Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost

Impact of value-based care on quality of life, clinical outcomes, patient satisfaction, and enhanced financial protection among hypertensive patients in Ghana: A protocol for a mixed method evaluation, 2024

BACKGROUND

Evidence on which hypertensive intervention is cost-effective is essential to inform strategy, policy development, practice, implementation, and resource allocation. Value-Based Care (VBC) is a healthcare delivery model that emphasizes improving patient outcomes while optimizing costs. It shifts the focus from the volume of services provided to the value delivered to patients. We hypothesize that innovative VBC intervention would be more cost-effective compared to standard care among individuals with poorly controlled hypertension.

METHODS

This study in Ghana will employ a mixed-methods evaluation design, a comprehensive and thorough approach that combines quantitative and qualitative methods. The quantitative component will involve a quasi-experimental study to measure the impact of the VBC intervention on quality of life, improved clinical outcomes, patient satisfaction, and enhanced financial protection among hypertensive patients registered with the National Health Insurance Authority. We will use a difference-in-difference analytic approach and a generalized estimation equation model with cluster-robust standard errors to quantify the impact of VBC, accounting for potential confounding variables. The qualitative component will involve in-depth interviews and focus group discussions to gather insights into the experiences and perceptions of the patients, caregivers, and policymakers involved in the VBC intervention and the benefits, barriers, costs of treatment, and challenges associated with the VBC intervention.

DISCUSSIONS

Despite the availability of safe treatment options for hypertension, most people with hypertension in LMICs do not have it controlled. There is currently a paucity of knowledge about the cost-effectiveness of VBC interventions in developing countries. This study aims to fill this knowledge gap and pave the way for more cost-effective hypertension treatment worldwide. The Ghana VBC intervention described in this paper is a pioneering approach to achieving safer, more consistent, and cost-effective care for hypertensive patients.

Supporting primary care clinicians in caring for patients with alcohol use disorder: study protocol for Records for Alcohol Care Enhancement (RACE), a factorial four-arm randomized trial

BACKGROUND

Unhealthy alcohol use, a spectrum of use inclusive of risky consumption and alcohol use disorder (AUD), is a leading cause of preventable death in the United States. Most people with unhealthy alcohol use do not receive evidence-based treatment. This four-arm factorial design randomized trial will assess whether population health management (PHM) and clinical care management (CCM) support for primary care providers (PCPs) are associated with improved AUD treatment engagement among their patients, beyond electronic health record (EHR) prompting and decision support alone.

METHODS

PCPs from an urban safety-net hospital-based primary care clinic are randomized to one of four groups (1) EHR best practice advisory (BPA) and clinical decision support tools for unhealthy alcohol use (BPA), (2) BPA plus population health manager support, (3) BPA plus clinical care manager support, and (4) all three. All PCPs will have access to the EHR BPA and decision support tools which provide chart-based advisories and order set navigation. PCPs assigned to receive PHM support will receive quarterly panel-level feedback on AUD treatment metrics for their patients. PCPs assigned to receive CCM support will receive CCM facilitation of AUD treatment processes including medication counseling, referrals, and support through direct patient interactions. The primary outcome will be the percent of patients engaged in AUD treatment among those with a new AUD diagnosis on a PCP's panel. Secondary outcomes include the percent of patients with a new diagnosis of AUD who (1) initiated AUD treatment, (2) were prescribed AUD medications within 90 days, and (3) numerical counts of a range of AUD health services (outpatient encounters, specialty AUD care encounters, referrals, and acute healthcare utilization) in this sample. We will assess the primary outcome and the acute healthcare utilization secondary outcomes using Medicaid claims; the remaining secondary outcomes will be assessed using EHR data.

DISCUSSION

The study will evaluate how a targeted EHR innovation alone, compared with population health and care management enhancements alone or in combination, impact engagement in AUD treatment, a national quality of care measure. Findings will advance understanding of supports needed to improve systems of care for AUD in general settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier/registration number (NCT number): NCT05492942.

The Impact of Interdisciplinary Team-Based Care on the Care and Outcomes of Chronically Ill Patients: A Systematic Review

Objective

To examine the impact of interdisciplinary team-based care (ITBC) on chronically ill patients and their outcomes as reported in relevant contemporary literature.

Methods

In this systematic review, PubMed, MEDLINE, Web of Science, CINAHL Plus Full Text, and ten publishers were searched to identify studies published between 2019 and 2024. Titles, abstracts, and full texts were screened for eligible studies and assessed for relevance. Inclusion and exclusion criteria were implemented to ensure that only studies relevant to our objective were included. The convergent integrated analysis framework suggested by the Joanna Briggs Institute was utilized for data synthesis.

Results

Ten studies were included in the systematic review. Data synthesis revealed five major themes at different levels: 1) Patient level, including themes of Patients' Self-Improvement and Patients' Health Outcomes; 2) Interpersonal level, including themes of Providers' Work Performance and Shared Decision Making; and 3) Organizational level, including the theme of Healthcare Utilization.

Conclusion

ITBC has a significant positive impact on chronically ill patients at multiple levels. At the patient level, it enhances self-management and health outcomes. At the interpersonal level, it improves healthcare providers' performance and promotes shared decision-making. At the organizational level, it leads to more efficient healthcare utilization.

Geographic disparities in physical and mental health comorbidities and socioeconomic status of residence among Medicaid beneficiaries in Utah

To examine the relationship between socioeconomic deprivation and complex needs, defined as mental and physical comorbidities, we conducted a cross-sectional retrospective cohort analysis of adult Utah Medicaid beneficiaries. Our analysis included Medicaid beneficiaries with geocoded addresses aged ≥18 years in Utah (N = 157,739). We geocoded beneficiary addresses and assigned them to census block groups. We compared the socioeconomic status of block groups (Singh's area deprivation index) with the proportion of complex needs, defined based on cluster analysis as 1 physical condition with depression or ≥ 2 physical with ≥1 mental health condition. Spatial mapping was performed of prevalence quantiles grouped by count overlaid with Medicaid-covered mental health facilities. Prevalence of complex needs was 18.9% (n = 29,742); beneficiaries with >3 emergency department visits had 12.8 odds of having complex needs; 39.7% of beneficiaries with >$5,000 in annual costs had complex needs. Common comorbid conditions among beneficiaries with complex needs were hypertension (56.0%), hyperlipidemia (35.5%), depression (68.8%), anxiety (56.2%), drug use (16.0%), and alcohol use disorders (15.2%). Census block groups with higher deprivation had a higher proportion of complex needs (ρ = 0.21, p < 0.001). There was a statistically significant spatial autocorrelation of the prevalence of complex needs (Moran's I index: 0.65; p < 0.001). Six high-count census blocks had no mental health facilities. Areas with increased socioeconomic deprivation had a greater proportion of complex needs and fewer mental health facilities. Integrated programs addressing both physical and mental health conditions with a focus on socioeconomically deprived areas might benefit Medicaid recipients in populations such as those in Utah.

Can integrated care interventions strengthen primary care and improve outcomes for patients with chronic diseases? A systematic review and meta-analysis

BACKGROUND

An increasing number of people live with chronic disease or multi-morbidity. Current consensus is that their care requires an integrated model bringing different professionals together to provide person-centred care. Although primary care has a central role in managing chronic disease, and integration may be important in strengthening this role, previous research has shown insufficient attention to the relationships between primary care and integration. This review summarizes primary care involvement in integrated care interventions and assesses the effect of those interventions on a range of measures of primary care functions and wider outcomes.

METHODS

We searched Medline and Embase using terms for "integrated care", "chronic disease" and "multimorbidity". We included integrated care interventions involving different levels of care organizations or different care sectors. Risk of bias was appraised, and the contents of integrated care interventions assessed using the Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE (SELFIE) conceptual framework. Effectiveness of integrated care interventions was assessed using meta-analysis of primary care functions (access, continuity, comprehensiveness and coordination) and wider outcomes (patient health and mortality, hospital admissions and costs). Sub-group analyses were conducted for different types of primary care involvement.

RESULTS

From 17,752 studies screened, 119 studies on integrated care were identified, of which 69 interventions (58%) involved primary care. Meta-analyses showed significant beneficial effects on two measures of primary care function: access (effect size: 0.17, 95% CI 0.05-0.29) and continuity (effect size: 0.32, 95% CI 0.14-0.50). For wider outcomes, the only statistically significant effect was found on costs (effect size: 0.02, 95% CI 0.02-0.03).

CONCLUSIONS

Integrated care interventions involving primary care can have positive effects on strengthening primary care functions, but these benefits do not necessarily translate consistently to wider outcomes.

Perspectives of Nursing Home Staff: Application of Dementia Training Approaches

Non-pharmacological strategies are prioritized to manage dementia-related symptoms in nursing homes (NHs). A multiple-case study design, embedded within a pragmatic trial, examined NH staff perspectives of applying a team-based (TB) or problem-based dementia training program to resident care. A purposive sample of staff was recruited from 23 NHs to participate in one-on-one interviews, which were analyzed using a rapid qualitative approach. Both approaches yielded staff who were able to apply their training to resident care. Staff described similarities in communication strategies, family interactions, recognizing sources of behaviors, providing comfort, and ensuring resident safety. In addition, staff demonstrated increased self-efficacy when caring for residents. Differences emerged for team collaboration, engaging residents, and managing behaviors. Among TB staff, training impacted how staff cared for residents and increased teamwork. Leaders may want to consider the benefits of each approach as they deliberate on which dementia care training to provide to their staff.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Provider engagement and outreach

The American Cancer Society National Lung Cancer Roundtable strategic plan for provider engagement and outreach addresses barriers to the uptake of lung cancer screening, including lack of provider awareness and guideline knowledge about screening, concerns about potential harms from false-positive examinations, lack of time to implement workflows within busy primary care practices, insufficient infrastructure and administrative support to manage a screening program and patient follow-up, and implicit bias based on sex, race/ethnicity, social class, and smoking status. Strategies to facilitate screening include educational programming, clinical reminder systems within the electronic medical record, decision support aids, and tools to track nodules that can be implemented across a diversity of practices and health care organizational structures. PLAIN LANGUAGE SUMMARY: The American Cancer Society National Lung Cancer Roundtable strategic plan to reduce deaths from lung cancer includes strategies designed to support health care professionals, to better understand lung cancer screening, and to support adults who are eligible for lung cancer screening by providing counseling, referral, and follow-up.

A qualitative study about the public's perception of primary care providers

OBJECTIVE

With the growth of physician associates/assistants (PAs) and NPs providing primary care services, we sought to understand the public's perception of the different types of healthcare providers (HCPs) they might encounter in a clinical setting, such as primary care.

OBJECTIVES

This study aimed to evaluate public perceptions about various types of primary care providers (PCPs), identify public preferences for PCPs in relation to experience and training, and examine public preferences for PCP credentials.

METHODS

We conducted semistructured interviews with adults, and used inductive and deductive coding and reflexive thematic analysis to analyze the data.

RESULTS

We reached thematic saturation after 12 completed interviews. Participants reported confusion about the types of HCPs they might encounter in a primary care setting (for example, physician, PA, NP). Participants who reported a preference for a physician valued more years in training and their role in the hierarchy of medicine; those who reported a preference for a PA or NP indicated that compassion, patience, and longer clinic visit times were most important to them.

CONCLUSIONS

Previous reports suggested that the public might be confused by the different types of HCPs they might encounter during a primary care visit. Participants identified specific characteristics that are important when they are choosing their PCP. A direct, coordinated marketing campaign may be needed to educate the public and reduce confusion about different types of PCPs, how they contribute to safe and high-quality care, and ensure preference-concordant care.

Primary care mental health integration to improve early treatment engagement for veterans who screen positive for depression

OBJECTIVE

To examine the relationship between the penetration (or reach) of a national program aiming to integrate mental health clinicians into all primary care clinics (PC-MHI) and rates of guideline-concordant follow-up and treatment among clinic patients newly identified with depression in the Veterans Health Administration (VA).

DATA SOURCES/STUDY SETTING

15,155 screen-positive patients 607,730 patients with 2-item Patient Health Questionnaire scores in 82 primary care clinics, 2015-2019.

STUDY DESIGN

In this retrospective cohort study, we used established depression care quality measures to assess primary care patients who (a) newly screened positive (score ≥3) and (b) were identified with depression by clinicians via diagnosis and/or medication (n = 15,155; 15,650 patient-years). Timely follow-up included ≥3 mental health, ≥3 psychotherapy, or ≥3 primary care visits for depression. Minimally appropriate treatment included ≥4 mental health visits, ≥3 psychotherapy, or ≥60 days of medication. In multivariate regressions, we examined whether higher rates of PC-MHI penetration in clinic (proportion of total primary care patients in a clinic who saw any PC-MHI clinician) were associated with greater depression care quality among cohort patients, adjusting for year, healthcare system, and patient and clinic characteristics.

DATA COLLECTION/EXTRACTION METHODS

Electronic health record data from 82 VA clinics across three states.

PRINCIPAL FINDINGS

A median of 9% of all primary care patients were seen by any PC-MHI clinician annually. In fully adjusted models, greater PC-MHI penetration was associated with timely depression follow-up within 84 days (∆P = 0.5; SE = 0.1; p < 0.001) and 180 days (∆P = 0.3; SE = 0.1; p = 0.01) of a positive depression screen. Completion of at least minimal treatment within 12 months was high (77%), on average, and not associated with PC-MHI penetration.

CONCLUSIONS

Greater PC-MHI program penetration was associated with early depression treatment engagement at 84-/180-days among clinic patients newly identified with depression, with no effect on already high rates of completion of minimally sufficient treatment within the year.

Rehabilitation coordinator - managers' experiences of a new function in health care

BACKGROUND

Several actions have been taken to improve the sick listing process, patient safety and return to work. One of them is the implementation of the rehabilitation coordinator function, of which the benefits have not yet been fully explored. Neither has the role of the manager, who has significant impact on the implementation and support of a new function. This study aimed to explore how first line managers', who employed a rehabilitation coordinator that had completed a one-year specialized study program, perceived, and experience the function rehabilitation coordinator.

METHODS

This is an interview study using a semi structured interview guide for data collection and thematic analysis was applied to the data. Ten first line managers in health care were interviewed.

RESULTS

Four themes were identified: The Saviour, A personalized function, Change takes time and Strengthen status and legitimacy. The managers experienced the rehabilitation coordinator as a valuable function who facilitates collaboration in the team and with external stakeholders and perceived them as a much-needed resources, supporting physicians with sick leave issues. The assignment was ambiguous and dependent on the rehabilitation coordinators individual characteristics, which may result in a risk of overload. The managers were engaged in the implementation process, but this required time. They considered it important to strengthen legitimacy for the function which required support and encouragement to take part in specialized education and training.

CONCLUSIONS

The managers experienced the rehabilitation coordinators as playing a crucial role in the return-to-work process. They were willing to support how this new function will improve and develop. The results from this can serve as a guidance for the implementation and support of the function rehabilitation coordinator.

Analyzing the roles, workflows, and communication dynamics of social workers within interprofessional care teams

Social workers frequent interprofessional healthcare teams, but few studies examine the day-to-day experiences of these providers on interprofessional teams. Our study utilized semi-structured interviews with 54 medical social workers practicing on interprofessional healthcare teams. A thematic analysis was used to analyze the day-to-day functions of these social workers. The analysis resulted in three primary themes: 1) Social Workers' Self-Perceptions of their Roles within Interprofessional Teams, 2) Social Workers Shifting Roles on Interprofessional Teams, and 3) Interprofessional Team Dynamics that Impact the Role of a Social Worker. Social workers perceived their primary roles as contributing a unique systems approach to interprofessional healthcare teams while emphasizing patient self-determination. These self-perceptions influenced their shifting roles on interprofessional healthcare teams (e.g. clinician, case manager, bridge builder). In addition to individual self-perceptions, the healthcare system infrastructure influenced social work roles. For example, social workers in outpatient settings more frequently assumed the role of a mental health practitioner compared to those in inpatient settings. Last, there was variation in interprofessional communication and workflow assignment based on the healthcare infrastructure. Future research should examine the education and training efforts of social workers and other allied health professions for interprofessional healthcare teams.

Whole Health Revolution: Value-Based Care + Lifestyle Medicine

An outdated and burdensome fee-for-service (FFS) reimbursement system has significantly compromised primary care delivery in the US for decades, leading to a dire shortage of primary care workers. Support for primary care must increase from all public and private payers with well-designed value-based primary care payment. Patient care enabled by value-based payment is typically described or "labeled" as value-based care and commonly viewed as distinctly different from other models of care delivery. Unfortunately, labels tend to put individuals in camps that can make the differences seem greater than they are in practice. Achieving the aims of value-based care, aligned with the quintuple aims of health care, is common across many delivery models. The shrinking primary care workforce is too fragile to be fragmented across competing camps. Seeing the alignment across otherwise separate disciplines, such as lifestyle medicine and value-based care, is essential. In this article, we point to the opportunities that arise when we widen the lens to look beyond these labels and make the case that a variety of models and perspectives can meld together in practice to produce the kind of high-quality primary care physicians, care teams, and patients are seeking.

Primary Care Informatics: Vitalizing the Bedrock of Health Care

Primary care informatics (PCI) professionals address workflow and technology solutions in a wide spectrum of health, ranging from optimizing the experience of the individual patient in the clinic room to supporting the health of populations and augmenting the work of frontline primary care clinical teams. PCI overlaps uniquely with 2 disciplines with an impact on societal health-primary care and health informatics. Primary care is a gateway to health care access and aims to synthesize and coordinate numerous, complex elements of patients' health and medical care in a holistic manner. However, over the past 25 years, primary care has become a specialty in crisis: in a post-COVID-19 world, workforce shortages, clinician burnout, and continuing challenges in health care access all contribute to difficulties in sustaining primary care. Informatics professionals are poised to change this trajectory. In this viewpoint, we aim to inform readers of the discipline of PCI and its importance in the design, support, and maintenance of essential primary care services. Although this work focuses on primary care in the United States, which includes general internal medicine, family medicine, and pediatrics (and depending on definition, includes specialties such as obstetrics and gynecology), many of the principles outlined can also be applied to comparable health care services and settings in other countries. We highlight (1) common global challenges in primary care, (2) recent trends in the evolution of PCI (personalized medicine, population health, social drivers of health, and team-based care), and (3) opportunities to move forward PCI with current and emerging technologies using the 4Cs of primary care framework. In summary, PCI offers important contributions to health care and the informatics field, and there are many opportunities for informatics professionals to enhance the primary care experience for patients, families, and their care teams.

Co-development of a national, bilingual, post-licensure accredited educational program for registered nurses in primary care: A knowledge-to-action exemplar

Registered nurses' practice in primary care varies and is sometimes sub-optimal. To fill the gap in primary care-specific knowledge, we co-constructed a national educational program to reinforce the nursing workforce. We based our project on the knowledge-to-action approach. Many lessons were learned during the development phase: (1) The experiential knowledge of patient partners and stakeholders allows an education program based on real needs; (2) The development of a national education program requires high-intensity investment from all involved persons; (3) An in-person meeting at the beginning of the project enables robust discussions and optimal co-creation; and (4) In a country where two official languages are spoken, it's essential to create a safe environment and a translation infrastructure that allows everyone to express themselves in the language of their choice. Finally, other initiatives in healthcare education or professional practice improvement could leverage our findings to realize national-scale projects using knowledge creation approaches.

The Chronic Conditions Care Collaborative (4C Collaborative): A Platform for Improving Diabetes and Heart Disease Outcomes in Rural South Carolina

Rural U.S. counties experience racial, geographic, and socioeconomic disparities in chronic diseases. Collaborations among stakeholders in rural areas are needed to make measurable changes in health care outcomes in South Carolina. The Chronic Conditions Care Collaborative (4C Collaborative) was developed to provide an opportunity for health care teams in medically underserved areas of South Carolina to convene to improve diabetes and heart disease outcomes. The 4C Collaborative was a quality improvement (QI) learning collaborative focused on the identification of patients with undiagnosed hypertension, team-based care through medication therapy management (MTM), and diabetes management. All QI work was approached through a health equity lens. Fifteen medical practices across two cohorts participated in the 4C Collaborative and gained access to more than 35 hours of educational content and guided action steps to create systemic changes specific to the needs of their patient population. Participation also conferred access to one-on-one technical assistance with faculty subject-matter experts. The activities within the 4C Collaborative allowed health care practices to identify areas of improvement within their practices and test improvement strategies through Plan-Do-Study-Act (PDSA) cycles. Best practices and lessons learned from learning collaborative participants were compiled into storyboards and presented during end of program celebrations.

Implementing an advanced team-based care model in a federally qualified health center (FQHC): Assessing implementation facilitators and challenges

OBJECTIVE

The objective of this paper is to assess implementation facilitators and challenges for advanced team-based care (aTBC) in a federally qualified health center (FQHC). In aTBC, care team coordinators room patients, perform vitals and agenda setting during patient intake, and remain present alongside providers during patient visits.

METHODS

The authors conducted a qualitative post-hoc analysis of the aTBC implementation using data from several sources. They used content analysis to code items as facilitators or challenges and thematic analysis to group those into larger themes. Finally, they applied a priori codes from the revised consolidated framework for implementation research (CFIR) to organize the facilitators and barriers into subdomains.

RESULTS

The existing evidence-base around aTBC, the FQHC's ability to pilot and adapt it, and strong implementation leads were key facilitating factors. Challenges included an external shock (i.e., the COVID-19 pandemic), aTBC complexity, and uncertainty about whether success required implementation of the full model versus easier-to-integrate smaller components.

CONCLUSIONS

FQHCs that wish to implement aTBC models need strong champions and internal structures for piloting, adapting, and disseminating interventions. FQHC leaders must think strategically about how to build support and demonstrate success to improve an FQHC's chances of expanding and sustaining aTBC.

Teamwork and implementation of innovations in healthcare and human service settings: a systematic review

BACKGROUND

Implementation of new practices in team-based settings requires teams to work together to respond to new demands and changing expectations. However, team constructs and team-based implementation approaches have received little attention in the implementation science literature. This systematic review summarizes empirical research examining associations between teamwork and implementation outcomes when evidence-based practices and other innovations are implemented in healthcare and human service settings.

METHODS

We searched MEDLINE, CINAHL, APA PsycINFO and ERIC for peer-reviewed empirical articles published from January 2000 to March 2022. Additional articles were identified by searches of reference lists and a cited reference search for included articles (completed in February 2023). We selected studies using quantitative, qualitative, or mixed methods to examine associations between team constructs and implementation outcomes in healthcare and human service settings. We used the Mixed Methods Appraisal Tool to assess methodological quality/risk of bias and conducted a narrative synthesis of included studies. GRADE and GRADE-CERQual were used to assess the strength of the body of evidence.

RESULTS

Searches identified 10,489 results. After review, 58 articles representing 55 studies were included. Relevant studies increased over time; 71% of articles were published after 2016. We were unable to generate estimates of effects for any quantitative associations because of very limited overlap in the reported associations between team variables and implementation outcomes. Qualitative findings with high confidence were: 1) Staffing shortages and turnover hinder implementation; 2) Adaptive team functioning (i.e., positive affective states, effective behavior processes, shared cognitive states) facilitates implementation and is associated with better implementation outcomes; Problems in team functioning (i.e., negative affective states, problematic behavioral processes, lack of shared cognitive states) act as barriers to implementation and are associated with poor implementation outcomes; and 3) Open, ongoing, and effective communication within teams facilitates implementation of new practices; poor communication is a barrier.

CONCLUSIONS

Teamwork matters for implementation. However, both team constructs and implementation outcomes were often poorly specified, and there was little overlap of team constructs and implementation outcomes studied in quantitative studies. Greater specificity and rigor are needed to understand how teamwork influences implementation processes and outcomes. We provide recommendations for improving the conceptualization, description, assessment, analysis, and interpretation of research on teams implementing innovations.

TRIAL REGISTRATION

This systematic review was registered in PROSPERO, the international prospective register of systematic reviews.

REGISTRATION NUMBER

CRD42020220168.

Adopting a nurse-led model of care to advance whole-person health and health equity within Medicaid

BACKGROUND

Medicaid payment reforms and delivery model innovations are needed to fully transform U.S. healthcare structuring and provision.

PURPOSE

To synthesize nurse-led models of care and their implications for improving health care access, quality, and reducing costs for Medicaid recipients.

METHODS

A critical review of the literature regarding nurse-led models and implications for addressing social determinants of health (SDOH), adopting population health approaches, managing complex care, and integrating behavioral and physical health care within Medicaid.

DISCUSSION

Three interrelated findings emerged (a) investing in dynamic nurse-led models is important for mitigating SDOH and adopting value-based care, (b) regulations preventing nurses from practicing at the fullest extent of their training and licensure limit clinical impact and value, and (c) directed payments can establish value-based expectations for Medicaid managed care.

CONCLUSION

Adoption of a nurse-led model of care has the potential to advance the goals of reducing inequity and promoting whole-person health within Medicaid and nationally.

Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey

BACKGROUND

Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload.

OBJECTIVES

This study aimed to investigate the association between primary care practices' organization, and quality and safety changes during the COVID-19 pandemic.

DESIGN

Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as "Only GPs", comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and "Multiprofessional," comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936).

RESULTS

Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more "Multiprofessional" practices, whereas "Only GPs" were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic.

CONCLUSIONS

Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams.

How Primary Healthcare Sector is Organized at the Territorial Level in France? A Typology of Territorial Structuring

BACKGROUND

Most the Organization for Economic Co-operation and Development (OECD) countries are currently facing the challenges of the health transition, the aging of their populations and the increase in chronic diseases. Effective and comprehensive primary healthcare (PHC) services are considered essential for establishing an equitable, and cost-effective healthcare system. Developing care coordination and, on a broader scale, care integration, is a guarantee of quality healthcare delivery. The development of healthcare systems at the meso-level supports this ambition and results in a process of territorial structuring of PHC. In France, the Health Territorial and Professional Communities (HTPC) constitute meso-level organizations in which healthcare professionals (HCPs) from the same territory gather. We conducted a study to determine, in a qualitative step, the key elements of the territorial structuring of PHC in France and, then, to develop, in a quantitative step, a typology of this structuring.

METHODS

A sequential-exploratory mixed-method study with a qualitative step using a multiple case approach and a quantitative step as a hierarchical clustering on principal components (HCPC) from a multiple correspondence analysis (MCA).

RESULTS

A total of 7 territories were qualitatively explored. Territorial structuring appears to depend on: past collaborations at the micro-level, meso-level coordination among HCPs and multiprofessional structures, diversity of independent professionals, demographic dynamics attracting young professionals, and public health investment through local health contracts (LHCs). The typology identifies 4 clusters of mainland French territories based on their level of structuring: under or unstructured (38.6%), with potential for structuring (34.7%), in the way for structuring (25.3%) and already structured territories (1.4%).

CONCLUSION

Interest in territorial structuring aligns with challenges in meso-level healthcare organization and the need for integrated care. Typologies of territorial structuring should be used to understand its impact on access, care quality, and medical resources.

Unmet need for primary health care and subsequent inpatient hospitalisation in Aotearoa New Zealand. A cohort study

Introduction The inability to afford a consultation with a general practitioner may lead to delays in accessing care pathways. Aim This study aimed to explore the characteristics of people by their unmet need for a general practitioner consultation because of cost, and the characteristics of subsequent inpatient hospitalisations. Methods From the New Zealand Health Surveys (2013/14-2018/19), two groups were formed based on their unmet need for a general practitioner consultation due to cost. These groups were compared by socio-demographic factors and subsequent inpatient hospitalisation characteristics during follow-up. Time to an inpatient hospitalisation was the outcome in a proportional hazards regression model with need status as the key variable. The model was expanded to include confounding variables: sex, age group, ethnicity, the New Zealand Deprivation Index and self-rated health. Results The need group, characterised by having a higher proportion of females, younger adults, Māori, increased socioeconomic deprivation and poorer self-rated health experienced a greater chance of hospitalisation, a similar number of visits during follow-up, shorter stays and a quicker time to hospitalisation compared to the no-need group. Proportional hazards survival models gave a 28% higher hazard rate for the time to an inpatient hospitalisation for the need group compared to the no-need group. The inclusion of all the confounders in the model gave a similar hazard ratio. Discussion Although consultation fees vary across general practices, it is evident that this may not eliminate the cost barriers to accessing care for some groups. Needing multiple consultations may contribute to persistent unmet needs.

Identifying strategies to support implementation of interprofessional primary care teams in Nova Scotia: Results of a survey and knowledge sharing event

BACKGROUND

Interprofessional primary care teams (IPCTs) work together to enhance care. Despite evidence on the benefits of IPCTs, implementation remains challenging. This research aims to 1) identify and prioritize barriers and enablers, and 2) co-develop team-level strategies to support IPCT implementation in Nova Scotia, Canada.

METHODS

Healthcare providers and staff of IPCTs were invited to complete an online survey to identify barriers and enablers, and the degree to which each item impacted the functioning of their team. Top ranked items were identified using the sum of frequency x impact for each response. A virtual knowledge sharing event was held to identify strategies to address local barriers and enablers that impact team functioning.

RESULTS

IPCT members (n = 117), with a mix of clinic roles and experience, completed the survey. The top three enablers identified were access to technological tools to support their role, standardized processes for using the technological tools, and having a team manager to coordinate collaboration. The top three barriers were limited opportunity for daily team communication, lack of conflict resolution strategies, and lack of capacity building opportunities. IPCT members, administrators, and patients attended the knowledge sharing event (n = 33). Five strategies were identified including: 1) balancing patient needs and provider scope of practice, 2) holding regular and accessible meetings, 3) supporting team development opportunities, 4) supporting professional development, and 5) supporting involvement in non-clinical activities.

INTERPRETATION

This research contextualized evidence to further understand local perspectives and experiences of barriers and enablers to the implementation of IPCTs. The knowledge exchange event identified actionable strategies that IPCTs and healthcare administrators can tailor to support teams and care for patients.

Building and Supporting Interprofessional Teams to Support Population Health

High-functioning teams can positively impact health care delivery and support population health. The authors discuss enabling and interfering factors that impact team-based care delivery and how the AHEC system can promote inter-professional education and practice across North Carolina.

Teamwork and its impact on chronic disease clinical outcomes in primary care: a systematic review and meta-analysis

OBJECTIVE

Teamwork positively affects staff performance and patient outcomes in chronic disease management. However, there is limited research on the impact of specific team components on clinical outcomes. This review aims to explore the impact of teamwork components on key clinical outcomes of chronic diseases in primary care.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This systematic review and meta-analysis conducted searching EMBASE, PubMed, Cochrane Central Register of Controlled Trials. Studies included must have at least one teamwork component, conducted in primary care for selected chronic diseases, and report an impact of teamwork on clinical outcomes. Mean differences and 95% confidence intervals were used to determine pooled effects of intervention.

RESULTS

A total of 54 studies from 1988 to 2021 were reviewed. Shared decision-making, roles sharing, and leadership were missing in most studies. Team-based intervention showed a reduction in mean systolic blood pressure (MD = 5.88, 95% CI 3.29-8.46, P= <0.001, I2 = 95%), diastolic blood pressure (MD = 3.23, 95% CI 1.53 to 4.92, P = <0.001, I2 = 94%), and HbA1C (MD = 0.38, 95% CI 0.21 to 0.54, P = <0.001, I2 = 58%). More team components led to better SBP and DBP outcomes, while individual team components have no impact on HbA1C. Fewer studies limit analysis of cholesterol levels, hospitalizations, emergency visits and chronic obstructive pulmonary disease-related outcomes.

CONCLUSION

Team-based interventions improve outcomes for chronic diseases, but more research is needed on managing cholesterol, hospitalizations, and chronic obstructive pulmonary disease. Studies with 4-5 team components were more effective in reducing systolic blood pressure and diastolic blood pressure. Heterogeneity should be considered, and additional research is needed to optimize interventions for specific patient populations.

Barriers and enablers to implementing interprofessional primary care teams: a narrative review of the literature using the consolidated framework for implementation research

BACKGROUND

Interprofessional primary care teams have been introduced across Canada to improve access (e.g., a regular primary care provider, timely access to care when needed) to and quality of primary care. However, the quality and speed of team implementation has not kept pace with increasing access issues. The aim of this research was to use an implementation framework to categorize and describe barriers and enablers to team implementation in primary care.

METHODS

A narrative review that prioritized systematic reviews and evidence syntheses was conducted. A search using pre-defined terms was conducted using Ovid MEDLINE, and potentially relevant grey literature was identified through ad hoc Google searches and hand searching of health organization websites. The Consolidated Framework for Implementation Research (CFIR) was used to categorize barriers and enablers into five domains: (1) Features of Team Implementation; (2) Government, Health Authorities and Health Organizations; (3) Characteristics of the Team; (4) Characteristics of Team Members; and (5) Process of Implementation.

RESULTS

Data were extracted from 19 of 435 articles that met inclusion/exclusion criteria. Most barriers and enablers were categorized into two domains of the CFIR: Characteristics of the Team and Government, Health Authorities, and Health Organizations. Key themes identified within the Characteristics of the Team domain were team-leadership, including designating a manager responsible for day-to-day activities and facilitating collaboration; clear governance structures, and technology supports and tools that facilitate information sharing and communication. Key themes within the Government, Health Authorities, and Health Organizations domain were professional remuneration plans, regulatory policy, and interprofessional education. Other key themes identified in the Features of Team Implementation included the importance of good data and research on the status of teams, as well as sufficient and stable funding models. Positive perspectives, flexibility, and feeling supported were identified in the Characteristics of Team Members domain. Within the Process of Implementation domain, shared leadership and human resources planning were discussed.

CONCLUSIONS

Barriers and enablers to implementing interprofessional primary care teams using the CFIR were identified, which enables stakeholders and teams to tailor implementation of teams at the local level to impact the accessibility and quality of primary care.

Women's trust in the healthcare system in Serbia: Validation of the Women's Trust and Confidence in Healthcare System scale

BACKGROUND

Women's role as patients is associated with power relationships embedded in society. Although trust in the health care system is a general prerequisite for positive health outcomes, practices regarding women's agency in healthcare systems in Southeastern Europe reinforce women's passivity. Most of the current psychological measures of trust have been constructed and validated in "WEIRD" (samples that are drawn from populations that are White, Educated, Industrialized, Rich, and Democratic) countries, thus having a limited application in other social contexts.

OBJECTIVES

We aimed to construct an instrument for assessing women's trust in healthcare systems to describe the structure of trust: Women's Trust and Confidence in the Healthcare System scale.

DESIGN

Two independent samples (N1 = 329; N2 = 333) of adult women in Serbia voluntarily completed an online questionnaire. The questionnaire comprised 20 trust-related items which were selected from an extensive collection of women's experiences in the healthcare system and evaluated by experts on a 5-point Likert-type scale.

METHODS

We used exploratory factor analysis of the Women's Trust and Confidence in the Healthcare System scale to analyze the structure of trust in the first sample data set and validated it with the second sample using confirmatory factor analysis. We tested concurrent validity by exploring how women's trust in the healthcare system predicts health-related behaviors (multigroup structural equation modeling). All analyses were conducted using R statistical software.

RESULTS

The Women's Trust and Confidence in the Healthcare System scale (Cronbach's alpha = 0.86) indicated a three-factor structure of trust in the healthcare system: trust in healthcare professionals, distrust in the public healthcare system, and confidence in healthcare system. This was validated using an independent sample. Interpersonal trust positively predicted women's desirable health behaviors, while trust in the system had a negative impact.

CONCLUSION

The Women's Trust and Confidence in the Healthcare System scale captures women's trust in a paternalistic healthcare system, is reliable, and has a stable three-factor structure. The study's findings reveal the relationship between women's trust and health-related behavior: in paternalistic environments, trust reinforces women's passivity.

Effects of Advanced Team-Based Care on Care Processes and Health Measures in a Federally Qualified Health Center

In a federally qualified health center, we assess a novel primary care delivery model, advanced team-based care (aTBC), that embeds care team members in patient visits. Using a difference-in-differences research design, we measure visit intensity, compliance with preventive care recommendations, and health outcomes among patients in the aTBC model compared with patients in a traditional team-based delivery model. We find increases in receipt of some recommended preventive care and in visit intensity, but no change in health outcomes. The aTBC model may improve some dimensions of care quality for low-income, vulnerable populations.

Patient Time Spent With Professional Medical Interpreters and the Care Experiences of Patients With Limited English Proficiency

INTRODUCTION/OBJECTIVES

More time spent with interpreters may support clinician-patient communication for patients with limited English proficiency (LEP), especially when interpreter support before and after clinical encounters is considered. We assessed whether more time spent with interpreters is associated with better patient-reported experiences of clinician-patient communication and interpreter support among patients with LEP.

METHODS

Patients with LEP (n = 338) were surveyed about their experiences with both the clinician and interpreter. Duration of interpreter support during the encounter (in min) and auxiliary time spent before and after encounters supporting patients (in min) were documented by interpreters. Multivariable linear regression models were estimated to assess the association of the time duration of interpreter support and patient experiences of (1) clinician-patient communication, and (2) interpreter support, controlling for patient and encounter characteristics.

RESULTS

The average encounter duration was 47.7 min (standard deviation, SD = 25.1), the average auxiliary time was 43.8 min (SD = 16.4), and the average total interpreter time was 91.1 min (SD = 28.6). LEP patients reported better experiences of interpreter support with a mean score of 97.4 out of 100 (SD = 6.99) compared to clinician-patient communication, with a mean score of 93.7 out of 100 (SD = 14.1). In adjusted analyses, total patient time spent with an interpreter was associated with better patient experiences of clinician-patient communication (β = 7.23, P < .01) when auxiliary time spent by interpreters supporting patients before and after the encounter was considered, but not when only the encounter time was considered.

CONCLUSIONS

Longer duration of time spent with an interpreter was associated with better clinician-patient communication for patients with LEP when time spent with an interpreter before and after the clinician encounter is considered. Policymakers should consider reimbursing health care organizations for time interpreters spend providing patient navigation and other support beyond clinical encounters.

Contextual Factors Influencing Screening for Diabetic Eye Disease in Alabama: Provider Perspectives

Introduction/Objectives: Comprehensive eye exams are recommended at least every 2 years for people with diabetes for early identification and treatment of diabetic eye disease, but screening rates remain suboptimal. Our objective was to qualitatively assess barriers and facilitators to completing recommended eye exam screening for patients with diabetes among providers and practice staff. Methods: As part of a larger initiative, we conducted discussion groups with healthcare providers and practice staff to evaluate factors related to referral and screening for diabetic eye disease at 2 sites, a safety-net healthcare system and a specialty clinic. Discussions were audio-recorded and transcribed. Combined inductive, deductive thematic content analysis was conducted, applying the Practical Robust Implementation and Sustainability Model to organize themes and subthemes. Results: Two discussion groups with 28 participants were conducted in August 2023. Themes included existing processes for referrals, scheduling, and tracking; patient-level determinants including transportation and financial barriers and other competing demands to receiving recommended eye screening; clinic or system-related factors, and considerations for process improvement for eye exam referrals and appointments. Conclusions: These findings can be applied to determine the most effective strategies to improve the rates of recommended eye exam referral and screening rates in people with diabetes.

The social work discipline in the management of Failure to thrive in infants and children: an integrated behavioral health approach to pediatric programming

Failure to thrive (FTT) is a DSM-5/ICD-10 diagnosis which describes infants and children who fail to grow within expected norms. The causes for poor growth are multifactorial and often include psychosocial factors. Social workers are important players in an interdisciplinary team approach to this diagnosis. This research and manuscript focus on the use of an integrated infant mental health pediatric model of practice, and outcomes for one case study. The article will review the social worker's role in the treatment of FTT, effective social work services provided in an integrated behavioral health approach, and a review of a cost-benefit analysis of treatment of FTT in a Primary Care Facility verses a hospital setting.

Effectiveness of an Integrated Ambulatory Care Program in Health Care and Medication Use in Patients With Multimorbidity and Polypharmacy

BACKGROUND AND OBJECTIVES

Multimorbidity increases risks, such as polypharmacy, inappropriate prescription, and functional decline. It also increases medical care utilization by older adults, placing a burden on health care systems. This study evaluated the effectiveness of an integrated ambulatory care program for health care and medication use in patients with multimorbidity and polypharmacy.

METHODS

We conducted a retrospective clinical review of adults with multimorbidity and polypharmacy who attended an integrated ambulatory care program at a 1193-bed university hospital between July 1 and September 30, 2019. This program involves multidisciplinary teamwork, comprehensive assessments, medication reviews, and case management. Outcomes, including the frequency of outpatient visits, emergency department visits, hospitalizations, chronic prescription medications, potentially inappropriate medications (PIMs), health care costs, and total medical expenditure, were compared before and after the program.

RESULTS

The mean age of participants (n = 134) at baseline was 74.22 ± 9.75 years. The mean number of chronic diagnoses was 9.45 ± 3.38. Participants included 72 (53.7%) women. At the 1-year follow-up, participants showed a significant decrease in the annual frequency of outpatient visits (19.78 ± 9.98 to 13.90 ± 10.22, P < .001), emergency department visits (1.04 ± 1.70 to 0.73 ± 1.40, P = .029), and chronic disease medications (10.71 ± 3.96 to 9.57 ± 3.67, P < .001) across all age groups. There was also a reduction in the annual number of PIMs (from 1.31 ± 1.01 to 1.12 ± 0.93, P = .002) among patients aged 65 years. However, no effects were observed on annual hospitalization, duration of hospital stay, or total health care expenditure, possibly due to the high disease-related treatment cost for certain participants.

CONCLUSIONS

Expanding integrated ambulatory care programs in Taiwan may help patients with multimorbidity reduce their use of outpatient and emergency services, chronic prescriptions, and PIMs.

Social workers roles in achieving health quality metrics in primary care: a quality improvement case study

Value-based payment models may improve patient health by targeting quality of care over quantity of health services. Social workers in primary care settings are well-positioned to improve the quality of health services for vulnerable patients by identifying and addressing patients' social determinants of health. This case study describes a Plan Do Study Act (PDSA) quality improvement approach implemented and refined by social workers to proactively address clinical quality gaps in one family medicine practice. The studied program - entitled Gap Closure Day - was led by a team of social workers to improve quality outcomes of patients. Findings highlight the important roles of social workers as members of health care teams to improve the quality of health services and address health equity.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

Multidisciplinary Care of Alcohol-related Liver Disease and Alcohol Use Disorder: A Narrative Review for Hepatology and Addiction Clinicians

PURPOSE

Models of integrated, multidisciplinary care are optimal in the setting of complex, chronic diseases and in the overlap of medical and mental health disease, both of which apply to alcohol-related liver disease (ALD). Alcohol use disorder (AUD) drives nearly all cases of ALD, and coexisting mental health disease is common. ALD is a complex condition with severe clinical manifestations and high mortality that can occasionally lead to liver transplantation. As a result, integrated care for ALD is an attractive proposition. The aim of this narrative review was to: (1) review the overlapping and concerning trends in the epidemiology of AUD and ALD; (2) use a theoretical framework for integrated care known as the "five-component model" as a basis to highlight the need for integrated care and the overlapping clinical manifestations and management of the 2 conditions; and (3) review the existing applications of integrated care in this area.

METHODS

We performed a narrative review of epidemiology, clinical manifestations, and management strategies in AUD and ALD, with a particular focus on areas of overlap that are pertinent to clinicians who manage each disease. Previously published models were reviewed for integrating care in AUD and ALD, both in the general ALD population and in the setting of liver transplantation.

FINDINGS

The incidences of AUD and ALD are rising, with a pronounced acceleration driven by the Coronavirus Disease 2019 pandemic. Hepatologists are underprepared to diagnose and treat AUD despite its high prevalence in patients with liver disease. A patient who presents with overlapping clinical manifestations of both AUD and ALD may not fit neatly into typical treatment paradigms for each individual disease but rather will require new management strategies that are appropriately adapted. As a result, the dimensions of integrated care, including collective ownership of shared goals, interdependence among providers, flexibility of roles, and newly created professional activities, are highly pertinent to the holistic management of both diseases.

IMPLICATIONS

Integrated care models have proliferated as recognition grows of the dual pathology of AUD and ALD. Ongoing coordination across disciplines and research in the fields of hepatology and addiction medicine are needed to further elucidate optimal mechanisms for collaboration and improved quality of care.

Integrated Care for Comprehensive Management of Patients with Osteoarthritis: Program Development and Implementation

Treatment of symptomatic osteoarthritis (OA) is often complicated by comorbidities, which put patients at potentially higher risks following operative interventions. Management of these comorbidities is usually separate from orthopaedic care, with patients invited to return to their orthopaedic surgeon once surgical risk factors are better controlled. However, this practice can lead to disjointed care, resulting in uncertainty, mistrust, unmanaged pain, and dissatisfaction for patients. Integrated care teams provide an effective option for coordinated comprehensive nonoperative and preoperative management of patients with knee OA and medical comorbidities. The objective of this article is to summarize the process for implementation of an integrated program to manage patients with symptomatic knee OA and the initial outcomes at our institution as an example of the effects of integrated patient management in orthopaedics. At the author's institution, an integrated program was implemented, successfully addressing the unmet need for coordinated care for patients with bone and joint health problems and medical comorbidities. Patients who completed the full program experienced significant improvements in both pain and function. Potential applications for knee surgeons considering implementing integrated care models could include pre- and postoperative management programs, nonoperative management program, and programs seeking to meet key metrics such as improved readmission rates, patient satisfaction, or value-based care. For effective program implementation, careful planning with convenient referral mechanisms, leadership buy-in, and patient-centered communication protocols are required.

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network.

Medicaid Costs and Utilization of Collaborative Versus Colocation Care for Patients With Depression

OBJECTIVE

The authors examined cost and utilization metrics for racially diverse Medicaid primary care patients with depression receiving care through either a collaborative care model (CoCM) of integration or the standard colocation model.

METHODS

Data from a retrospective cohort of Medicaid patients screening positive for clinically significant depression during January 2016-December 2017 were analyzed to assess health care costs and selected utilization measures. Seven primary care clinics providing CoCM were compared with 16 clinics providing colocated behavioral health care. Data for the first year and second year after a patient received an initial Patient Health Questionnaire-9 score ≥10 were analyzed.

RESULTS

In the first year, compared with patients receiving colocated care (N=3,061), CoCM patients (N=4,315) had significantly lower odds of emergency department (ED) visits (OR=0.95) and medical specialty office visits (OR=0.92), with slightly higher odds of primary care provider (PCP) visits (OR=1.03) and behavioral health office visits (OR=1.03). In year 2, CoCM patients (N=2,623) had significantly lower odds of inpatient medical admissions (OR=0.87), ED visits (OR=0.84), medical specialty office visits (OR=0.89), and PCP visits (OR=0.94) than the colocated care patients (N=1,838). The two groups did not significantly differ in total cost in both years.

CONCLUSIONS

Access to CoCM treatment in primary care for racially diverse Medicaid patients with depression was associated with more positive health care utilization outcomes than for those accessing colocated treatment. As organizations continue to seek opportunities to integrate behavioral health care into primary care, consideration of health care costs and utilization may be helpful in the selection and implementation of integration models.

General Practitioners activity patterns: the medium-term impacts of Primary Care Teams in France

Faced with the fragmentation of the French primary care system, public policies aim to promote multiprofessional teamwork to improve both delivery efficiency and health professionals' working conditions. Thus, a practice-level add-on payment backed by cooperation commitments is implemented to foster and sustain the development of multiprofessional primary care groups (MPCGs). We study the impact of practising in MPCGs for general practitioners (GPs) in terms of the supply of care, practice patterns and income. Based on this quasiexperimental framework with a panel dataset covering the period 2005-2017, we account for the selection into MPCGs by combining a difference-in-differences design with propensity score matching to prebalance samples. We show that GPs in MPCGs increased their patient list more rapidly than control GPs (+10% increase of encountered patients) without increasing their provision of services (number of visits and drug prescriptions) more rapidly. Instead, compared to control GPs, MPCG GPs had a significantly faster reduction in the average number of visits (+5.5% reduction) and the euro-amounts of drug prescriptions per patient (+7.2% reduction) and other prescriptions. The growth of these effects between the short and medium term moreover suggests that the properties of multi-professional coordination and cooperation need time to develop.

Economics of Team-Based Care for Blood Pressure Control: Updated Community Guide Systematic Review

INTRODUCTION

This paper examined the recent evidence from economic evaluations of team-based care for controlling high blood pressure.

METHODS

The search covered studies published from January 2011 through January 2021 and was limited to those based in the U.S. and other high-income countries. This yielded 35 studies: 23 based in the U.S. and 12 based in other high-income countries. Analyses were conducted from May 2021 through February 2023. All monetary values reported are in 2020 U.S. dollars.

RESULTS

The median intervention cost per patient per year was $438 for U.S. studies and $299 for all studies. The median change in healthcare cost per patient per year after the intervention was -$140 for both U.S. studies and for all studies. The median net cost per patient per year was $439 for U.S. studies and $133 for all studies. The median cost per quality-adjusted life year gained was $12,897 for U.S. studies and $15,202 for all studies, which are below a conservative benchmark of $50,000 for cost-effectiveness.

DISCUSSION

Intervention cost and net cost were higher in the U.S. than in other high-income countries. Healthcare cost averted did not exceed intervention cost in most studies. The evidence shows that team-based care for blood pressure control is cost-effective, reaffirming the favorable cost-effectiveness conclusion reached in the 2015 systematic review.

Improving teamwork in multidisciplinary cross-sector teams: Adaption and pilot testing of a team training for Child Advocacy Center teams

Background

Effective teamwork is critical to the mission of Child Advocacy Center (CAC) multidisciplinary teams. Team interventions designed to fit the unique cross-organizational context of CAC teams may improve teamwork in CACs.

Methods

A collaborative, community-engaged approach was used to adapt TeamSTEPPS, an evidence-based team training for healthcare, for CAC multidisciplinary teams. The adapted training was piloted with one team and evaluated using mixed methods. Team members completed pre-training (n = 26) and follow-up surveys (n = 22) and participated in qualitative interviews (n = 9).

Results

The adaptation process resulted in the creation of TeamTRACS (Team Training in Roles, Awareness, Communication, and Support). Participants rated TeamTRACS as highly acceptable, appropriate, feasible, relevant, and useful for CAC teams. They identified positive and negative aspects of the training, ideas for improvement, and future uses for TeamTRACS.

Conclusions

TeamTRACS is a feasible approach to team training in CACs, and team members find the content and skills relevant and useful. Additional research is needed to test the effectiveness of TeamTRACS and identify appropriate implementation strategies to support its use.

Econometric evaluation of implementing a behavioral health integration intervention in primary care settings

Integrated behavioral health (IBH) is an approach to patient care that brings medical and behavioral health providers (BHPs) together to address both behavioral and medical needs within primary care settings. A large, pragmatic, national study aimed to test the effectiveness and measure the implementation costs of an intervention to improve IBH integration within primary care practices (IBH-PC). Assess the time and cost to practices of implementing a comprehensive practice-level intervention designed from the perspective of clinic owners to move behavioral service integration from co-location toward full integration as part of the IBH-PC study. IBH-PC program implementation costs were estimated in a representative sample of 8 practices using standard micro-econometric evaluation of activities outlined in the implementation workbook, including program implementation tasks, remote quality improvement coaching services, educational curricula, and learning community activities, over a 24-month period. The total median cost of implementing the IBH-PC program across all stages was $20,726 (range: $12,381 - $60,427). The median cost of the Planning Stage was $10,258 (range: $4,625 - $14,840), while the median cost of the Implementation Stage was $9,208 (range: $6,017 - 49,993). There were no statistically significant differences in practice or patient characteristics between the 8 selected practices and the larger IBH-PC practice sample (N=34). This study aimed to quantify the relative costs associated with integrating behavioral health into primary care. Although the cost assessment approach did not include all costs (fixed, variable, operational, and opportunity costs), the study aimed to develop a replicable and pragmatic measurement process with flexibility to adapt to emerging developments in each practice environment, providing a reasonable ballpark estimate of costs associated with implementation to help guide future executive decisions.

Population Health in Pediatric Primary Care as a Means to Achieving Child Health Equity

We propose population health as a model of care to advance efforts to achieve child health equity. We use the structure-process-outcome framework to highlight key structures of pediatric population health necessary to catalyze what has been slow progress to date. Using specific ongoing examples, we then show how different models of integrated health care delivery systems align population health structures to enable processes aimed to achieve child health equity. We conclude by highlighting the critical role of committed leadership to drive progress.

Evaluating non-pharmacological approaches to nursing home dementia care: A protocol

Background

The COVID-19 pandemic has underscored the daily challenges nursing home (NH) staff face caring for the residents living with Alzheimer's Disease and Related Dementias (ADRD). Non-pharmacological approaches are prioritized over off-label medication to manage the behavioral and psychological symptoms of ADRD. Yet, it is not clear how to best equip NH staff and families with the knowledge and strategies needed to provide non-pharmacological approaches to these residents.

Methods

This clustered randomized trial will compare team- and problem-based approaches to non-pharmacological ADRD care. The team-based approach includes core training for all NH staff using a common language and strategies to support continuity and sustainability. The problem-based approach capitalizes on the expertise of the professional healthcare providers to target issues that arise. A convergent mixed methods design will be used to examine (a) comparative effectiveness of the two approaches on long-term NH resident outcomes and (b) whether either approach is protective against the negative consequences of COVID-19. The primary outcome is the percentage of ADRD residents with off-label antipsychotic medication use, which will be evaluated with an intent-to-treat approach. Staff and family caregiver perspectives will be explored using a multiple case study approach.

Conclusion

This trial will be the first-ever evaluation of team- and problem-based approaches to ADRD care across multiple NHs and geographic regions. Results can provide health system leaders and policymakers with evidence on how to optimize ADRD training for staff in an effort to enhance ADRD care delivery.

Reducing hospital acquired pressure injury in a learning health center: Making the case for quality

Introduction

The purpose of this descriptive study is to examine a learning health system (LHS) continuous improvement and learning approach as a case for increased quality, standardized processes, redesigned workflows, and better resource utilization. Hospital acquired pressure injuries (HAPI) commonly occur in the hospitalized patient and are costly and preventable. This study examines the effect of a LHS approach to reducing HAPI within a large academic medical center.

Methods

Our learning health center implemented a 6-year series of iterative improvements that included both process and technology changes, with robust data and analytical reforms. In this descriptive, observational study, we retrospectively examined longitudinal data from April 1, 2018 to March 31, 2022, examining the variables of total number of all-stage HAPI counts and average length of stay (ALOS). We also analyzed patient characteristics observed/expected mortality ratios, as well as total patient days, and the case-mix index to determine whether these factors varied over the study period. We used the Agency for Healthcare Research and Quality cost estimates to identify the estimated financial benefit of HAPI reductions on an annualized basis.

Results

HAPI per 1000 patient days for FY 20 (October 1-September 30) and FY 21, decreased from 2.30 to 1.30 and annualized event AHRQ cost estimates for HAPI decreased by $4 786 980 from FY 20 to FY 21. A strong, statistically significant, negative and seemingly counterintuitive correlation was found (r = -.524, P = .003) between HAPI and ALOS.

Conclusions

The LHS efforts directed toward HAPI reduction led to sustained improvements during the study period. These results demonstrate the benefits of a holistic approach to quality improvement offered by the LHS model. The LHS model goes beyond a problem-based approach to process improvement. Rather than targeting a specific problem to solve, the LHS system creates structures that yield process improvement benefits over a continued time period.

Assessing the Needs of Those Who Serve the Underserved: A Qualitative Study among US Oncology Clinicians

BACKGROUND

The American Society of Clinical Oncology established the 'Supporting Providers Serving the Underserved' (SUS) Task Force with a goal to develop recommendations to support cancer clinicians who deliver care for populations at risk for cancer disparities. As a first step, the Task Force explored barriers and facilitators to equitable cancer care delivery.

METHODS

Clinicians across the United States who deliver care predominantly for low-income and racially and ethnically minoritized populations were identified based on lists generated by the Task Force and the Health Equity Committee. Through purposive sampling based on geographical location, clinicians were invited to participate in 30-60 min semi-structured interviews to explore experiences, barriers, and facilitators in their delivery of cancer care. Interviews were recorded, transcribed, imported into qualitative data management software, and analyzed using thematic analysis.

RESULTS

Thematic analysis revealed three major themes regarding barriers (lack of executive leadership recognition of resources; patient-related socio-economic needs; clinician burnout) and two major themes regarding facilitators (provider commitment, experiential training).

CONCLUSIONS

Findings reveal modifiable barriers and potential solutions to facilitate equitable cancer care delivery for populations at risk for cancer disparities.

Team-focused implementation strategies to improve implementation of mental health screening and referral in rural Children's Advocacy Centers: study protocol for a pilot cluster randomized hybrid type 2 trial

BACKGROUND

Children's Advocacy Centers (CACs) use multidisciplinary teams to investigate and respond to maltreatment allegations. CACs play a critical role in connecting children with mental health needs to evidence-based mental health treatment, especially in low-resourced rural areas. Standardized mental health screening and referral protocols can improve CACs' capacity to identify children with mental health needs and encourage treatment engagement. In the team-based context of CACs, teamwork quality is likely to influence implementation processes and outcomes. Implementation strategies that target teams and apply the science of team effectiveness may enhance implementation outcomes in team-based settings.

METHODS

We will use Implementation Mapping to develop team-focused implementation strategies to support the implementation of the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), a standardized screening and referral protocol. Team-focused strategies will integrate activities from effective team development interventions. We will pilot team-focused implementation in a cluster-randomized hybrid type 2 effectiveness-implementation trial. Four rural CACs will implement the CPM-PTS after being randomized to either team-focused implementation (n = 2 CACs) or standard implementation (n = 2 CACs). We will assess the feasibility of team-focused implementation and explore between-group differences in hypothesized team-level mechanisms of change and implementation outcomes (implementation aim). We will use a within-group pre-post design to test the effectiveness of the CPM-PTS in increasing caregivers' understanding of their child's mental health needs and caregivers' intentions to initiate mental health services (effectiveness aim).

CONCLUSIONS

Targeting multidisciplinary teams is an innovative approach to improving implementation outcomes. This study will be one of the first to test team-focused implementation strategies that integrate effective team development interventions. Results will inform efforts to implement evidence-based practices in team-based service settings.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05679154 . Registered on January 10, 2023.

The Association of Teamlets and Teams with Physician Burnout and Patient Outcomes

BACKGROUND

Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team.

OBJECTIVE

To determine the prevalence and performance of teamlets and teams.

DESIGN

Cross-sectional observational study linking survey responses to Medicare claims.

PARTICIPANTS

Six hundred eighty-eight general internists and family physicians.

INTERVENTIONS

Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team).

MAIN MEASURES

Descriptive: percentage of physicians in teamlet/team categories.

OUTCOME MEASURES

physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending.

KEY RESULTS

77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries.

CONCLUSIONS

Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.

Value-Based Integrated Care (VBIC) Concept Implementation in a Real-World Setting-Problem-Based Analysis of Barriers and Challenges

Healthcare effectiveness measurement and value in health have been common topics in public health literature since 2006 when value-based healthcare (VBHC) was first defined by Porter and Teisberg. The aim of this study was to identify the barriers and challenges related to the implementation of VBHC solutions in the example of Poland. A case presentation was used as a method. The national integrated care programs (KOS-Infarction, POZ-Plus, and comprehensive treatment of chronic wounds) were used to present general challenges, along with the Integrated Care Model (ICM) for patients with advanced chronic obstructive pulmonary disease (COPD), to determine specific difficulties. ICM has been operating since 2012 in Gdańsk and gradually adapted the value-based integrated care (VBIC) approach. An analysis of the available data showed that the greatest difficulties related to the implementation of the VBHC and VBIC concepts are a lack of legal and reimbursement solutions, staff shortages, a lack of educational standards for some members of the multidisciplinary team, and insufficient awareness of the role of integrated care. As the level of preparation to implement VBHC policies varies between individual countries, the conclusions drawn from the experience of ICM and other Polish projects may be a valuable voice in discussion.

The Role of Primary Care in Improving Population Health

Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.