhanced access services in primary care. DESIGN, SETTING, AND PARTICIPANTS Internet-based survey that took place with a national online panel from December 8, 2011, to December 22, 2011. Participants included 820 parents of children aged 0 to 17 years. Hispanic and black non-Hispanic parents were each oversampled to 20% of the sample. The survey included a discrete choice experiment with questions that asked parents to choose between hypothetical primary care practices with different levels of enhanced access and other primary care services. MAIN OUTCOMES AND MEASURES We estimated parents' relative preferences for different enhanced access services using travel time to the practice as a trade-off and parents' marginal willingness to travel in minutes for practices with different levels of services. RESULTS The response rate of parents who participated in the study was 41.2%. Parents were most likely to choose primary care offices that guaranteed same-day sick visits (coefficient, 0.57 [SE, 0.05]; P < .001) followed by those with higher professional continuity (coefficient, 0.36 [SE, 0.03]; P < .001). Parents were also significantly more likely to choose practices with 24-hour telephone advice plus nonurgent email advice (0.08 [0.04]; P < .05), evening hours 4 or more times a week (0.14 [0.04]; P < .001), and at least some hours on weekends. Parents were significantly less likely to choose practices that were closed during some weekday daytime hours or had wait times longer than 4 weeks for preventive care visits. There was very little variation in preferences among parents with different sociodemographic characteristics. Parents' marginal willingness to travel was 14 minutes (95% CI, 11-16 minutes) for guaranteed same-day sick visits and 44 minutes (95% CI, 37-51 minutes) for an office with idealized levels of all services. CONCLUSIONS AND RELEVANCE As primary care practices for children implement aspects of the medical home model, those that emphasize same-day sick care and professional continuity are more likely to meet parents' preferences for enhanced access. Practices should seek to engage families in prioritizing changes in practice services as part of medical home implementation.
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Affiliation(s)
- Joseph S. Zickafoose
- Mathematica Policy Research, Ann Arbor, Michigan3Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor
| | - Lisa R. DeCamp
- Division of General Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Lisa A. Prosser
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor
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Mundt MP, Gilchrist VJ, Fleming MF, Zakletskaia LI, Tuan WJ, Beasley JW. Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease. Ann Fam Med 2015; 13:139-48. [PMID: 25755035 PMCID: PMC4369607 DOI: 10.1370/afm.1754] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease. METHODS Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months. RESULTS Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50-0.77) and lower medical care costs (-$556; 95% CI, -$781 to -$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09-1.94) and greater costs ($506; 95% CI, $202-$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes. CONCLUSIONS Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost.
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Affiliation(s)
- Marlon P Mundt
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Valerie J Gilchrist
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Michael F Fleming
- Departments of Psychiatry and Family Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Larissa I Zakletskaia
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Wen-Jan Tuan
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John W Beasley
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Abstract
Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.
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Affiliation(s)
- D Edward Deneke
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA.
| | - Heather E Schultz
- Inpatient Psychiatry, University of Michigan Hospital and Health Systems, University of Michigan University Hospital, 9C 9150, 1500 East Medical Center Drive, SPC 5120, Ann Arbor MI 48109, USA
| | - Thomas E Fluent
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA
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Chase SM, Crabtree BF, Stewart EE, Nutting PA, Miller WL, Stange KC, Jaén CR. Coaching strategies for enhancing practice transformation. Fam Pract 2015; 32:75-81. [PMID: 25281823 DOI: 10.1093/fampra/cmu062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current research on primary care practice redesign suggests that outside facilitation can be an important source of support for achieving substantial change. OBJECTIVES To analyse the specific sequence of strategies used by a successful practice facilitator during the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP). METHODS This secondary analysis describes a sequence of strategies used to produce change in family medicine practices attempting to adopt a new model of care. The authors analysed qualitative data generated by one facilitator and six practices by coding facilitator field notes, site visit reports, qualitative summaries, depth interviews and email strings. RESULTS The facilitator utilized practice member coaching in addition to consulting, negotiating and connecting approaches. Coaching strategies encouraged: (i) expansive, multi-directional, attentive styles of communication; (ii) solving practical problems together; (iii) modelling facilitative leadership and (iv) encouraging an expanded vision of care. Practice members who received consistent coaching reported internal shifts and new ways of conceptualizing work, not just success at implementing model components. They indicated that their facilitator had helped them think and behave in new ways while helping them achieve benchmarks. CONCLUSIONS It was once believed that the transition from traditional models of family medicine practice to new models of care meant implementing new technological components, suggesting that outside facilitators should act as technological and care delivery consultants. However, coaches may be especially useful in helpful in practices undertake substantial changes.
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Affiliation(s)
- Sabrina M Chase
- Rutgers School of Nursing, Rutgers Biomedical and Health Sciences, Rutgers University, Newark, NJ,
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Paul A Nutting
- Department of Family Medicine, University of Colorado Health Sciences Center, Denver, CO
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA
| | - Kurt C Stange
- Family Medicine and Community Health, Epidemiology and Biostatistics, Sociology, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland Clinical and Translational Science Collaborative, Cleveland, OH and
| | - Carlos R Jaén
- Departments of Family and Community Medicine and Epidemiology and Biostatistics, Research to Address Community Health (REACH) Center, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Minimally Disruptive Medicine: A Pragmatically Comprehensive Model for Delivering Care to Patients with Multiple Chronic Conditions. Healthcare (Basel) 2015; 3:50-63. [PMID: 27417747 PMCID: PMC4934523 DOI: 10.3390/healthcare3010050] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 01/21/2015] [Indexed: 01/21/2023] Open
Abstract
An increasing proportion of healthcare resources in the United States are directed toward an expanding group of complex and multimorbid patients. Federal stakeholders have called for new models of care to meet the needs of these patients. Minimally Disruptive Medicine (MDM) is a theory-based, patient-centered, and context-sensitive approach to care that focuses on achieving patient goals for life and health while imposing the smallest possible treatment burden on patients’ lives. The MDM Care Model is designed to be pragmatically comprehensive, meaning that it aims to address any and all factors that impact the implementation and effectiveness of care for patients with multiple chronic conditions. It comprises core activities that map to an underlying and testable theoretical framework. This encourages refinement and future study. Here, we present the conceptual rationale for and a practical approach to minimally disruptive care for patients with multiple chronic conditions. We introduce some of the specific tools and strategies that can be used to identify the right care for these patients and to put it into practice.
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82
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Meeker WC, Watkins R, Kranz KC, Munsterman SD, Johnson C. Improving Our Nation's Health Care System: Inclusion of Chiropractic in Patient-Centered Medical Homes and Accountable Care Organizations. JOURNAL OF CHIROPRACTIC HUMANITIES 2014; 21:49-64. [PMID: 25431542 PMCID: PMC4245703 DOI: 10.1016/j.echu.2014.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/11/2014] [Accepted: 09/19/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE This report summarizes the closing plenary session of the Association of Chiropractic Colleges Educational Conference-Research Agenda Conference 2014. The purpose of this session was to examine patient-centered medical homes and accountable care organizations from various speakers' viewpoints and to discuss how chiropractic could possibly work within, and successfully contribute to, the changing health care environment. DISCUSSION The speakers addressed the complex topic of patient-centered medical homes and accountable care organizations and provided suggestions for what leadership strategies the chiropractic profession may need to enhance chiropractic participation and contribution to improving our nation's health. CONCLUSION There are many factors involved in the complex topic of chiropractic inclusion in health care models. Major themes resulting from this panel included the importance of building relationships with other professionals, demonstrating data and evidence for what is done in chiropractic practice, improving quality of care, improving health of populations, and reducing costs of health care.
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Affiliation(s)
| | - R.W. Watkins
- Senior Physician Consultant, Community Care of NC Raleigh, NC
- Adjunct Associate Professor, Family Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Karl C. Kranz
- Executive Director/Staff Counsel, New York State Chiropractic Association Niskayuna, NY
| | | | - Claire Johnson
- Professor, National University of Health Sciences Lombard, IL
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Leykum LK, Lanham HJ, Pugh JA, Parchman M, Anderson RA, Crabtree BF, Nutting PA, Miller WL, Stange KC, McDaniel RR. Manifestations and implications of uncertainty for improving healthcare systems: an analysis of observational and interventional studies grounded in complexity science. Implement Sci 2014; 9:165. [PMID: 25407138 PMCID: PMC4239371 DOI: 10.1186/s13012-014-0165-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/27/2014] [Indexed: 12/02/2022] Open
Abstract
Background The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory. Methods We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results. Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease. Results We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion). Conclusions Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0165-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luci K Leykum
- South Texas Veterans Health Care System, San Antonio, TX, USA.
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84
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Kumar S, Deshmukh V, Adhish VS. Building and leading teams. Indian J Community Med 2014; 39:208-13. [PMID: 25364143 PMCID: PMC4215500 DOI: 10.4103/0970-0218.143020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 09/24/2014] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sanjiv Kumar
- Executive Director, National Health Systems Resource Centre, National Health Mission, Ministry of Health and Family Welfare, Government of India, NIHFW Campus, Baba Gangnath Marg, Munirka, New Delhi, India
| | | | - Vivek S Adhish
- Department of Community Health Administration, National Institute of Health and Family Welfare, New Delhi, India
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Getting on with living life: experiences of older adults after home care. ACTA ACUST UNITED AC 2014; 31:493-501; quiz 501-3. [PMID: 24081131 DOI: 10.1097/nhh.0b013e3182a87654] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Providers in all settings are increasingly aware of the need to focus on transitional care needs and services across healthcare settings to improve quality of life, maintain optimal health, and prevent unnecessary hospitalizations. Home care is an essential piece of the transitional care puzzle, especially in providing services to support older adults with chronic comorbid conditions to remain at home safely with optimal health and psychosocial well-being. Home care is essential in bridging the gap from acute hospital care to home; however, little is known about the needs of older adults after discharge from home care. Our study investigated the perceptions of older adults with chronic health conditions after discharge from home care regarding their daily activities and healthcare needs and identified how these needs were met.
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86
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Kennedy BM, Cerise F, Horswell R, Griffin WP, Willis KH, Moody-Thomas S, Besse JA, Katzmarzyk PT. Obtaining the Patient's Voice from within Three Patient-Centered Medical Homes. Clin Transl Sci 2014; 8:367-75. [PMID: 25066616 DOI: 10.1111/cts.12192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The purpose of this qualitative program was to determine if a trend exists across three LSU medical homes according to patient feedback concerning their experiences within the medical home for ongoing disease management and quality healthcare; and to obtain recommendations for the most effective way to involve patients in shaping system policies, procedures, and practices consistent with patient and family-centered care principles. A total of 94 adult patients participated in either cognitive interviews (n = 45) or structured focus groups (n = 49) using the Nominal Group Technique (NGT). Exit surveys collected demographic information and feedback from patients about opportunities for their involvement in shaping medical homes. Cognitive interviews and NGT sessions both revealed some patient-perceived gratifications (i.e., friendliness and helpfulness of the clinic staff), and deficiencies (i.e., improving scheduling of appointments and reducing wait time in the clinic) within these medical homes. However, the perceived gratifications far exceeded the deficiencies found within each of three LSU medical homes.
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Affiliation(s)
- Betty M Kennedy
- The Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Frederick Cerise
- The LSU Health Sciences Center School of Medicine, New Orleans, Louisiana, USA
| | - Ronald Horswell
- The Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Willene P Griffin
- The Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Kathleen H Willis
- The LSU Health System Lallie Kemp Medical Center, Independence, Louisiana, USA
| | - Sarah Moody-Thomas
- The Louisiana State University (LSU) Health Sciences Center School of Public Health, New Orleans, Louisiana, USA
| | - Jay A Besse
- The LSU Health Care Services Division, Louisiana, USA
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Janamian T, Jackson CL, Glasson N, Nicholson C. A systematic review of the challenges to implementation of the patient‐centred medical home: lessons for Australia. Med J Aust 2014; 201:S69-73. [DOI: 10.5694/mja14.00295] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 05/29/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Tina Janamian
- Centre of Research Excellence in Primary Health Care Microsystems, University of Queensland, Brisbane, QLD
| | - Claire L Jackson
- Discipline of General Practice, University of Queensland, Brisbane, QLD
- Centres for Primary Care Reform Research Excellence, University of Queensland, Brisbane, QLD
| | - Nicola Glasson
- Faculty of Medicine, James Cook University, Townsville, QLD
| | - Caroline Nicholson
- Discipline of General Practice, University of Queensland, Brisbane, QLD
- Mater–UQ Centre for Primary Healthcare Innovation, Mater Health Services, Brisbane, QLD
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Forman J, Harrod M, Robinson C, Annis-Emeott A, Ott J, Saffar D, Krein SL, Greenstone CL. First things first: foundational requirements for a medical home in an academic medical center. J Gen Intern Med 2014; 29 Suppl 2:S640-8. [PMID: 24715389 PMCID: PMC4070244 DOI: 10.1007/s11606-013-2674-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2010, the Veterans Health Administration (VHA) began implementation of its medical home, Patient Aligned Care Teams (PACT), in 900 primary care clinics nationwide, with 120 located in academically affiliated medical centers. The literature on Patient-Centered Medical Home (PCMH) implementation has focused mainly on small, nonacademic practices. OBJECTIVE To understand the experiences of primary care leadership, physicians and staff during early PACT implementation in a VHA academically affiliated primary care clinic and provide insights to guide future PCMH implementation. DESIGN We conducted a qualitative case study during early PACT implementation. PARTICIPANTS Primary care clinical leadership, primary care providers, residents, and staff. APPROACH Between February 2011 and March 2012, we conducted 22 semi-structured interviews, purposively sampling participants by clinic role, and convenience sampling within role. We also conducted observations of 30 nurse case manager staff meetings, and collected data on growth in the number of patients, staff, and physicians. We used a template organizing approach to data analysis, using select constructs from the Consolidated Framework for Implementation Research (CFIR). KEY RESULTS Establishing foundational requirements was an essential first step in implementing the PACT model, with teamlets able to do practice redesign work. Short-staffing undermined development of teamlet working relationships. Lack of co-location of teamlet members in clinic and difficulty communicating with residents when they were off-site hampered communication. Opportunities to educate and reinforce PACT principles were constrained by the limited clinic hours of part-time primary care providers and residents, and delays in teamlet formation. CONCLUSIONS Large academic medical centers face special challenges in implementing the medical home model. In an era of increasing emphasis on patient-centered care, our findings will inform efforts to both improve patient care and train clinicians to move from physician-centric to multidisciplinary care delivery.
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Affiliation(s)
- Jane Forman
- PACT Research Inspiring Innovations and Self-Management (PRIISM) Demonstration Laboratory, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA,
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89
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Finkelstein SR, Liu N, Jani B, Rosenthal D, Poghosyan L. Appointment reminder systems and patient preferences: Patient technology usage and familiarity with other service providers as predictive variables. Health Informatics J 2014; 19:79-90. [PMID: 23715208 DOI: 10.1177/1460458212458429] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study had two aims: to measure patient preferences for medical appointment reminder systems and to assess the predictive value of patient usage and familiarity with other service providers contacting them on responsiveness to appointment reminder systems. We used a cross-sectional design wherein patients' at an urban, primary-care clinic ranked various reminder systems and indicated their usage of technology and familiarity with other service providers contacting them over text messages and e-mails. We assessed the impact of patient usage of text messages and e-mails and patient familiarity with other service providers contacting them over text messages and e-mails on effectiveness of and responsiveness to appointment reminder systems. We found that patient usage of text messages or e-mails and familiarity with other service providers contacting them are the best predictors of perceived effectiveness and responsiveness to text message and e-mail reminders. When these variables are accounted for, age and other demographic variables do not predict responsiveness to reminder systems.
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Abstract
Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.
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Affiliation(s)
- D Edward Deneke
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA.
| | - Heather Schultz
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA
| | - Thomas E Fluent
- Department of Psychiatry, University of Michigan Health System, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109-2700, USA
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Bartels SJ, Pratt SI, Mueser KT, Naslund JA, Wolfe RS, Santos M, Xie H, Riera EG. Integrated IMR for psychiatric and general medical illness for adults aged 50 or older with serious mental illness. Psychiatr Serv 2014; 65:330-7. [PMID: 24292559 PMCID: PMC4994884 DOI: 10.1176/appi.ps.201300023] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Self-management is promoted as a strategy for improving outcomes for serious mental illness as well as for chronic general medical conditions. This study evaluated the feasibility and effectiveness of an eight-month program combining training in self-management for both psychiatric and general medical illness, including embedded nurse care management. METHODS Participants were 71 middle-aged and older adults (mean age=60.3 ± 6.5) with serious mental illness and chronic general medical conditions who were randomly assigned to receive integrated Illness Management and Recovery (I-IMR) (N=36) or usual care (N=35). Feasibility was determined by attendance at I-IMR and nurse sessions. Effectiveness outcomes were measured two and six months after the intervention (ten- and 14-month follow-ups) and included self-management of psychiatric and general medical illness, participation in psychiatric and general medical encounters, and self-reported acute health care utilization. RESULTS I-IMR participants attended 15.8 ± 9.5 I-IMR and 8.2 ± 5.9 nurse sessions, with 75% attending at least ten I-IMR and five nurse sessions. Compared with usual care, I-IMR was associated with greater improvements in participant and clinician ratings for psychiatric illness self-management, greater diabetes self-management, and an increased preference for detailed diagnosis and treatment information during primary care encounters. The proportion of I-IMR participants with at least one psychiatric or general medical hospitalization decreased significantly between baseline and ten- and 14-month follow-ups. CONCLUSIONS I-IMR is a feasible intervention for this at-risk group and demonstrated potential effectiveness by improving self-management of psychiatric illness and diabetes and by reducing the proportion of participants requiring psychiatric or general medical hospitalizations.
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Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA 2014; 311:815-25. [PMID: 24570245 PMCID: PMC6348473 DOI: 10.1001/jama.2014.353] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear. OBJECTIVE To measure associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multipayer medical home pilots conducted in the United States, and changes in the quality, utilization, and costs of care. DESIGN, SETTING, AND PARTICIPANTS Thirty-two volunteering primary care practices participated in the pilot (conducted from June 1, 2008, to May 31, 2011). We surveyed pilot practices to compare their structural capabilities at the pilot's beginning and end. Using claims data from 4 participating health plans, we compared changes (in each year, relative to before the intervention) in the quality, utilization, and costs of care delivered to 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices (selected for size, specialty, and location similar to pilot practices) using a difference-in-differences design. EXPOSURES Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). MAIN OUTCOMES AND MEASURES Practice structural capabilities; performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care. RESULTS Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention. CONCLUSIONS AND RELEVANCE A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.
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Affiliation(s)
- Mark W Friedberg
- RAND Corporation, Boston, Massachusetts2Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Eric C Schneider
- RAND Corporation, Boston, Massachusetts2Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Department of Medicine, Harvard Medical School, Boston, Massachusetts4Department of Health Policy and Management, Harvard Sc
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Kevin G Volpp
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania6Center for Health Incentives and Behavioral Economics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia7Division of Gene
| | - Rachel M Werner
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania7Division of General Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia
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93
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Glasgow RE. What does it mean to be pragmatic? Pragmatic methods, measures, and models to facilitate research translation. HEALTH EDUCATION & BEHAVIOR 2014; 40:257-65. [PMID: 23709579 DOI: 10.1177/1090198113486805] [Citation(s) in RCA: 237] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND One of the reasons for the slow and uncertain translation of research into practice is likely due to the emphasis in science on explanatory models and efficacy designs rather than more pragmatic approaches. METHODS Following a brief definition of what constitutes a pragmatic approach, I provide examples of pragmatic methods, measures, and models and how they have been applied. RESULTS Descriptions are provided of pragmatic trials and related designs, practical measures including patient-reported items for the electronic health record, and the Evidence Integration Triangle and RE-AIM practical models, each of which can help increase the relevance of research to policy makers, practitioners, and patients/consumers. CONCLUSIONS By focusing on the perspective of stakeholders and the context for application of scientific findings, pragmatic approaches can accelerate the integration of research, policy, and practice. Progress has been made, especially in pragmatic trials but even more opportunities remain.
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94
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Shunk R, Dulay M, Chou CL, Janson S, O'Brien BC. Huddle-coaching: a dynamic intervention for trainees and staff to support team-based care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:244-250. [PMID: 24362383 DOI: 10.1097/acm.0000000000000104] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Many outpatient clinics where health professionals train will transition to a team-based medical home model over the next several years. Therefore, training programs need innovative approaches to prepare and incorporate trainees into team-based delivery systems. To address this need, educators at the San Francisco Veterans Affairs (VA) Medical Center included trainees in preclinic team "huddles," or briefing meetings to facilitate care coordination, and developed an interprofessional huddle-coaching program for nurse practitioner students and internal medicine residents who function as primary providers for patient panels in VA outpatient primary care clinics. The program aimed to support trainees' partnerships with staff and full participation in the VA's Patient Aligned Care Teams. The huddle-coaching program focuses on structuring the huddle process via scheduling, checklists, and designated huddle coaches; building relationships among team members through team-building activities; and teaching core skills to support collaborative practice. A multifaceted evaluation of the program showed positive results. Participants rated training sessions and team-building activities favorably. In interviews, trainees valued their team members and identified improvements in efficiency and quality of patient care as a result of the team-based approach. Huddle checklists and scores on the Team Development Measure indicated progress in team processes and relationships as the year progressed. These findings suggest that the huddle-coaching program was a worthwhile investment in trainee development that also supported the clinic's larger mission to deliver team-based, patient-aligned care. As more training sites shift to team-based care, the huddle-coaching program offers a strategy for successfully incorporating trainees.
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Affiliation(s)
- Rebecca Shunk
- Dr. Shunk is associate professor, Department of Medicine, San Francisco VA Medical Center and University of California, San Francisco, San Francisco, California. Dr. Dulay is assistant professor, Department of Medicine, San Francisco VA Medical Center and University of California, San Francisco, San Francisco, California. Dr. Chou is professor, Department of Medicine, San Francisco VA Medical Center and University of California, San Francisco, San Francisco, California. Dr. Janson is professor, Department of Community Health Systems, School of Nursing, and Department of Medicine, University of California, San Francisco, San Francisco, California. Dr. O'Brien is assistant professor, Department of Medicine and Office of Research and Development in Medical Education, University of California, San Francisco, San Francisco, California
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95
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Keeley RD, West DR, Tutt B, Nutting PA. A qualitative comparison of primary care clinicians' and their patients' perspectives on achieving depression care: implications for improving outcomes. BMC FAMILY PRACTICE 2014; 15:13. [PMID: 24428952 PMCID: PMC3907132 DOI: 10.1186/1471-2296-15-13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 01/05/2014] [Indexed: 01/05/2023]
Abstract
Background Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into “Patient-centered Medical Homes” (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient’s perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians’ and their patients’ perceptions of the patients’ experiences, expectations and preferences as they try to achieve care for depression. Methods We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings. Results Three processes on the way to satisfactory depression care emerged: 1. a journey, often from fractured to connected care; 2. a search for a personal understanding of their depression; 3. creation of unique therapeutic spaces for treating current depression and preventing future episodes. Relative to patients’ observations regarding stigma’s effects on accepting a depression diagnosis and seeking treatment, clinicians tended to underestimate the presence and effects of stigma. Patients preferred clinicians who were empathetic listeners, while clinicians worried that discussing depression could open “Pandora’s box” of lengthy discussions and set them irrecoverably behind in their clinic schedules. Clinicians and patients agreed that somatic manifestations of mental distress impeded the patients’ ability to understand their suffering as depression. Clinicians reported supporting several treatment modalities beyond guideline-based approaches for depression, yet also displayed surface-level understanding of the often multifaceted support webs their patient described. Conclusions Improving processes and outcomes in primary care may demand heightened ability to understand and measure the patients’ experiences, expectations and preferences as they receive primary care. Future research would investigate a potential mismatch between clinicians’ and patients’ perceptions of the effects of stigma on achieving care for depression, and on whether time spent discussing depression during the clinical visit improves outcomes. Improving care and outcomes for chronic disorders such as depression may require primary care clinicians to understand and support their patients’ unique ‘therapeutic spaces.’
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Affiliation(s)
- Robert D Keeley
- Department of Family Medicine, University of Colorado, Denver, Mail Stop F-496, Academic Office 1, 12631 E, 17th Ave, Aurora, CO 80045, USA.
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96
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Kangovi S, Grande D. Transitional Care Management Reimbursement to Reduce COPD Readmission. Chest 2014; 145:149-155. [DOI: 10.1378/chest.13-0787] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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97
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Westfall JM, Zittleman L, Ringel M, Sutter C, McCaffrey K, Gale S, Gerk T, Sanchez S, LeBlanc W, Dickinson LM, Dickinson P. How do rural patients benefit from the patient-centred medical home? A card study in the High Plains Research Network. LONDON JOURNAL OF PRIMARY CARE 2014; 6:136-48. [PMID: 25949735 DOI: 10.1080/17571472.2014.11494365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Context The patient-centred medical home (PCMH) has become a dominant model for improving the quality and cost of primary care. Geographic isolation, small populations, privacy concerns and staffing requirements may limit implementation of the PCMH in clinical practice. Objective To determine the primary care provider perceived benefit of PCMH for patients in rural Colorado. Design, setting and participants The High Plains Research Network (HPRN) is a community and practice-based research network spanning 30 000 square miles in 16 counties in eastern Colorado. The HPRN consists of 58 practices, 120 primary care clinicians and 145 000 residents. Main outcome measures Providers' perceived benefit of PCMH for individual patients. Results Seventy-eight providers in 37 practices saw 1093 patients and completed 1016 surveys. There was wide variation among the provider-perceived benefits of PCMH elements ranging from 9% for group visits to 64% for electronic prescribing. Provider-perceived benefit was higher for patients with a chronic medical condition. Conclusions Rural primary care providers perceived patient benefit for numerous elements of the PCMH. There is need to consider what PCMH elements may be required in practice and what components might be optional. Our findings reveal that rural practices share PCMH aspirations including commitment to quality, safety, outcomes, cost reduction, and patient and provider satisfaction. These findings support the need for ongoing conversation about how to best provide a locally relevant medical home.
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Affiliation(s)
| | | | | | | | | | - Susan Gale
- High Plains Research Network, Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tony Gerk
- Northeast Colorado Family Medicine, Sterling, CO, USA
| | - Sergio Sanchez
- High Plains Research Network, Community Advisory Council, USA
| | | | | | - Perry Dickinson
- High Plains Research Network, Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Halladay JR, DeWalt DA, Wise A, Qaqish B, Reiter K, Lee SY, Lefebvre A, Ward K, Mitchell CM, Donahue KE. More extensive implementation of the chronic care model is associated with better lipid control in diabetes. J Am Board Fam Med 2014; 27:34-41. [PMID: 24390884 PMCID: PMC4096824 DOI: 10.3122/jabfm.2014.01.130070] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Chronic disease collaboratives help practices redesign care delivery. The North Carolina Improving Performance in Practice program provides coaches to guide implementation of 4 key practice changes: registries, planned care templates, protocols, and self-management support. Coaches rate progress using the Key Drivers Implementation Scales (KDIS). This study examines whether higher KDIS scores are associated with improved diabetes outcomes. METHODS We analyzed clinical and KDIS data from 42 practices. We modeled whether higher implementation scores at year 1 of participation were associated with improved diabetes measures during year 2. Improvement was defined as an increase in the proportion of patients with hemoglobin A1C values <9%, blood pressure values <130/80 mmHg, and low-density lipoprotein (LDL) levels <100 mg/dL. RESULTS Statistically significant improvements in the proportion of patients who met the LDL threshold were noted with higher "registry" and "protocol" KDIS scores. For hemoglobin A1C and blood pressure values, none of the odds ratios were statistically significant. CONCLUSIONS Practices that implement key changes may achieve improved patient outcomes in LDL control among their patients with diabetes. Our data confirm the importance of registry implementation and protocol use as key elements of improving patient care. The KDIS tool is a pragmatic option for measuring practice changes that are rooted in the Chronic Care Model.
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Affiliation(s)
- Jacqueline R Halladay
- the Department of Family Medicine and the Division of General Medicine and Clinical Epidemiology, Cecil G. Sheps Center for Health Services Research, and the Departments of Biostatistics and Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill; the Department of Health Policy and Management, University of Michigan School of Public Health, Ann Arbor; and the North Carolina Area Health Education Centers, Chapel Hill
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Stange KC, Etz RS, Gullett H, Sweeney SA, Miller WL, Jaén CR, Crabtree BF, Nutting PA, Glasgow RE. Metrics for assessing improvements in primary health care. Annu Rev Public Health 2014; 35:423-42. [PMID: 24641561 PMCID: PMC6360939 DOI: 10.1146/annurev-publhealth-032013-182438] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include long-term, meaning- and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.
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100
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Nutting PA, Crabtree BF, McDaniel RR. Small primary care practices face four hurdles--including a physician-centric mind-set--in becoming medical homes. Health Aff (Millwood) 2013; 31:2417-22. [PMID: 23129671 DOI: 10.1377/hlthaff.2011.0974] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model. We found that small practices were extremely physician-centric, lacked meaningful communication among physicians, were dominated by authoritarian leadership behavior, and were underserved by midlevel clinicians who had been cast into unimaginative roles. Our analysis suggests that in addition to payment reform, a shift in the mind-set of primary care physicians is needed. Unless primary care physicians can adopt new mental models and think in new ways about themselves and their practices, it will be very difficult for them and their practices to create innovative care teams, become learning organizations, and act as good citizens within the health care neighborhood.
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Affiliation(s)
- Paul A Nutting
- University of Colorado Health Sciences Center, Denver, Colorado, USA.
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