Defining and measuring the patient-centered medical home

Study protocol for transforming health equity research in integrated primary care: Antiracism as a disruptive innovation

Among the consequences of systemic racism in health care are significant health disparities among Black/African American individuals with comorbid physical and mental health conditions. Despite decades of studies acknowledging health disparities based on race, significant change has not occurred. There are shockingly few evidence-based antiracism interventions. New paradigms are needed to intervene on, and not just document, racism in health care systems. We are developing a transformative paradigm for new antiracism interventions for primary care settings that integrate mental and physical health care. The paradigm is the first of its kind to integrate community-based participatory research and systems science, within an established model of early phase translation to rigorously define new antiracism interventions. This protocol will use a novel application of systems sciences by combining the qualitative systems sciences methods (group model building; GMB) with quantitative methods (simulation modeling) to develop a comprehensive and community-engaged view of both the drivers of racism and the potential impact of antiracism interventions. Community participants from two integrated primary health care systems will engage in group GMB workshops with researchers to 1) Describe and map the complex dynamic systems driving racism in health care practices, 2) Identify leverage points for disruptive antiracism interventions, policies and practices, and 3) Review and prioritize a list of possible intervention strategies. Advisory committees will provide feedback on the design of GMB procedures, screen potential intervention components for impact, feasibility, and acceptability, and identify gaps for further exploration. Simulation models will be generated based on contextual factors and provider/patient characteristics. Using Item Response Theory, we will initiate the process of developing core measures for assessing the effectiveness of interventions at the organizational-systems and provider levels to be tested under a variety of conditions. While we focus on Black/African Americans, we hope that the resulting transformative paradigm can be applied to improve health equity among other marginalized groups.

'The big value of it is getting the patient seen by the right person at the right time': clinician perceptions of the value of allied health primary contact models of care

Allied health primary contact clinic models of care have increasingly been used as a strategy to increase public health service capacity. A recent systematic review found little consistency or agreement on how primary contact clinics are evaluated. The concept of value of primary contact clinics, which has important implications for evaluation, has not yet been explored in-depth. To explore allied health clinicians' perceptions of the value of allied health primary contact clinics, with the goal of informing an evaluation framework, a descriptive qualitative approach utilizing semi-structured interviews was employed. Participants included allied health staff embedded in clinical lead roles within primary contact clinics across four acute care hospitals in a metropolitan health service located in South-East Queensland, Australia. Lead staff from 30 identified primary contact clinic models in the health service were approached to take part via email. All eligible participants who provided consent were included. An inductive thematic analysis approach was used. A total of 23 clinicians (n = 23) representing 22 diverse models of primary contact clinics participated. Most participants were physiotherapists, dietitians, or occupational therapists, although speech pathology, audiology, and podiatry were also represented. Participant perceptions of the 'value' of PCCs were a highly complex phenomenon, comprising five intersecting domains: (i) patient satisfaction; (ii) clinical outcomes; (iii) care pathway and resource use; (iv) health service performance; and (v) staff satisfaction and professional standing. These five core value domains were positively or negatively influenced by 12 perceived benefits and 8 perceived drawbacks, respectively. Value domains were also highly interrelated and impacted upon each other. The concept of 'value' relating to primary contact clinics involves multiple intersecting domains encompassing different perspectives. This study highlighted potential benefits and drawbacks of primary contact clinics that have not yet been measured or explored in the literature, and as such may be useful for healthcare administrators to consider. The findings of this study will inform an evaluation framework including health economics calculator for primary contact clinics.

Overcoming silos in health care systems through meso-level organisations - a case study of health reforms in New South Wales, Australia

Fragmented care delivery is a barrier to improving health system performance worldwide. Investment in meso-level organisations is a potential strategy to improve health system integration, however, its effectiveness remains unclear. In this paper, we provide an overview of key international and Australian integrated care policies. We then describe Collaborative Commissioning - a novel health reform policy to integrate primary and hospital care sectors in New South Wales (NSW), Australia and provide a case study of a model focussed on older person's care. The policy is theorised to achieve greater integration through improved governance (local stakeholders identifying as part of one health system), service delivery (communities perceive new services as preferable to status quo) and incentives (efficiency gains are reinvested locally with progressively higher value care achieved). If effectively implemented at scale, Collaborative Commissioning has potential to improve health system performance in Australia and will be of relevance to similar reform initiatives in other countries.

Increased Organizational Stress in Primary Care: Understanding the Impact of the COVID-19 Pandemic, Medicaid Expansion, and Practice Ownership

BACKGROUND

Primary care is the foundation of health care, resulting in longer lives and improved equity. Primary care was the frontline of the COVID-19 pandemic public response and essential for access to care. Yet primary care faces substantial structural and systemic challenges. As part of a longitudinal analysis to track the capacity and health of primary care, we surveyed every primary care practice in Virginia in 2018 and again in 2022.

METHODS

Surveys were emailed or mailed up to 6 times and nonresponders received a phone call. Questions assessed organizational characteristics, scope of care, capacity, and organizational stress in the prior year. From respondents, 39 clinicians, nurses, staff, administrators, and practice managers were interviewed.

RESULTS

526 out of 2296 primary care practices (23% response rate) completed the survey, with broad representation across geography, ownership, and payer mix. Compared with 2018, in 2022 there were increases in practices owned by health systems (25% vs 43%, P < .0001) and average percent of patients with Medicaid per practice (12% vs 22%, P < .0001). The percent of practices reporting any major stressor increased from 34% to 53% (P < .0001). The main increased stress was losing a clinician, with 13% of practices in 2018 versus 42% in 2022 reporting losing a clinician (P < .0001).

CONCLUSIONS

Primary care practices are resilient and continue to serve their communities, including a broad scope of services and care for underserved people. However, the COVID-19 pandemic caused significant stress. With an increase in clinicians leaving clinical practice, we anticipate worsening access to primary care.

Thinking and Enacting the Patient Medical Home Under Pandemic Conditions: A Qualitative Study From Primary Care in Alberta, Canada

BACKGROUND

The COVID-19 (C19) pandemic shocked primary care systems around the world. Those systems responded by supporting patients in the community, and acute care facilities in crisis. In Canada, the Patient Medical Home (PMH) is a widely adopted care model that aims to operationalize the tenets and principles of Primary Health Care (PHC) as developed since the Alma-Ata Declaration. This paper describes how personnel working in and with Primary Care Networks (PCNs) in Alberta, Canada deployed the PMH model and its underlying PHC principles to frame and respond to the C19 shock.

METHODS

Using purposive and snowball sampling techniques, we interviewed 57 participants who worked in public health and primary care, including community-based family physicians. We used interpretive description to analyze the interviews.

RESULTS

PCN staff and physicians described how the PMH model was foundational to normal operations, and how C19 responses were framed by the patient-centric, team-delivered, and continuous care principles the model shares with PHC. Specifically, participants described ensuring access to care, addressing the social determinants of health, being patient centered, and redeploying and expanding PHC teams to accomplish these goals.

DISCUSSION

Delivering PHC through the PMH allowed physicians and allied health staff to deliver patient-centered, team-based, holistic bio-medical services to Albertans. In tailoring services to meet the specific social and health needs of the populations served by each PCN, healthcare providers were able to ensure relevant support remained available and accessible.

Interprofessional collaboration in primary health care from the perspective of implementation science

The objective was to analyze the perceptions of primary health care (PHC) workers about interprofessional collaboration from the perspective of implementation science. This is a qualitative study that used in-depth interview as a data production technique. Interviews were conducted with 15 workers (three community health agents, one nursing assistant, three nurses, three managers, three physicians, and two nursing technicians) from basic health units in the Municipality of São Bernardo do Campo, São Paulo State, Brazil. The interview plan was based on three domains of the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis was used. In the interprofessional collaboration characteristics domain, respondents highlighted the complexity, and its possible influence, as to the implementation and sustainability of this practice. In the inner setting domain, factors that influence interprofessional collaboration were identified, namely: how the time allocated to formal communication/team meetings is used; social interactions between professionals; and leadership characteristics, such as feedback, autonomy and participation in decisions. In the individuals characteristics domain, participants noted interprofessional collaboration geared to quality of care and the need for integration between knowledge centers. Thus, measures to enhance the quality of communication, collective team building and leadership can contribute to improve interprofessional collaboration in PHC and leverage its impacts on health care.

Transformation to a patient-centred medical home led and delivered by an urban Aboriginal and Torres Strait Islander community, and association with engagement and quality-of-care: quantitative findings from a pilot study

BACKGROUND

The patient-centred medical home (PCMH) is a model of team-based primary care that is patient-centred, coordinated, accessible, and focused on quality and safety. In response to substantial population growth and increasing demand on existing primary care services, the Institute for Urban Indigenous Health (IUIH) developed the IUIH System of Care-2 (ISoC2), based on an international Indigenous-led PCMH. ISoC2 was piloted at an urban Aboriginal and Torres Strait Islander Community-Controlled Health Service in South-East Queensland between 2019-2020, with further adaptations made to ensure its cultural and clinical relevance to local Aboriginal and Torres Strait Islander people. Little is known on the implementation and impact of PCMH in the Australian Indigenous primary care setting. Changes in implementation process measures and outcomes relating to engagement and quality-of-care are described here.

METHODS

De-identified routinely collected data extracted from electronic health records for clients regularly attending the service were examined to assess pre-post implementation changes relevant to the study. Process measures included enrolment in PCMH team-based care, and outcome measures included engagement with the health service, continuity-of-care and clinical outcomes.

RESULTS

The number of regular clients within the health service increased from 1,186 pre implementation to 1,606 post implementation; representing a small decrease as a proportion of the services' catchment population (38.5 to 37.6%). In clients assigned to a care team (60% by end 2020), care was more evenly distributed between providers, with an increased proportion of services provided by the Aboriginal and Torres Strait Islander Health Worker (16-17% versus 10-11%). Post-implementation, 41% of clients had continuity-of-care with their assigned care team, while total, preventive and chronic disease services were comparable pre- and post-implementation. Screening for absolute cardiovascular disease risk improved, although there were no changes in clinical outcomes.

CONCLUSIONS

The increase in the number of regular clients assigned to a team and their even distribution of care among care team members provides empirical evidence that the service is transforming to a PCMH. Despite a complex transformation process compounded by the COVID-19 pandemic, levels of service delivery and quality remained relatively stable, with some improvements in risk factor screening.

Scaling and sustaining COVID-19 vaccination through meaningful community engagement and care coordination for underserved communities: hybrid type 3 effectiveness-implementation sequential multiple assignment randomized trial

BACKGROUND

COVID-19 inequities are abundant in low-income communities of color. Addressing COVID-19 vaccine hesitancy to promote equitable and sustained vaccination for underserved communities requires a multi-level, scalable, and sustainable approach. It is also essential that efforts acknowledge the broader healthcare needs of these communities including engagement in preventive services.

METHODS

This is a hybrid type 3 effectiveness-implementation study that will include a multi-level, longitudinal, mixed-methods data collection approach designed to assess the sustained impact of a co-created multicomponent strategy relying on bidirectional learning, shared decision-making, and expertise by all team members. The study capitalizes on a combination of implementation strategies including mHealth outreach with culturally appropriate messaging, care coordination to increase engagement in high priority preventive services, and the co-design of these strategies using community advisory boards led by Community Weavers. Community Weavers are individuals with lived experience as members of an underserved community serving as cultural brokers between communities, public health systems, and researchers to co-create community-driven, culturally sensitive public health solutions. The study will use an adaptive implementation approach operationalized in a sequential multiple assignment randomized trial design of 300 participants from three sites in a Federally Qualified Health Center in Southern California. This design will allow examining the impact of various implementation strategy components and deliver more intensive support to those who benefit from it most. The primary effectiveness outcomes are COVID-19 vaccine completion, engagement in preventive services, and vaccine confidence. The primary implementation outcomes are reach, adoption, implementation, and maintenance of the multicomponent strategy over a 12-month follow-up period. Mixed-effects logistic regression models will be used to examine program impacts and will be triangulated with qualitative data from participants and implementers.

DISCUSSION

This study capitalizes on community engagement, implementation science, health equity and communication, infectious disease, and public health perspectives to co-create a multicomponent strategy to promote the uptake of COVID-19 vaccination and preventive services for underserved communities in San Diego. The study design emphasizes broad engagement of our community and clinic partners leading to culturally sensitive and acceptable strategies to produce lasting and sustainable increases in vaccine equity and preventive services engagement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05841810 May 3, 2023.

The Association of Learning Health System Practicing Hospitals and other Health Information Interested Hospitals with Patient-Generated Health Data Uptake

Patient generated health data (PGHD) has been described as a necessary addition to provider-generated information for improving care processes in US hospitals. This study evaluated the distribution of Health Information Interested (HII) US hospitals that are more likely to capture or use PGHD. The literature suggests that HII hospitals are more likely to capture and use PGHD. Cross-sectional analysis of the 2018 American Hospital Association's (AHA) health-IT-supplement and other supporting datasets showed that HII hospitals collectively and majority of HII hospital subcategories evaluated were associated with increased PGHD capture and use. The full Learning Health System (LHS) hospital subcategory had the highest association and hospitals in the meaningful use stage three compliant (MU3) and PCORI funded subcategory also had higher rates of PGHD capture or use when in combination with LHS hospitals. Hence, being LHS appears to be the strongest practice and policy lever to increase PGHD capture and use.

The quality of migrant patients' primary healthcare experiences and patient-centered medical home achievement by community health centers: results from the China greater bay area study

BACKGROUND

In China, Community Health Centers (CHCs) provide primary healthcare (PHC); however, few studies have examined the quality of PHC services experienced by migrant patients. We examined the potential association between the quality of migrant patients' PHC experiences and the achievement of Patient-Centered Medical Home by CHCs in China.

METHODS

Between August 2019 and September 2021, 482 migrant patients were recruited from ten CHCs in China's Greater Bay Area. We evaluated CHC service quality using the National Committee for Quality Assurance Patient-Centered Medical Home (NCQA-PCMH) questionnaire. We additionally assessed the quality of migrant patients' PHC experiences using the Primary Care Assessment Tools (PCAT). General linear models (GLM) were used to examine the association between the quality of migrant patients' PHC experiences and the achievement of PCMH by CHCs, adjusting for covariates.

RESULTS

The recruited CHCs performed poorly on PCMH1, Patient-Centered Access (7.2 ± 2.0), and PCMH2, Team-Based Care (7.4 ± 2.5). Similarly, migrant patients assigned low scores to PCAT dimension C-First-contact care-which assesses access (2.98 ± 0.03), and D-Ongoing care (2.89 ± 0.03). On the other hand, higher-quality CHCs were significantly associated with higher total and dimensional PCAT scores, except for dimensions B and J. For example, the total PCAT score increased by 0.11 (95% CI: 0.07-0.16) with each increase of CHC PCMH level. We additionally identified associations between older migrant patients (> 60 years) and total PCAT and dimension scores, except for dimension E. For instance, the average PCAT score for dimension C among older migrant patients increased by 0.42 (95% CI: 0.27-0.57) with each increase of CHC PCMH level. Among younger migrant patients, this dimension only increased by 0.09 (95% CI: 0.03-0.16).

CONCLUSION

Migrant patients treated at higher-quality CHCs reported better PHC experiences. All observed associations were stronger for older migrants. Our results may inform future healthcare quality improvement studies that focus on the PHC service needs of migrant patients.

Community paramedicine in Central Oregon: A promising model to reduce non-urgent emergency department utilization among medically complex Medicaid beneficiaries

Background

Community paramedicine has emerged as a promising model to redirect persons with nonmedically emergent conditions to more appropriate and less expensive community-based health care settings. Outreach through community paramedicine to patients with a history of high hospital emergency department (ED) use and chronic health conditions has been found to reduce ED use. This study examined the effect of community paramedicine implemented in 2 rural counties in reducing nonemergent ED use among a sample of Medicaid beneficiaries with complex medical conditions and a history of high ED utilization.

Methods

A cluster randomized trial approach with a stepped wedge design was used to test the effect of the community paramedicine intervention. ED utilization for non-urgent care was measured by emergency medicine ED visits and avoidable ED visits.

Results

The community paramedicine intervention reduced ED utilization among a sample of 102 medically complex Medicaid beneficiaries with a history of high ED utilization. In the unadjusted models, emergency medical ED visits decreased by 13.9% (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.76-0.98) or 6.1 visits saved for every 100 people. Avoidable emergency department visits decreased by 38.9% (IRR, 0.61; 95% CI, 0.44-0.84) or 2.3 visits saved for every 100 people.

Conclusion

Our results suggest community paramedicine is a promising model to achieve a reduction in ED utilization among medically complex patients by managing complex health conditions in a home-based setting.

Improving the Approach to Defining, Classifying, Reporting and Monitoring Adverse Events in Seriously Ill Older Adults: Recommendations from a Multi-stakeholder Convening

BACKGROUND

Clinical trials are needed to study topics relevant to older adults with serious illness. Investigators conducting clinical trials with this population are challenged by how to appropriately define, classify, report, and monitor serious and non-serious adverse events (SAEs/AEs), given that some traditionally reported AEs (pressure ulcers, delirium) and SAEs (death, hospitalization) are common in persons with serious illness, and may be consistent with their goals of care.

OBJECTIVES

A multi-stakeholder group convened to establish greater clarity on and new approaches to address this critical issue.

PARTICIPANTS

Thirty-two study investigators, members of regulatory and sponsor agencies, and patient stakeholders took part.

APPROACH

The group met virtually four times and, using a collaborative approach, conducted a survey, select interviews, and reviewed regulatory guidance to collectively define the problem and identify a new approach.

RESULTS

SAE/AE challenges fell into two areas: (1) definitions and classifications, including (a) implausible relationships, (b) misalignment with patient-centered care goals, and (c) well-known associations, and (2) reporting and monitoring, including (a) limited guidance, (b) inconsistent standards across regulators, and (c) Data Safety Monitoring Board (DSMB) member knowledge gaps. Problems largely reflected practice norms rather than regulatory requirements that already support context-specific and aggregate reporting. Approaches can be improved by adopting principles that better align strategies for addressing adverse events with the type of intervention being tested, favoring routine and aggregate over expedited reporting, and prioritizing how SAE/AEs relate to patient-centered care goals. Reporting plans and decisions should follow an algorithm underpinned by these principles.

CONCLUSIONS

Adoption of the proposed approach-and supporting it with education and better alignment with regulatory guidance and procedures-could improve the quality and efficiency of clinical trials' safety involving older adults with serious illness and other vulnerable populations.

Providing a health-promotion behaviors model in elderly: Psychological capital, perceived social support, and attitudes toward death with mediating role of cognitive emotion regulation strategies

Background and Aims

The aim of this study was to present a health-promotion behaviors model in the elderly based on psychological capital, social support, and attitudes toward death mediated with mediating role of emotional cognitive regulation strategies in the elderly in Ardabil.

Methods

The research method was correlational which was done by the path analysis method. The statistical population of the study consisted of all elderly people in Ardabil in 2020, from which 250 people were selected by convenient sampling method and were investigated with research tools including Health-Promotion Lifestyle Profile (1998), attitudes toward death profile (1994), Psychological Capitals (2007), social support (1988) and Cognitive Emotion Regulation (2001). Data were analyzed by Amos-24 software and using structural equation modeling.

Results

The results showed that psychological capital, social support, and attitude towards death directly affect health-promotion behaviors and also indirectly improve them through cognitive emotion regulation strategies. These results can have a significant impact on promoting health and improving the quality of life of the elderly population.

Conclusions

Based on the findings of the present study, it can be claimed that the proposed model for the health of the elderly has an acceptable fitness and this model can be used in developing educational programs and intervention techniques to improve the health of this group of people.

Advancing digital patient-centered measurement methods for team-based care

Objectives

To conceptualize new methods for integrating patient-centered measurement into team-based care.

Methods

A standalone portal was introduced into a rural clinic to support conceptualization of new methods for integration of patient-centered measurement in team-based care. The portal housed mental health-related online resources, three patient-reported measures and a self-action plan. Six providers and four patients used the portal for four months. Our data collection techniques included clinic discussions, one-on-one interviews, workflow diagrams and data generated through the portal. Analysis was supported through coding interview transcripts, looking across multiple sources of research data and research team discussions.

Results

Our research team conceptualized five team-based patient-centered measurement methods through this study. Patient-centered measurement Team Mapping offfers a technique to provide greater clarity of care-team roles and responsibilities in data collected through patient-centered measurement. Longitudinal Care Alignment can guide the care-team on incorporating patient-centered measurement into ongoing provider-patient interactions. Digital Tool Exploration can be used to evaluate a team's readiness toward digital tool adoption, and the impact of these tools. Team-based quality improvement serves as a framework for engaging teams in patient-centered quality improvement. Shared learning is a method that promotes patientprovider interactions that validate patient's perspectives of their care.

Conclusion

The portal illuminated new methods for the integration of patient-centered measurement in team-based care. The first three proposed patient-centered measurement methods provides ways to assess how a clinic can incorporate patient-centered measurement methods into team-based care. The latter two methods focus on the aim of patient-generated data in which patient's values and perspectives are represented and quality of patient-centered care can be evaluated. Further testing is needed to assess the utility of these patient-centered measurement methods across different clinical settings and domains.

Factors that support readiness to implement integrated evidence-based practice to increase cancer screening

BACKGROUND

In 2015, the Centers for Disease Control and Prevention (CDC) funded the Colorectal Cancer Control Program (CRCCP), which partners with health care systems and primary care clinics to increase colorectal cancer (CRC) screening uptake. We interviewed CRCCP stakeholders to explore the factors that support readiness for integrated implementation of evidence-based interventions (EBIs) and supporting activities to promote CRC screening with other screening and chronic disease management activities in primary care clinics.

METHODS

Using the Consolidated Framework for Implementation Research (CFIR), we conducted a literature review and identified constructs to guide data collection and analysis. We purposively selected four CRCCP awardees that demonstrated ongoing engagement with clinic partner sites, willingness to collaborate with CDC and other stakeholders, and availability of high-quality data. We gathered background information on the selected program sites and conducted primary data collection interviews with program site staff and partners. We used NVivo QSR 11.0 to systematically pilot-code interview data, achieving a kappa coefficient of 0.8 or higher, then implemented a step-wise process to identify site-specific and cross-cutting emergent themes. We also included screening outcome data in our analysis to examine the impact of integrated cancer screening efforts on screening uptake.

RESULTS

We identified four overarching factors that contribute to clinic readiness to implement integrated EBIs and supporting activities: the funding environment, clinic governance structure, information sharing within clinics, and clinic leadership support. Sites reported supporting clinic partners' readiness for integrated implementation by providing coordinated funding application processes and braided funding streams and by funding partner organizations to provide technical assistance to support efficient incorporation of EBIs and supporting activities into existing clinic workflows. These actions, in turn, support clinic readiness to integrate the implementation of EBIs and supporting activities that promote CRC screening along with other screening and chronic disease management activities.

DISCUSSION

The selected CRCCP program sites supported clinics' readiness to integrate CRC EBIs and supporting activities with other screening and chronic disease management activities increasing uptake of CRC screening and improving coordination of patient care.

CONCLUSIONS

We identified the factors that support clinic readiness to implement integrated EBIs and supporting activities including flexible funding mechanisms, effective data sharing systems, coordination across clinical staff, and supportive leadership. The findings provide insights into how public health programs and their clinic partners can collectively support integrated implementation to promote efficient, coordinated patient-centered care.

The benefits and challenges of established peer support programmes for patients, informal caregivers, and healthcare providers

PURPOSE

Peer support programmes that provide services for various health conditions have been in existence for many years; however, there is little study of their benefits and challenges. Our goal was to explore how existing peer support programmes help patients with a variety of health conditions, the challenges that these programmes meet, and how they are addressed.

METHODS

We partnered with 7 peer support programmes operating in healthcare and community settings and conducted 43 semi-structured interviews with key informants. Audiorecordings were transcribed and qualitative analysis was conducted using grounded theory methods.

RESULTS

Peer support programmes offer informational and psychosocial support, reduce social isolation, and connect patients and caregivers to others with similar health issues. These programmes provide a supportive community of persons who have personal experience with the same health condition and who can provide practical information about self-care and guidance in navigating the health system. Peer support is viewed as different from and complementary to professional healthcare services. Existing programmes experience challenges such as matching of peer supporter and peer recipient and maintaining relationship boundaries. They have gained experience in addressing some of these challenges.

CONCLUSIONS

Peer support programmes can help persons and caregivers manage health conditions but also face challenges that need to be addressed through organizational processes. Peer support programmes have relevance for improving healthcare systems, especially given the increased focus on becoming more patient-centred. Further study of peer programmes and their relevance to improving individuals' well-being is warranted.

Examining child flourishing, family resilience, and adversity in the 2016 National Survey of Children's Health

PURPOSE

Explore factors associated with flourishing and family resilience among children aged 6 months to 5 years old in the 2016 National Survey of Children's Health (NSCH).

DESIGN AND METHODS

Cross-sectional analysis of the 2016 NSCH was conducted using Kleinman and Norton's Regression Risk Analysis method to derive adjusted risk measures for logistic regression models to assess factors contributing to (1) child flourishing and (2) child flourishing stratified between resilient and non-resilient families.

RESULTS

In multivariable models, resilient families less often reported a child with two or more lifetime ACE exposures (ARD -0.11, 95% CI -0.15, -0.08), more likely to live in a supportive neighborhood (ARD 0.08, 95% CI 0.05,0.11), and more likely to report emotional support in raising children (ARD 0.07, 95% CI 0.12, 0.40). Accounting for ACE exposures, within resilient families, child flourishing was more likely when the child lived in a supportive neighborhood (ARD 0.09, 95% CI 0.03, 0.15), received care in a patient centered medical home (ARD 0.09, 95% CI 0.02,0.15), and when parents reported having emotional support in raising children (ARD 0.10, 95% CI 0.05, 0.17) Within non-resilient families, child flourishing was more likely when parents had emotional support in raising children (ARD 0.15, 95% CI 0.04,0.27).

CONCLUSION

Promoting emotional support for parents may bolster family resilience and help young children to flourish despite adversity.

PRACTICE IMPLICATIONS

Further research and innovative models of care are needed to optimize the role of pediatric primary care in promoting safe, stable, nurturing relationships and environments for children and families.

Challenges and Strategies for Patient Safety in Primary Care: A Qualitative Study

Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data included interviews (N = 101), focus groups (N = 65), and observations of safety processes (N = 79) collected from 10 patient-centered medical homes. Key safety issues included the lack of interoperability among health information systems, clinician-patient communication failures, and challenges with medication reconciliation. Commonly cited safety strategies leveraged health information systems or involved dedicated resources (eg, providing access to social workers). Patients also identified strategies not mentioned by clinicians, emphasizing the need for their involvement in developing safety solutions. This work provides insight into safety issues of greatest concern to clinicians, staff, and patients and strategies to improve safety in the ambulatory setting.

Cost analysis of a Patient-Centred Medical Home for community-dwelling older adults with complex needs in Singapore

INTRODUCTION

The Patient-Centred Medical Home (PCMH) demonstration in Singapore, launched in November 2016, aimed to deliver integrated and patient-centred care for patients with biopsychosocial needs. Implementation was based on principles of comprehensiveness, coordinated care and shared decision-making.

METHOD

We conducted a prospective single-arm pre-post study design, which aimed to perform cost analysis of PCMH from the perspectives of patients, healthcare providers and society. We assessed short-to-intermediate-term health-related costs by analysing data on resource use and unit costs of resources.

RESULTS

We analysed 165 participants enrolled in PCMH from November 2017 to April 2020, with mean age of 77 years. Compared to the 3-month period before enrolment, mean total direct and indirect participant costs and total health system costs increased, but these were not statistically significant. There was a significant decrease in mean cost for primary care (government primary care and private general practice) in the first 3-month and second 3-month periods after enrolment, accompanied by a significant decrease in service utilisation and mean costs for PCMH services in the second 3-month period post-enrolment. This suggested a shift in resource costs from primary care to community-based care provided by PCMH, which had added benefits of both clinic-based primary care and home-based care management. Findings were consistent with a lower longer-term cost trajectory for PCMH after the initial onboarding period. Indirect caregiving costs remained stable.

CONCLUSION

The PCMH care model was associated with reduced costs to the health system and patients for usual primary care, and did not significantly change societal costs.

Implementing a new physiotherapist-led primary care model for low back pain: a qualitative study of patient and primary care team perspectives

Background

Low back pain (LBP) is one of the most common reasons for primary care visits and is the leading contributor to years lived with disability worldwide. The purpose of this study was to understand the perspectives of patients and primary care team members related to their experiences with a new physiotherapist-led primary care model for LBP.

Methods

We conducted an interpretive description qualitative study. Data were collected using a combination of semi-structured interviews and focus group discussions and analyzed using thematic analysis. Participants included adults (> 18 years of age) with LBP and primary care team members who participated in a physiotherapist-led primary care model for LBP in Kingston, Ontario, Canada.

Results

We conducted 18 semi-structured interviews with patients with LBP (10 women; median age of 52) as well as three focus group discussions with a total of 20 primary care team members representing three teams. Four themes (each with sub-themes) were constructed: 1) enhanced primary care delivery for LBP (improved access and engagement in physiotherapy care, improved communication and care integration between the physiotherapist and primary care team, less inappropriate use of healthcare resources); 2) positive patient experiences and perceived outcomes with the new model of care (physiotherapist built therapeutic alliance, physiotherapist provided comprehensive care, improved confidence in managing LBP, decreased impact of pain on daily life); 3) positive primary care team experiences with the new model of care (physiotherapist fit well within the primary care team, physiotherapist provided expertise on LBP for the primary care team, satisfaction in being able to offer a needed service for patients); and 4) challenges implementing the new model of care (challenges with prompt access to physiotherapy care, challenges making the physiotherapist the first contact for LBP, and opportunities to optimize communication between the physiotherapist and primary care team).

Conclusions

A new physiotherapist-led primary care model for LBP was described by patients and primary care team members as contributing to positive experiences and perceived outcomes for patients, primary care team members, and potentially the health system more broadly. Results suggest that this model of care may be a viable approach to support integrated and guideline adherent management of LBP in primary care settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01817-5.

Residential substance use treatment outcomes for pregnant and postpartum women: Distinct patterns for women enrolled before versus during the COVID-19 pandemic

Introduction

Substance use among pregnant and postpartum women (PPW) is a serious public health concern. The COVID‐19 pandemic has exacerbated substance use among the general population including pregnant women, and disrupted operations for substance use treatment centers. Little is known about the outcomes of substance use treatment for PPW before and during the COVID‐19 pandemic.

Method

Data from a longitudinal program evaluation were analyzed to examine outcomes among 136 PPW participating in a residential SUD treatment program, and to explore differences in treatment outcomes for women who enrolled in services before versus during the COVID‐19 pandemic. Analyses were used to test the significance of change from treatment intake to 6‐month post‐intake on assessments of substance use, mental health symptoms, and functioning collected to evaluate the Healthy Families Program (HFP), a comprehensive program for PPW located within a gender‐specific SUD treatment facility in the United States.

Results

Results indicated that from treatment intake to follow‐up assessment, clients self‐reported statistically significant improvements in family functioning and daily functioning as well as reduced days of substance use. Notably, the rate of treatment intakes declined during the COVID‐19 pandemic. In separate analyses by subgroup, mental health indicators showed improvements only for clients engaged in treatment before the COVID‐19 pandemic and not for clients served during the COVID‐19 pandemic, but substance use decreased significantly for both pre‐pandemic and pandemic enrollees.

Conclusion

Specialized treatment considerations and implications for PPW are discussed, including a need for added emphasis on co‐occurring mental health symptoms and family system stress during a pandemic, and the role of nurses in identifying and addressing these concerns. Additionally, potential relapse prevention efforts during COVID‐19 for PPW with substance use disorders are examined.

Clinical Relevance

The present research continues to highlight the importance of specialized treatment programming for PPW with SUDs as well as the potential need for additional recovery support mechanisms to be utilized during the COVID‐19 pandemic.

Examining the Relationship of Family Social Capital and Use of Pediatric Primary Health Care Services in the 2016-19 National Survey of Children's Health

INTRODUCTION

This study examined the relationship of family social capital (FSC) and pediatric primary health care services (PHCU) among young children aged 0-5 years in the United States. FSC involves the interrelated contexts of child health and family characteristics. Understanding how this impacts PHCU may reveal important considerations for supporting access and use of essential health care services.

METHOD

Using data from the 2016-19 National Survey of Children's Health (weighted N = 21,496,634), we conducted descriptive statistics and logistic regression to ascertain the relationship between FSC and PHCU.

RESULTS

Statistically significant contributions included FSC (odds ratio [OR] = 1.2; confidence interval [CI] = 1.08-1.40), high school (OR = 0.49; CI = 2.65-5.39), and some college (OR = 0.72; CI = 0.62-0.85) DISCUSSION: Findings support that FSC and parent academic achievement impact PHCU. Interventions that foster family connection and parent adult health literacy may enhance PHCU.

A double-edged sword: The effects of social network ties on job satisfaction in primary care organizations

BACKGROUND

Social ties between health care workers may be an important driver of job satisfaction; however, research on this topic is limited.

PURPOSE

We used social network methods to collect data describing two types of social ties, (a) instrumental ties (i.e., exchange of advice that enables work) and (b) expressive ties (i.e., exchange of social support), and related those ties to workers' job satisfaction.

METHODOLOGY

We surveyed 456 clinicians and staff at 23 primary care practices about their social networks and workplace attitudes. We used multivariable linear regression to estimate the relationship between an individual's job satisfaction and two network properties: (a) eigenvector centrality (a measure of the importance of an individual in a network) and (b) ego network density (a measure of the cohesiveness of an individual's network). We examined this relationship for both instrumental and expressive ties.

RESULTS

Individuals who were more central in the expressive network were less satisfied in their job, b = -0.40 (0.19), p < .05, whereas individuals who had denser instrumental networks were more satisfied in their job, b = 0.49 (0.21), p < .05.

CONCLUSION

Workplace relationships affect worker well-being. Centrality in an expressive network may require greater emotional labor, increasing workers' risk for job dissatisfaction. On the other hand, a dense instrumental network may promote job satisfaction by strengthening workers' access to full information, supporting competence and confidence.

PRACTICE IMPLICATIONS

Efforts to increase job satisfaction should consider both the positive and negative effects of social networks on workers' sense of well-being.

The 12 Ds of geriatric medical-psychiatry: A new format for geriatric case presentation

Background: We present a new format for geriatric case presentation called the 12 Ds of Geriatric Medical-Psychiatry that facilitates an integrated discussion of both the physical and mental health issues that pertain to any geriatric patient. The format can be used to replace or to complement traditional medical model case presentation and can also be used as a teaching aid to provide the parameters for a holistic view of the geriatric patient. Methods: We developed the 12 Ds of Geriatric Medical-Psychiatry for case presentation by modifying the SBAR (situation, background, assessment, recommendations) with 12 clinical considerations that apply to any geriatric patient. Following implementation of the 12 Ds of Geriatric Medical-Psychiatry case presentation in our integrated team of geriatric medicine and psychiatry healthcare providers, we successfully used the 12 Ds model to present more than 180 patients and found the model easy to use and well received by learners and colleagues. Conclusion: The 12 Ds of Geriatric Medical-Psychiatry provides a comprehensive format to discuss the pertinent issues facing geriatric patients. When used in an SBAR format, it appears to be an efficient means for integrated case presentation and/or can be used as a tool for teaching and understanding a holistic view of complex geriatric cases.

From COVID-19 Pandemic to Patient Safety: A New “Spring” for Telemedicine or a Boomerang Effect?

During the Covid-19 health emergency, telemedicine was an essential asset through which health systems strengthened their response during the critical phase of the pandemic. According to the post-pandemic economic reform plans of many countries, telemedicine will not be limited to a tool for responding to an emergency condition but it will become a structural resource that will contribute to the reorganization of Healthcare Systems and enable the transfer of part of health care from the hospital to the home-based care. However, scientific evidences have shown that health care delivered through telemedicine can be burdened by numerous ethical and legal issues. Although there is an emerging discussion on patient safety issues related to the use of telemedicine, there is a lack of reseraches specifically designed to investigate patient safety. On the contrary, it would be necessary to determine standards and specific application rules in order to ensure safety. This paper examines the telemedicine-risk profiles and proposes a position statement for clinical risk management to support continuous improvement in the safety of health care delivered through telemedicine.

A Patient-Centred Medical Home Care Model for Community-Dwelling Older Adults in Singapore: A Mixed-Method Study on Patient's Care Experience

Patient-Centred Medical Home (PCMH) is a strategy to enhance patient-centredness to improve care experience. We aimed to understand patient experience of an integrated PCMH model for complex community-dwelling older adults in Singapore. We used a mixed-method design with a prospective single-group pre-post quantitative component and a concurrent qualitative component. Participants were administered the validated Consumer Assessment of Health Providers and Systems Clinician & Group Survey (CG-CAHPS) at baseline (N = 184) and 6-month (N = 166) post-enrolment. We conducted focus group discussions (FGDs) on a purposive sample of 24 participants. Both methods suggest better care experience in PCMH relative to usual care. There were improvements in the CG-CAHPS measures on patient–provider communication, care coordination, office staff interactions, support for patients in caring for their own health, and provider rating in PCMH relative to usual care. In the FGDs, participants reported benefits of consolidated appointments and positive experience in sustained patient–provider relationship, shared-decision making, and family/caregiver engagement in PCMH. Participants may not fully comprehend the concept of integrated care, hindering both the effective communication of the intended care model and perceived benefits such as the provision of multidisciplinary team-based care.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

BACKGROUND

Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms.

METHODS

We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life.

DISCUSSION

This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Culturally Sensitive Interventions in Pediatric Primary Care Settings: A Systematic Review

CONTEXT

Culturally sensitive interventions in the pediatric primary care setting may help reduce health disparities. Less is known on the development of these interventions, their target groups, and their feasibility, acceptability, and impact on health outcomes.

OBJECTIVE

We conducted a systematic review to describe culturally sensitive interventions developed for the pediatric primary care setting.

DATA SOURCES

PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo (January 2000 to July 2020).

STUDY SELECTION

Studies were eligible for inclusion if they were (1) original research on an intervention with an evaluation, (2) within a pediatric primary care setting, (3) not limited to education for providers, (4) not limited to interpreter use, and (5) based in the United States.

DATA EXTRACTION

The following were extracted: study topic, study design, intervention, cultural sensitivity strategies and terminology, setting, target group, sample size, feasibility, acceptability, and health outcomes.

RESULTS

Twenty-five studies described 23 interventions targeting a variety of health topics. Multiple cultural sensitivity strategies were used, most commonly sociocultural (83%). Most interventions (57%) were focused on Hispanic/Latino families. Interventions were generally reported as being feasible and acceptable; some also changed health outcomes.

LIMITATIONS

Small samples and heterogenous methods subject to bias were used. Relevant articles may have been missed because of the variety of terms used to describe cultural sensitivity.

CONCLUSIONS

The included articles provide preliminary evidence that culturally sensitive interventions can be feasible and effective and may help eliminate disparities for patients from communities with barriers to equitable care.

The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results

BACKGROUND

Primary Care Medical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements" (HVEs) for cost and utilization may improve effectiveness.

OBJECTIVES

The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals.

RESEARCH DESIGN

A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results.

SUBJECTS

Eight primary care clinics that were engaged in PCMH reform.

MEASURES

We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years.

RESULTS

In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03).

DISCUSSION

The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms.

Does improving indoor air quality lessen symptoms associated with chemical intolerance?

Aim:

To determine whether environmental house calls that improved indoor air quality (IAQ) is effective in reducing symptoms of chemical intolerance (CI).

Background:

Prevalence of CI is increasing worldwide. Those affected typically report symptoms such as headaches, fatigue, ‘brain fog’, and gastrointestinal problems – common primary care complaints. Substantial evidence suggests that improving IAQ may be helpful in reducing symptoms associated with CI.

Methods:

Primary care clinic patients were invited to participate in a series of structured environmental house calls (EHCs). To qualify, participants were assessed for CI with the Quick Environmental Exposure and Sensitivity Inventory. Those with CI volunteered to allow the EHC team to visit their homes to collect air samples for volatile organic compounds (VOCs). Initial and post-intervention IAQ sampling was analyzed by an independent lab to determine VOC levels (ng/L). The team discussed indoor air exposures, their health effects, and provided guidance for reducing exposures.

Findings:

Homes where recommendations were followed showed the greatest improvements in IAQ. The improvements were based upon decreased airborne VOCs associated with reduced use of cleaning chemicals, personal care products, and fragrances, and reduction in the index patients’ symptoms. Symptom improvement generally was not reported among those whose homes showed no VOC improvement.

Conclusion:

Improvements in both IAQ and patients’ symptoms occur when families implement an action plan developed and shared with them by a trained EHC team. Indoor air problems simply are not part of most doctors’ differential diagnoses, despite relatively high prevalence rates of CI in primary care clinics. Our three-question screening questionnaire – the BREESI – can help physicians identify which patients should complete the QEESI. After identifying patients with CI, the practitioner can help by counseling them regarding their home exposures to VOCs. The future of clinical medicine could include environmental house calls as standard of practice for susceptible patients.

Physiotherapy Practice in Primary Health Care: A Survey of Physiotherapists in Team-Based Primary Care Organizations in Ontario

Purpose: This study describes (1) the current state of physiotherapy practice in team-based primary care organizations in Ontario, (2) the perceived barriers to and facilitators of providing physiotherapy services, and (3) recommendations for improving how these services are provided. Method: This was a cross-sectional, web-based survey. We analyzed the responses using descriptive statistics and summative content analysis. Results: A total of 66 responses were received, and 61 were included in the final analysis. The respondents reported that most of their practice was directed toward musculoskeletal care, followed by multi-system, neurological, and cardiorespiratory conditions, and that most of their direct patient care was focused on in-person, one-to-one assessment or follow-up. Frequently identified barriers to providing physiotherapy services included a lack of space, resources, time, and equipment. The most common facilitators were support from management, recognition and support from other health care providers about the value and role of physiotherapists, and appropriate referrals from other health care providers. The most common recommendation was to increase the physiotherapist-to-patient ratio at primary care sites. Conclusions: Physiotherapists provide care to diverse populations in team-based primary care, which is influenced by specific barriers and facilitators. Our results highlight opportunities for physiotherapists in this context, such as increasing the provision of first-contact care and group-based interventions.

Team-based care Evaluation and Adoption Model (TEAM) Framework: Supporting the comprehensive evaluation of primary care transformation over time

OBJECTIVE

To introduce the new Team-based care Evaluation and Adoption Model (TEAM) Framework.

QUALITY OF EVIDENCE

The initial TEAM Framework was derived from a series of reviews and consultations with academic and clinical experts. In a parallel process, team-based primary and community care evaluation in Canada was assessed through a structured review of academic literature, followed by a review of policy literature of existing primary care evaluation frameworks.

MAIN MESSAGE

The review of academic articles alongside an analysis of policy documents and existing evaluation frameworks in primary care resulted in the development of the 10-dimension TEAM Framework.

CONCLUSION

Primary care transformation requires evaluation over time. The TEAM Framework provides a comprehensive framework for assessing evidence needed to support short- and long-term actionable improvements for team-based primary and community care in Canada. This framework will inform the development of an evaluation tool kit for primary care teams.

Impact of Social and Relational Adversity on Access to Services among US Children with Autism Spectrum Disorder 2016–2019

To explore the impact of social and relational adversity on access to key health services among US children with autism spectrum disorders (ASD), cross-sectional analyses of the 2016–2019 National Survey of Children’s Health assessed use of key health services by children with ASD, accounting for differences in demographic characteristics, medical needs, and experience of social and relational adversities. sUS children with ASD were more than twice as likely as peers without ASD to report two or more social adversities and more than three times as likely to report two or more relational adversities. In multivariable models, relational adversities were significantly associated with greater odds of medication use for ASD (OR 1.50, 95%CI:1.02, 2.17). Social adversities were neither associated with receipt of behavioral therapies nor prescription of medication to treat ASD. Screening for various forms of adversity among youth with ASD is of great importance; even one adverse experience may be enough to influence care of a child with ASD, with differences in effect according to the nature of the particular adversity. Further research should evaluate the role that childhood adversity plays in physical and mental health outcomes in ASD.

Revisiting the four core functions (4Cs) of primary care: operational definitions and complexities

BACKGROUND

The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health. However, their broad definitions have led to variations in their assessment, in the innovations implemented to improve these functions and ultimately in their performance.

OBJECTIVES

To update and operationalise the 4Cs' definitions by using a literature review and analysis of enhancement strategies, and to identify innovations that may lead to their enhancement.

METHODS

Narrative, descriptive analysis of the 4Cs definitions, coming from PC international reports and organisations, to identify measurable features for each of these functions. Additionally, we performed an electronic search and analysis of enhancement strategies to improve these four Cs, to explore how the 4Cs inter-relate.

RESULTS

Specific operational elements for first contact include modality of contact, and conditions for which PC should be approached; for comprehensiveness, scope of services and spectrum of population needs; for coordination, links between PC and higher levels of care and social/community-based services, and workforce managing transitions and for continuity, type, level and context of continuity. Several innovations like enrolment, digital health technologies and new or enhanced PC provider's roles, simultaneously influenced two or more of the 4Cs.

CONCLUSION

Providing clear, well-defined operational elements for these 4Cs to measure their achievement and improve the way they function, and identifying the complex network of interactions among them, should contribute to the field in a way that supports efforts at practice innovation to optimise the processes and outcomes in PC.

The Distressed State of Primary Care in Virginia Pre-Medicaid Expansion and Pre-Pandemic

BACKGROUND

Primary care is crucial to the health of individuals and communities, but it faces numerous structural and systemic challenges. Our study assessed the state of primary care in Virginia to prepare for Medicaid expansion. It also provides insight into the frontline of health care prior to an unprecedented global COVID-19 pandemic.

METHODS

We surveyed 1622 primary care practices to understand organizational characteristics, scope of care, capacity, and organizational stress.

RESULTS

Practices (484) varied in type, ownership, location, and care for medically underserved and diverse patient populations. Most practices accepted uninsured and Medicaid patients. Practices reported a broad scope of care, including offering behavioral health and medication-assisted therapy for opioid addiction. Over half addressed social needs like transportation and unstable housing. One in three practices experienced a significant stress in 2019, prepandemic, and only 18.8% of practices anticipated a stress in 2020.

CONCLUSIONS

Primary care serves as the foundation of our health care system and is an essential service, but it is severely stressed, under-resourced, and overburdened in the best of times. Primary care needs strategic workforce planning, adequate access to resources, and financial investment to sustain its value and innovation.

Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework

BACKGROUND

Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients' health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response.

METHODS

Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis.

RESULTS

Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach.

CONCLUSION

Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.

Shared Language for Shared Work in Population Health

People working on behalf of population health, community health, or public health often experience confusion or ambiguity in the meaning of these and other common terms-the similarities and differences and how they bear on the tasks and division of labor for care delivery and public health. Shared language must be clear enough to help, not hinder people working together as they ultimately come to mutual understanding of roles, responsibilities, and actions in their joint work. Based on an iterative lexicon development process, the authors developed and propose a definitional framework as an aid to navigating among related population and community health terms. These terms are defined, similarities and differences clarified, and then organized into 3 categories that reflect goals, realities, and ways to get the job done. Goals include (a) health as well-being for persons, (b) population health as that goal expressed in measurable terms for groups, and (c) community health as population health for particular communities of interest, geography, or other defining characteristic-groups with shared identity and particular systemic influences on health. Realities are social determinants as influences, health disparities as effects, and health equity as both a goal and a design principle. Ways to get the job done include health care delivery systems for enrollees and public health in population-based civic activities-with a broad zone of collaboration where streams of effort converge in partnership with served communities. This map of terms can enable people to move forward together in a broad zone of collaboration for health with less confusion, ambiguity, and conflict.

Performance of the Person Centered Primary Care Measure in Pediatric Continuity Clinic

OBJECTIVE

Improvement efforts in pediatric primary care would benefit from measures that capture families' holistic experience of the practice. We sought to assess the reliability and validity of the new Person-Centered Primary Care Measure (PCPCM) in a pediatric resident continuity clinic serving low-income families.

METHODS

We incorporated the 11-item PCPCM, stems adapted to reflect a parent responding about their child's visit, into a telephone survey of 194 parents presenting for care in October 2019 at a pediatric resident continuity clinic in Cleveland Ohio (64% response rate). We evaluated PCPCM items using factor analysis and Rasch modeling, and assessed associations of the PCPCM with parents' demographics and perceptions of specific elements of their child's care.

RESULTS

In this sample of low-income families, the PCPCM had good reliability (Cronbach's alpha 0.85). All items loaded onto a single factor in principal axes factor analysis. Of the 11 aspects of primary care represented in the scale, "shared experience" was most difficult for parents to endorse in Rasch modeling. All 11 items contributed significantly to the total scale score with corrected item-total correlations >0.4. The PCPCM score was independent of socio demographics and was associated with parent's report that their child's clinician spends enough time with them.

CONCLUSIONS

The PCPCM performs well in a pediatric continuity clinic setting, warranting consideration for its use as a parsimonious parent-reported measure of what patients and clinicians say matters most in pediatric primary care.

Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore

BACKGROUND

The first Patient-Centered Medical Home (PCMH) demonstration in Singapore was launched in November 2016, which aimed to deliver integrated and patient-centered care for patients with bio-psycho-social needs. Implementation was guided by principles of comprehensiveness, coordinated care, shared decision-making, accessible services, and quality and safety. We aimed to investigate the impact of implementing the PCMH in primary care on quality of life (QoL) and patient activation.

METHODS

The study design was a prospective single-arm pre-post study. We applied the 5-level EuroQol 5-dimension (EQ-5D-5L) and Visual Analog Scale (EQ VAS) instruments to assess health-related QoL. The CASP-19 tool was utilised to examine the degree that needs satisfaction was fulfilled in the domains of Control, Autonomy, Self-realisation, and Pleasure. The 13-item Patient Activation Measure (PAM-13) was used to evaluate knowledge, skills and confidence in management of conditions and ability to self-care. Multivariable linear regression models with random intercepts were applied to examine the impact of the PCMH intervention on outcome measures at 3 months and 6 months post-enrolment, compared to baseline.

RESULTS

We analysed 165 study participants enrolled into the PCMH from November 2017 to April 2020, with mean age 77 years (SD: 9.9). Within-group pre-post (6 months) EQ-5D-5L Index (β= -0.01, p-value = 0.35) and EQ VAS score (β=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (β = 1.34, p-value = 0.05) and 6 months post-enrolment (β = 1.15, p-value = 0.08) that were marginally out of statistical significance. There was also a significant impact of the PCMH on the CASP-19 Pleasure domain (β = 0.62, p = 0.03) at 6 months post-enrolment, compared to baseline. We found improved patient activation from a 15.2 % reduction in the proportion of participants in lower PAM levels, and a 23.4 and 16.7 % rise in proportion for higher PAM levels 3 and 4, respectively, from 3 months to 6 months post-enrolment.

CONCLUSIONS

Preliminary demonstration of the PCMH model shows evidence of improved needs satisfaction and patient activation, with potential to have a greater impact after a longer intervention duration.

Change in Glycemic Control for Patients Enrolled in a Membership-Based Primary Care Program: Longitudinal Observational Study

Background

Both primary care practices based on the chronic care model (CCM) and digital therapeutics have been shown to improve the care of patients with diabetes.

Objective

The aim of this observational study was to examine the change in diabetes control for patients enrolled in a membership-based primary care service that is based on the CCM.

Methods

Using a diabetes registry, we analyzed the change in glycated hemoglobin (HbA_1c) for patients with uncontrolled diabetes mellitus (initial HbA_1c≥9%). All patients had access to a technology-enhanced primary care practice built on the CCM.

Results

The registry included 621 patients diagnosed with uncontrolled diabetes. All patients had at least two HbA_1c measurements, with the average time between the first and last measurement of 1.2 years (SD 0.4). The average starting value of HbA_1c was 10.7, which decreased to 8.7, corresponding to a reduction of 2.03 (P<.001). Secondary analyses showed statistically significant reductions in total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides.

Conclusions

Patients with initially uncontrolled diabetes who undergo care in a technology-enhanced primary care practice based on the CCM have long-term clinically meaningful reductions in HbA_1c.

Associations of patient-centered medical home with quality of care, patient experience, and health expenditures: A STROBE-compliant cross-sectional study

In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015-2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.

Assessment of feasibility and acceptability of family-centered care implemented at a neonatal intensive care unit in India

Background

A family-centered care (FCC) parent participation program that ensures an infant is not separated from parents against their will was developed for the caring of their small or sick newborn at a neonatal intensive care unit (NICU) in Delhi, India. Healthcare provider sensitization training directed at psychosocial and tangible support and an audio-visual training tool for parent-attendants were developed that included: 1) handwashing, infection prevention, protocol for entry; 2) developmentally supportive care, breastfeeding, expression of breastmilk and assisted feeding; 3) kangaroo mother care; and 4) preparation for discharge and care at home. The study aimed to examine the feasibility and acceptability of the FCC model in a NICU in India.

Methods

A prospective cohort design collected quantitative data on each parent-attendant/infant dyad at enrollment, during the NICU stay, and at discharge. Feasibility of the FCC program was measured by assessing the participation of parent-attendants and healthcare providers, and whether training components were implemented as intended. Acceptability was measured by the proportion of parent-attendants who participated in the trainings and their ability to accurately complete program activities.

Results

Of 395 NICU admissions during the study period, eligible participants included 333 parent-attendant/infant dyads, 24 doctors, and 21 nurses. Of the 1242 planned parent-attendant training sessions, 939 (75.6%) were held, indicating that program fidelity was high, and the majority of trainings were implemented as intended. While 50% of parent-attendants completed all 4 FCC training sessions, 95% completed sessions 1 and 2; 60% of the total participating parent-attendants completed session 3, and 75% completed session 4. Compliance rates were over 96% for 5 of 10 FCC parent-attendant activities, and 60 to 78% for the remaining 5 activities.

Conclusions

FCC was feasible to implement in this setting and was acceptable to participating parent-attendants and healthcare providers. Parents participated in trainings conducted by NICU providers and engaged in essential care to their infants in the NICU. A standard care approach and behavior norms for healthcare providers directed psychosocial and tangible support to parent-attendants so that a child is not separated from his or her parents against their will while receiving advanced care in the NICU.

Cross-sectional study evaluating the association between integrated care and health-related quality of life (HRQOL) in Dutch primary care

OBJECTIVES

The aim of this study was to evaluate the association between integrated care and health-related quality of life (HRQOL) in a primary care practice population.

DESIGN

A cross-sectional survey study.

SETTING

Primary care practice population.

PARTICIPANTS

A sample (n=5562) of patients in two general practitioner practices in the Netherlands.

PRIMARY OUTCOME MEASURES

The Rainbow Model of Integrated Care Measurement Tool patient version and EQ-5D was used to assess integrated service delivery and HRQOL. The association between integrated care and HRQOL groups was analysed using multivariate logistic regression.

RESULTS

Overall, 933 respondents with a mean age of 62 participated (20% response rate) in this study. The multivariate analysis revealed that positive organisational coordination experiences were linked to better HRQOL (OR=1.87, 95% CI 1.18 to 2.95), and less anxiety and depression problems (OR=0.36, 95% CI 0.20 to 0.63). Unemployment was associated with a poor HRQOL (OR=0.15, 95% CI 0.08 to 0.28). Ageing was associated with more mobility (OR=1.06, 95% CI 1.04 to 1.09), self-care (OR=1.06, 95% CI 1.02 to 1.11), usual activity (OR=1.03, 95% CI 1.01 to 1.05) and pain problems (OR=1.02, 95% CI 1.01 to 1.04). Being married improved the overall HRQOL (OR=1.60, 95% CI 1.13 to 2.26) and decreased anxiety and depression (OR=0.47, 95% CI 0.31 to 0.72). Finally, females had a poor overall HRQOL (OR=1.67, 95% CI 0.48 to 0.93) and more pain and discomfort problems (OR=1.47, 95% CI 1.11 to 1.95).

CONCLUSION

This study shows for the first time that organisational coordination activities are positively associated with HROQL of adult patients in a primary care context, adding to the evidence of an association between integrated care and HRQOL. Also, unemployment, ageing and being female are accumulating risk factors that should be considered when designing integrated primary care programmes. Further research is needed to explore how various integration types relate to HRQOL for people in local communities.

The Future(s) of Pediatric Primary Care

Pediatric primary care (PPC) arose in the early 20th century as the fusion of acute and chronic pediatric illness care with preventive elements borrowed from public and maternal and child health. Well-established and thriving by the 1930s, PPC saw major changes in childhood morbidity and mortality in the latter half of the 20th century with the recognition of the "new morbidity" of school, behavior, and social problems. At the same time, PPC experienced changes in its workforce, which became increasingly female and added nurse practitioners and physician assistants as practitioners. Independent practice, previously the dominant business model, decreased in prominence at the end of the 20th century as health systems bought practices and other sites morphed into federally qualified health centers. In the present century, electronic health records (EHRs) have brought profound changes in PPC workflows and practitioner experience. In addition, disruptive market competition such as retail clinics and corporate telemedicine providers coupled with changes in health insurance from fee-for-service to value-based payment further challenge the care model and economics of PPC. Finally, recognition of family social circumstances as major determinants of children's health presents another challenge to the status quo. As such, although one PPC future may resemble its present state, a more innovative future is likely to include clinics and practices more oriented toward and linked to communities and directed at the social determinants of health. In addition, the rise in physical, behavioral, and social problems in practice call for a growing focus on wellness, including sleep, nutrition, and activity, that promises to reorient the PPC future in productive new directions. The half-way technology of current EHR systems will ideally be spun into electronic hubs that facilitate teamwork between PPC, specialists, and community groups. Research and practice improvement strategies including involvement in "learning health systems" will be critical to making PPC effective in an evolving society. Although threatened by 21st century forces and hard-to-anticipate change, PPC is ideally positioned to build upon its core functions to create multidisciplinary teams that reach into the community, promoting a holistic wellness for children consistent with the broadest definition of health.

Patient-centred innovation for multimorbidity care: a mixed-methods, randomised trial and qualitative study of the patients' experience

Background

Patient-centred interventions to help patients with multimorbidity have had mixed results.

Aim

To assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.

Design and setting

Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.

Method

Patients aged 18–80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients’ experiences of the intervention.

Results

A total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.

Conclusion

Overall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference’s recommendations.

Access to after-hours primary care: a key determinant of children's medical home status

BACKGROUND

The medical home (MH) model has been promoted by both the federal and state governments in the United States in recent years. To ascertain American children's MH status, many studies have relied on a large set of survey items, posing a considerable burden on their parents. We aimed to identify individual survey items or domains that best predict MH status for children and use them to develop brief markers of MH status. We also examined whether the identified items differed by status of special health care needs and by racial/ethnic group.

METHOD

Using the 9-year data from Medical Expenditure Panel Survey, we examined associations between children's MH status and individual survey items or domains. We randomly split the data into two halves with the first half (training sample, n = 8611) used to identify promising items, and the second half (validation sample, n = 8779) used to calculate all statistical measures. After discovering significant predictors of children's MH status, we incorporated them into several brief markers of MH status. We also conducted stratified analyses by status of special health care needs and by racial/ethnic group.

RESULTS

Less than half (48.7%) of the 8779 study children had a MH. The accessibility domain has stronger association with children's MH status (specificity = 0.84, sensitivity = 1, Kappa = 0.83) than other domains. The top two items with the strongest association with MH status asked about after-hours primary care access, including doctors' office hours at night or on the weekend and children's difficulty accessing care after hours. Both belong to the accessibility domain and are one of several reliable markers for children's MH status. While each of the two items did not differ significantly by status of special health care needs, there were considerable disparities across racial/ethnic groups with Latino children lagging behind other children.

CONCLUSION

Accessibility, especially the ability to access health care after regular office hours, appears to be the major predictor of having a MH among children. The ongoing efforts to promote the MH model need to target improving accessibility of health care after regular hours for children overall and especially for Latino children.