1
|
Sum G, Sim SYH, Chay J, Ho SH, Ginting ML, Lim ZZB, Yoong J, Wong CH. An Integrated Patient-Centred Medical Home (PCMH) Care Model Reduces Prospective Healthcare Utilisation for Community-Dwelling Older Adults with Complex Needs: A Matched Observational Study in Singapore. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6848. [PMID: 37835116 PMCID: PMC10572627 DOI: 10.3390/ijerph20196848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/04/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (β = -0.85; 95%CI = -1.55 to -0.14) and primary care visits (β = -1.70; 95%CI = -2.17 to -1.22) and a decrease in specialist outpatient visits (β = -0.29; 95%CI = -0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.
Collapse
Affiliation(s)
- Grace Sum
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Silvia Yu Hui Sim
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Junxing Chay
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore 169857, Singapore;
| | - Soon Hoe Ho
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Mimaika Luluina Ginting
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Zoe Zon Be Lim
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Joanne Yoong
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
- Research for Impact, Singapore 159964, Singapore
| | - Chek Hooi Wong
- Research for Impact, Singapore 159964, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
| |
Collapse
|
2
|
Eder M, Jacobsen R, Peterson KA, Solberg LI. Quality and team care response to the pandemic stresses in high performing primary care practices: A qualitative study. PLoS One 2022; 17:e0278410. [PMID: 36454787 PMCID: PMC9714700 DOI: 10.1371/journal.pone.0278410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To learn how high performing primary care practices organized care for patients with diabetes during the initial months of the COVID-19 pandemic. PARTICIPANTS AND METHODS Semi-structured interviews were conducted between August 10 and December 10, 2020 with 16 leaders from 11 practices that had top quartile performance measures for diabetes outcomes pre-COVID. Each clinic had completed a similar interview and a survey about the existence of care management systems associated with quality outcomes before the pandemic. Transcript analysis utilized a theoretical thematic analysis at the semantic level. RESULTS The pandemic disrupted the primary care practices' operations and processes considered important for quality prior to the pandemic, particularly clinic reliance on proactive patient care. Safety concerns resulted from the shift to virtual visits, which produced documentation gaps and led practices to reorder their use of proactive patient care processes. Informal interactions with patients also declined. These practices' challenges were mitigated by technical, informational and operational help from the larger organizations of which they were a part. Care management processes had to accommodate both in-person and virtual visits. CONCLUSION These high performing practices demonstrated an ability to adapt their use of proactive patient care processes in pursuing quality outcomes for patients with diabetes during the pandemic. Continued clinic transformation and improvements in quality within primary care depend on the ability to restructure the responsibilities of care team members and their interactions with patients.
Collapse
Affiliation(s)
- Milton Eder
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, United States of America
- * E-mail:
| | - Rachel Jacobsen
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Kevin A. Peterson
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Leif I. Solberg
- HealthPartners Institute, Bloomington, Minnesota, United States of America
| |
Collapse
|
3
|
Heginbotham L, Baugh G, Lefeber T, Friehling L, Barnhart C, Miller LA, Moore L, Cottrell L. A parent-led, patient-centered medical home model instruction for interprofessional undergraduate and graduate learning opportunities. MEDICAL EDUCATION ONLINE 2022; 27:2012105. [PMID: 34919018 PMCID: PMC8725748 DOI: 10.1080/10872981.2021.2012105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/14/2021] [Accepted: 11/25/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Despite national efforts to establish patient-centered medical homes (PCMH), 57.3% of children with special health care needs are receiving care that does not meet medical home criteria. Project DOCC, a national curriculum designed by parents of children with disabilities or chronic disease, has shown documented strengths in medical resident learner education of children with special health care needs from the parent perspectives for over a decade. Because of the importance of PCMH and the need to provide compassionate care, our team adapted the curriculum to incorporate team-based learning in the rural setting. MATERIALS AND METHODS Reading materials were distributed to learners prior to an in-person workshop at which time, learners reviewed a video and discussed PCMH materials to identify elements of the PCMH. Learners then engaged with parent mentors across three breakout sessions. A final group reflection was completed to review and discuss efforts providers would take to establish and maintain the PCMH in their own practice. Baseline and post-workshop PCMH perceptions and parent mentor reflections were collected and compared using t-test comparisons. RESULTS Learner knowledge, perceptions, and comfort significantly increased after the workshop. Parent mentor comments also highlighted an increased understanding for the provider. Discussion: The adapted PCMH curriculum significantly impacted learner outcomes using a feasible approach that fit nicely within health professional curricula and limited resources of the rural setting. Parents enjoyed the opportunity to serve as mentors and valued the instruction format.
Collapse
Affiliation(s)
- Lori Heginbotham
- Center for Excellence in Disabilities, West Virginia University, Morgantown, WV, USA
| | - Gina Baugh
- Director of the Wv Office of Interprofessional Education, West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - Timothy Lefeber
- Department of Pediatrics, West Virginia University, Morgantown, WV, USA
| | - Linda Friehling
- Department of Pediatrics, West Virginia University, Morgantown, WV, USA
| | - Christy Barnhart
- Nursing Workshop, West Virginia University Adult Health Department
| | - Lee Ann Miller
- West Virginia University, Patient Safety Simulation Center (WV STEPS), Morgantown, WV, USA
| | - Lucas Moore
- Center for Excellence in Disabilities, West Virginia University, Morgantown, WV, USA
| | - Lesley Cottrell
- Center for Excellence in Disabilities, West Virginia University, Morgantown, WV, USA
- Department of Pediatrics, West Virginia University, Morgantown, WV, USA
| |
Collapse
|
4
|
Bodenheimer T. Revitalizing Primary Care, Part 2: Hopes for the Future. Ann Fam Med 2022; 20:469-478. [PMID: 36228059 PMCID: PMC9512544 DOI: 10.1370/afm.2859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams.
Collapse
Affiliation(s)
- Thomas Bodenheimer
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California
| |
Collapse
|
5
|
Sudeshika T, Naunton M, Deeks LS, Thomas J, Peterson GM, Kosari S. General practice pharmacists in Australia: A systematic review. PLoS One 2021; 16:e0258674. [PMID: 34648595 PMCID: PMC8516208 DOI: 10.1371/journal.pone.0258674] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/03/2021] [Indexed: 11/29/2022] Open
Abstract
Background The inclusion of pharmacists into general practices in Australia has expanded in recent years. This systematic review aimed to synthesise the literature of qualitative and quantitative studies, and identify the knowledge gaps, related to pharmacists working in general practice in Australia. Methods This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, EBSCOhost, EMBASE, and the Cochrane Library were searched from the inception of databases to January 2021. The search was focused on studies investigating general practice pharmacists in Australia. The quality of each study was appraised using the Mixed Method Appraisal Tool criteria. The narrative synthesis approach was utilised to describe data due to the heterogeneity among study designs and measures. Results Twenty-five studies were included in this review. General practice pharmacists engaged in various non-dispensing patient care services, with medication management reviews being the primary activity reported. General practice pharmacists’ characteristics and an environment with a willingness of collaboration were the notable influencing factors for successfully including pharmacists in general practices. Factors that posed a challenge to the adoption of general practice pharmacists were lack of funding and other resources, poorly defined roles, and absence of mentoring/training. Conclusion This review has summarised the characteristics, activities, benefits, barriers, and facilitators of including pharmacists in general practices in Australia. General practice pharmacists are well accepted by stakeholders, and they can engage in a range of patient-centred activities to benefit patients. There is a need for more robust research to explore the patient and economic outcomes related to clinical activities that a pharmacist can perform in general practice, as a foundation to developing an appropriate and sustainable funding model. The findings of this review will be beneficial for pharmacists, researchers, policymakers, and readers who wish to implement the role of general practice pharmacists in the future.
Collapse
Affiliation(s)
- Thilini Sudeshika
- Faculty of Health, Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia
- Faculty of Allied Health Sciences, Department of Pharmacy, University of Peradeniya, Peradeniya, Sri Lanka
- * E-mail:
| | - Mark Naunton
- Faculty of Health, Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Louise S. Deeks
- Faculty of Health, Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Jackson Thomas
- Faculty of Health, Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Gregory M. Peterson
- Faculty of Health, Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | - Sam Kosari
- Faculty of Health, Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia
| |
Collapse
|
6
|
Burton RA, Zuckerman S, Haber SG, Keyes V. Patient-Centered Medical Home Activities Associated With Low Medicare Spending and Utilization. Ann Fam Med 2020; 18:503-510. [PMID: 33168678 PMCID: PMC7708292 DOI: 10.1370/afm.2589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/27/2020] [Accepted: 04/07/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To identify components of the patient-centered medical home (PCMH) model of care that are associated with lower spending and utilization among Medicare beneficiaries. METHODS Regression analyses of changes in outcomes for Medicare beneficiaries in practices that engaged in particular PCMH activities compared with beneficiaries in practices that did not. We analyzed claims for 302,719 Medicare fee-for-service beneficiaries linked to PCMH surveys completed by 394 practices in the Centers for Medicare & Medicaid Services' 8-state Multi-Payer Advanced Primary Care Practice demonstration. RESULTS Six activities were associated with lower spending or utilization. Use of a registry to identify and remind patients due for preventive services was associated with all 4 of our outcome measures: total spending was $69.77 less per beneficiary per month (PBPM) (P = 0.00); acute-care hospital spending was $36.62 less PBPM (P = 0.00); there were 6.78 fewer hospital admissions per 1,000 beneficiaries per quarter (P1KBPQ) (P = 0.003); and 11.05 fewer emergency department (ED) visits P1KBPQ (P = 0.05). Using a patient registry for pre-visit planning and clinician reminders was associated with $29.31 lower total spending PBPM (P = 0.05). Engaging patients with chronic conditions in goal setting and action planning was associated with 4.62 fewer hospital admissions P1KBPQ (P = 0.01) and 11.53 fewer ED visits P1KBPQ (P = 0.00). Monitoring patients during hospital stays was associated with $22.06 lower hospital spending PBPM (P = 0.03). Developing referral protocols with commonly referred-to clinicians was associated with 11.62 fewer ED visits P1KBPQ (P = 0.00). Using quality improvement approaches was associated with 13.47 fewer ED visits P1KBPQ (P =0.00). CONCLUSIONS Practices seeking to deliver more efficient care may benefit from implementing these 6 activities.
Collapse
Affiliation(s)
| | | | | | - Vincent Keyes
- RTI International, Research Triangle Park, North Carolina
| |
Collapse
|