1
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Bloomfield GS, Hill CL, Chiswell K, Cooper L, Gray S, Longenecker CT, Louzao D, Marsolo K, Meissner EG, Morse CG, Muiruri C, Thomas KL, Velazquez EJ, Vicini J, Pettit AC, Sanders G, Okeke NL. Cardiology Encounters for Underrepresented Racial and Ethnic Groups with Human Immunodeficiency Virus and Borderline Cardiovascular Disease Risk. J Racial Ethn Health Disparities 2024; 11:1509-1519. [PMID: 37160576 PMCID: PMC10632543 DOI: 10.1007/s40615-023-01627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/27/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Underrepresented racial and ethnic groups (UREGs) with HIV have a higher risk of cardiovascular disease (CVD) compared with the general population. Referral to a cardiovascular specialist improves CVD risk factor management in high-risk individuals. However, patient and provider factors impacting the likelihood of UREGs with HIV to have an encounter with a cardiologist are unknown. METHODS We evaluated a cohort of UREGs with HIV and borderline CVD risk (10-year risk ≥ 5% by the pooled cohort equations or ≥ 7.5% by Framingham risk score). Participants received HIV-related care from 2014-2020 at four academic medical centers in the United States (U.S.). Adjusted Cox proportional hazards regression was used to estimate the association of patient and provider characteristics with time to first ambulatory cardiology encounter. RESULTS A total of 2,039 people with HIV (PWH) and borderline CVD risk were identified. The median age was 45 years (IQR: 36-50); 52% were female; and 94% were Black. Of these participants, 283 (14%) had an ambulatory visit with a cardiologist (17% of women vs. 11% of men, p < .001). In fully adjusted models, older age, higher body mass index (BMI), atrial fibrillation, multimorbidity, urban residence, and no recent insurance were associated with a greater likelihood of an encounter with a cardiologist. CONCLUSION In UREGs with HIV and borderline CVD risk, the strongest determinants of a cardiology encounter were diagnosed CVD, insurance type, and urban residence. Future research is needed to determine the extent to which these encounters impact CVD care practices and outcomes in this population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04025125.
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Affiliation(s)
- Gerald S Bloomfield
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA.
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Linda Cooper
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Shamea Gray
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Chris T Longenecker
- Division of Cardiology and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Darcy Louzao
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Keith Marsolo
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric G Meissner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Caryn G Morse
- Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | - Charles Muiruri
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kevin L Thomas
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Joseph Vicini
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - April C Pettit
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Gretchen Sanders
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Nwora Lance Okeke
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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2
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Murray GF, Lakin JR, Paasche-Orlow MK, Tulsky JA, Volandes A, Davis AD, Zupanc SN, Carney MT, Burns E, Martins-Welch D, LaVine N, Itty JE, Fix GM. Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial. J Gen Intern Med 2023; 38:3558-3565. [PMID: 37488368 PMCID: PMC10713958 DOI: 10.1007/s11606-023-08320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN Qualitative interview study. PARTICIPANTS Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Genevra F Murray
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Tufts University School of Medicine, Division of General Internal Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - James A Tulsky
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Section of General Internal Medicine, Boston, MA, USA
- ACP Decisions, Waban, MA, USA
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria T Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Edith Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Diana Martins-Welch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Nancy LaVine
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jennifer E Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Gemmae M Fix
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA, USA
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3
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Schexnayder J, Perry KR, Sheahan K, Majette Elliott N, Subramaniam S, Strawbridge E, Webel AR, Bosworth HB, Gierisch JM. Team-Based Qualitative Rapid Analysis: Approach and Considerations for Conducting Developmental Formative Evaluation for Intervention Design. QUALITATIVE HEALTH RESEARCH 2023; 33:778-789. [PMID: 37278662 DOI: 10.1177/10497323231167348] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Qualitative rapid analysis is one of many rapid research approaches that offer a solution to the problem of time constrained health services evaluations and avoids sacrificing the richness of qualitative data that is needed for intervention design. We describe modifications to an established team-based, rapid analysis approach that we used to rapidly collect and analyze semi-structured interview data for a developmental formative evaluation of a cardiovascular disease prevention intervention. Over 18 weeks, we conducted and analyzed 35 semi-structured interviews that were conducted with patients and health care providers in the Veterans Health Administration to identify targets for adapting the intervention in preparation for a clinical trial. We identified 12 key themes describing actionable targets for intervention modification. We highlight important methodological decisions that allowed us to maintain rigor when using qualitative rapid analysis for intervention adaptation and we provide practical guidance on the resources needed to execute similar qualitative studies. We additionally reflect on the benefits and challenges of the described approach when working within a remote research team environment.ClinicalTrials.gov: NCT04545489.
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Affiliation(s)
- Julie Schexnayder
- University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA
| | - Kathleen R Perry
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | | | - Nadya Majette Elliott
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | | | - Elizabeth Strawbridge
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | - Allison R Webel
- University of Washington School of Nursing, Seattle, WA, USA
| | - Hayden B Bosworth
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
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4
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Spinella S, McCune N, McCarthy R, El-Tahch M, George J, Dorritie M, Ford A, Posteraro K, DiNardo D. WVSUD-PACT: a Primary-Care-Based Substance Use Disorder Team for Women Veterans. J Gen Intern Med 2022; 37:837-841. [PMID: 36042085 PMCID: PMC9481786 DOI: 10.1007/s11606-022-07577-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sara Spinella
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA. .,VA Pittsburgh Healthcare System, Pittsburgh, USA.
| | - Nicole McCune
- VA Pittsburgh Healthcare System, Pittsburgh, USA.,Waynesburg University, Waynesburg, USA
| | | | - Maria El-Tahch
- Primary Care Mental Health Integration, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | | | | | - Alyssa Ford
- Primary Care Mental Health Integration, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | | | - Deborah DiNardo
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA.,VA Pittsburgh Healthcare System, Pittsburgh, USA
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5
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Protocol for a type 1 hybrid effectiveness/implementation clinical trial of collaborative specialty care for Veterans with Gulf War Illness. Life Sci 2021; 292:120004. [PMID: 34599935 DOI: 10.1016/j.lfs.2021.120004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022]
Abstract
AIMS We describe a clinical trial to determine the effectiveness and understand implementation outcomes for tele-collaborative specialty care for Veterans with GWI. MAIN METHODS This study will be a hybrid type 1 randomized effectiveness/implementation trial comparing tele-collaborative specialty care to electronic consultation for Gulf War Veterans with GWI (N = 220). In tele-collaborative specialty care, the specialty provider team will deliver health coaching and problem-solving treatment to Veterans and recommend a plan for analgesic optimization. In electronic consultation, the specialty provider team will make a one-time recommendation to the primary care team for locally delivered health coaching, problem-solving treatment and analgesic optimization. The primary aim will be to determine the effectiveness of tele-collaborative specialty care to reduce disability related to GWI. Our secondary aim will be to understand implementation outcomes. SIGNIFICANCE There is a need to improve care for Veterans with GWI. A potentially useful model to address these barriers and improve care is tele-collaborative specialty care where the specialists work with primary care provider to synergistically treat the patients. DISCUSSION This is the first clinical trial to prospectively compare different models of care for Veterans with GWI. This responds to multiple calls for research to improve treatment for Veterans with GWI, including from the National Academy of Medicine.
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6
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Individual-Level and Clinic-Level Factors Associated With Achieving Glycemic Control in a Large Cohort of People With HIV in Care-Washington, DC. J Acquir Immune Defic Syndr 2021; 85:113-122. [PMID: 32541383 DOI: 10.1097/qai.0000000000002416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal management of noncommunicable diseases, including diabetes mellitus (DM), is crucially important as people with HIV (PWH) live longer with antiretroviral therapy. Our objective was to assess patient-level and clinic-level factors associated with achieving hemoglobin A1c (HbA1c) ≤7.0% among PWH and DM. SETTING The DC Cohort, an observational clinical cohort of PWH, followed from 2011 to 2019 at 12 sites in Washington, DC. METHODS Among PWH with diagnosed DM and elevated HbA1c (>7.0%), we examined the association between achieving HbA1c ≤7.0% and demographic and clinical factors, including time-updated medication data, and clinic-level factors related to services and structure. A multilevel marginal extended Cox regression model was generated to identify factors associated with time to HbA1c ≤7.0%. RESULTS Over half (52.3%) of 419 participants achieved HbA1c ≤7.0%. Individual-level factors associated with HbA1c ≤7.0% included a diagnosis of DM after enrollment and a longer time since HIV diagnosis [hazard ratio (HR) = 2.65 and 1.13, P < 0.05 for both]. Attending a clinic with an endocrinologist was associated with the outcome [adjusted HR (aHR) = 1.41 95% confidence interval (CI): (1.01 to 1.97)]. In addition, comparing clinics that treat everyone, refer everyone or have a mix of treating and referring, showed an association between attending a clinic that treats everyone [aHR = 1.52 95% CI: (1.21 to 1.90)] or a clinic that refers everyone [aHR = 2.24 95% CI: (1.63 to 3.07)] compared with clinics with a mix in achieving glycemic control. CONCLUSION Multiple factors are associated with achieving glycemic control in an urban cohort of PWH. Determining if specific services or structures improve DM outcomes may improve health outcomes for PWH and DM.
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7
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O'Loughlin M, Mills J, McDermott R, Harriss L. Review of patient-reported experience within Patient-Centered Medical Homes: insights for Australian Health Care Homes. Aust J Prim Health 2019; 23:429-439. [PMID: 28927493 DOI: 10.1071/py17063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/24/2017] [Indexed: 12/24/2022]
Abstract
Understanding patient experience is necessary to advance the patient-centred approach to health service delivery. Australia's primary healthcare model, the 'Health Care Home', is based on the 'Patient-Centered Medical Home' (PCMH) model developed in the United States. Both these models aim to improve patient experience; however, the majority of existing PCMH model evaluations have focussed on funding, management and quality assurance measures. This review investigated the scope of evidence reported by adult patients using a PCMH. Using a systematic framework, the review identified 39 studies, sourced from 33 individual datasets, which used both quantitative and qualitative approaches. Patient experience was reported for model attributes, including the patient-physician and patient-practice relationships; care-coordination; access to care; and, patient engagement, goal setting and shared decision-making. Results were mixed, with the patient experience improving under the PCMH model for some attributes, and some studies indicating no difference in patient experience following PCMH implementation. The scope and quality of existing evidence does not demonstrate improvement in adult patient experience when using the PCMH. Better measures to evaluate patient experience in the Australian Health Care Home model are required.
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Affiliation(s)
- Mary O'Loughlin
- Australian Institute of Tropical Health and Medicine, Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, PO Box 6811, Cairns, Qld 4870, Australia
| | - Jane Mills
- College of Health, Massey University, PO Box 756, Wellington 6140, New Zealand
| | - Robyn McDermott
- Australian Institute of Tropical Health and Medicine, Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, PO Box 6811, Cairns, Qld 4870, Australia
| | - Linton Harriss
- Australian Institute of Tropical Health and Medicine, Centre for Chronic Disease Prevention, College of Public Health, Medical and Veterinary Sciences, James Cook University, PO Box 6811, Cairns, Qld 4870, Australia
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8
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Agarwal SK, Foster WG, Groessl EJ. Rethinking endometriosis care: applying the chronic care model via a multidisciplinary program for the care of women with endometriosis. Int J Womens Health 2019; 11:405-410. [PMID: 31413643 PMCID: PMC6661982 DOI: 10.2147/ijwh.s207373] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/29/2019] [Indexed: 12/18/2022] Open
Abstract
Endometriosis is a chronic, painful disease without a cure. Due largely to chronic pain, endometriosis can lead to significant physical, mental, relationship, and financial burdens. Within the conventional single provider model of care—in which the patient is primarily taken care of by her physician and complementary strategies based on psychology, nutrition, pain medicine, pelvic physical therapy, and so on may not be readily available in a coordinated manner—most women with endometriosis live with unresolved pain and the consequences of that pain. We therefore propose that there is an urgent need to search for alternative models of care. In the current paper, we discuss our experiences with an model of care in which we adopt a long-term, patient-focused, and multidisciplinary chronic care model for women with endometriosis. Our objective is to improve long-term clinical outcomes for women with endometriosis. For geographical areas and healthcare systems in which it is feasible, we propose consideration of this multidisciplinary model of care as an alternative to the single provider model and offer guidance for those considering establishment of such a program. We also initiate a conversation about which clinical outcomes pertaining to endometriosis are important and should be tracked to assess the efficacy and value of multidisciplinary and other endometriosis healthcare models.
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Affiliation(s)
- Sanjay K Agarwal
- Center for Endometriosis Research and Treatment, University of California San Diego, La Jolla, CA 92037, USA
| | - Warren G Foster
- Center for Endometriosis Research and Treatment, University of California San Diego, La Jolla, CA 92037, USA.,Department of Obstetrics & Gynaecology, Mcmaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Erik J Groessl
- Departments of Family Medicine and Public Health, University of California San Diego, La Jolla, CA 92037, USA.,VA San Diego Medical Center, La Jolla, CA 92037, USA
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9
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Perez Jolles M, Lengnick-Hall R, Mittman BS. Core Functions and Forms of Complex Health Interventions: a Patient-Centered Medical Home Illustration. J Gen Intern Med 2019; 34:1032-1038. [PMID: 30623387 PMCID: PMC6544719 DOI: 10.1007/s11606-018-4818-7] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 02/03/2023]
Abstract
Despite policy and practice support to develop and test interventions designed to increase access to quality care among high-need patients, many of these interventions fail to meet expectations once deployed in real-life clinical settings. One example is the Patient-Centered Medical Home (PCMH) model, designed to deliver coordinated care. A meta-analysis of PCMH initiatives found mixed evidence of impacts on service access, quality, and costs. Conceptualizing PCMH as a complex health intervention can generate insights into the mechanisms by which this model achieves its effects. It can also address heterogeneity by distinguishing PCMH core functions (the intervention's basic purposes) from forms (the strategies used to meet each function). We conducted a scoping review to identify core functions and forms documented in published PCMH models from 2007 to 2017. We analyzed and summarized the data to develop a PCMH Function and Form Matrix. The matrix contributes to the development of an explicit theory-based depiction of how an intervention achieves its effects, and can guide decision-support tools in the field. This innovative approach can support transformations of clinical settings and implementation efforts by building on a clear understanding of the intervention's standard core functions and the forms adapted to local contexts' characteristics.
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Affiliation(s)
- Mónica Perez Jolles
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 South Olive Street, Suite 1421, Los Angeles, CA 90015 USA
| | - Rebecca Lengnick-Hall
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 South Olive Street, Suite 1421, Los Angeles, CA 90015 USA
| | - Brian S. Mittman
- Health Services Research & Implementation Science, Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
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10
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Cordasco KM, Frayne SM, Kansagara D, Zulman DM, Asch SM, Burke RE, Post EP, Fihn SD, Klobucar T, Meyer LJ, Kirsh SR, Atkins D. Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. J Gen Intern Med 2019; 34:11-17. [PMID: 31098966 PMCID: PMC6542870 DOI: 10.1007/s11606-019-04970-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.
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Affiliation(s)
- Kristina M Cordasco
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA.
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Devan Kansagara
- VA Portland Healthcare System, Portland, OR, USA.,Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Donna M Zulman
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Steven M Asch
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P Post
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephan D Fihn
- VA Office of Clinical System Development and Evaluation, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services and Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Laurence J Meyer
- VA Office of Specialty Care Services, Washington, DC, USA.,VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan R Kirsh
- Office of Veterans Access to Care, Washington, DC, USA.,Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David Atkins
- VA Office of Research and Development, Health Services Research and Development, Washington, DC, USA
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11
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Kendall CE, Shoemaker ES, Boucher L, Rolfe DE, Crowe L, Becker M, Asghari S, Rourke SB, Rosenes R, Bibeau C, Lundrigan P, Liddy C. The organizational attributes of HIV care delivery models in Canada: A cross-sectional study. PLoS One 2018; 13:e0199395. [PMID: 29924865 PMCID: PMC6010295 DOI: 10.1371/journal.pone.0199395] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/06/2018] [Indexed: 11/25/2022] Open
Abstract
HIV treatment in Canada has rapidly progressed with the advent of new drug therapies and approaches to care. With this evolution, there is increasing interest in Canada in understanding the current delivery of HIV care, specifically where care is delivered, how, and by whom, to inform the design of care models required to meet the evolving needs of the population. We conducted a cross-sectional survey of Canadian care settings identified as delivering HIV care between June 2015 and January 2016. Given known potential differences in delivery approaches, we stratified settings as primary care or specialist settings, and described their structure, geographic location, populations served, health human resources, technological resources, and available clinical services. We received responses from 22 of 43 contacted care settings located in seven Canadian provinces (51.2% response rate). The total number of patients and HIV patients served by the participating settings was 38,060 and 17,678, respectively (mean number of HIV patients in primary care settings = 1,005, mean number of HIV patients in specialist care settings = 562). Settings were urban for 20 of the 22 (90.9%) clinics and 14 (63.6%) were entirely HIV focused. Primary care settings were more likely to offer preventative services (e.g., cervical smear, needle exchange, IUD insertion, chronic disease self-management program) than specialist settings. The study illustrates diversity in Canadian HIV care settings. All settings were team based, but primary care settings offered a broader range of preventative services and comprehensive access to mental health services, including addictions and peer support.
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Affiliation(s)
- Claire E. Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Esther Susanna Shoemaker
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lisa Boucher
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Lois Crowe
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Marissa Becker
- Departments of Medicine, Medical Microbiology and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shabnam Asghari
- Department of Family Medicine, Centre for Rural Health Studies, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Sean B. Rourke
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Ron Rosenes
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Christine Bibeau
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Philip Lundrigan
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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12
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Sheaff R, Brand SL, Lloyd H, Wanner A, Fornasiero M, Briscoe S, Valderas JM, Byng R, Pearson M. From programme theory to logic models for multispecialty community providers: a realist evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06240] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.
Objectives
To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.
Design
Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.
Data sources
Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.
Results
The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.
Limitations
The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.
Conclusions
Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.
Study registration
This study is registered as PROSPERO CRD42016038900.
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
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Affiliation(s)
- Rod Sheaff
- School of Law, Criminology and Government, University of Plymouth, Plymouth, UK
| | - Sarah L Brand
- Y Lab Public Service Innovation Lab for Wales, School of Social Sciences, Cardiff University, Cardiff, UK
| | - Helen Lloyd
- Community and Primary Care Research Group, Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Amanda Wanner
- Community and Primary Care Research Group, Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Mauro Fornasiero
- Community and Primary Care Research Group, Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Simon Briscoe
- NIHR CLAHRC for the South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Jose M Valderas
- NIHR CLAHRC for the South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Mark Pearson
- NIHR CLAHRC for the South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, Exeter, UK
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13
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Hogan TP, Luger TM, Volkman JE, Rocheleau M, Mueller N, Barker AM, Nazi KM, Houston TK, Bokhour BG. Patient Centeredness in Electronic Communication: Evaluation of Patient-to-Health Care Team Secure Messaging. J Med Internet Res 2018; 20:e82. [PMID: 29519774 PMCID: PMC5864998 DOI: 10.2196/jmir.8801] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 02/09/2018] [Accepted: 02/11/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As information and communication technology is becoming more widely implemented across health care organizations, patient-provider email or asynchronous electronic secure messaging has the potential to support patient-centered communication. Within the medical home model of the Veterans Health Administration (VA), secure messaging is envisioned as a means to enhance access and strengthen the relationships between veterans and their health care team members. However, despite previous studies that have examined the content of electronic messages exchanged between patients and health care providers, less research has focused on the socioemotional aspects of the communication enacted through those messages. OBJECTIVE Recognizing the potential of secure messaging to facilitate the goals of patient-centered care, the objectives of this analysis were to not only understand why patients and health care team members exchange secure messages but also to examine the socioemotional tone engendered in these messages. METHODS We conducted a cross-sectional coding evaluation of a corpus of secure messages exchanged between patients and health care team members over 6 months at 8 VA facilities. We identified patients whose medical records showed secure messaging threads containing at least 2 messages and compiled a random sample of these threads. Drawing on previous literature regarding the analysis of asynchronous, patient-provider electronic communication, we developed a coding scheme comprising a series of a priori patient and health care team member codes. Three team members tested the scheme on a subset of the messages and then independently coded the sample of messaging threads. RESULTS Of the 711 messages coded from the 384 messaging threads, 52.5% (373/711) were sent by patients and 47.5% (338/711) by health care team members. Patient and health care team member messages included logistical content (82.6%, 308/373 vs 89.1%, 301/338), were neutral in tone (70.2%, 262/373 vs 82.0%, 277/338), and respectful in nature (25.7%, 96/373 vs 33.4%, 113/338). Secure messages from health care team members sometimes appeared hurried (25.4%, 86/338) but also displayed friendliness or warmth (18.9%, 64/338) and reassurance or encouragement (18.6%, 63/338). Most patient messages involved either providing or seeking information; however, the majority of health care team member messages involved information provision in response to patient questions. CONCLUSIONS This evaluation is an important step toward understanding the content and socioemotional tone that is part of the secure messaging exchanges between patients and health care team members. Our findings were encouraging; however, there are opportunities for improvement. As health care organizations seek to supplement traditional encounters with virtual care, they must reexamine their use of secure messaging, including the patient centeredness of the communication, and the potential for more proactive use by health care team members.
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Affiliation(s)
- Timothy P Hogan
- Center for Evaluating Patient-Centered Care in the Veterans Health Administration, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Tana M Luger
- Center for Evaluating Patient-Centered Care in the Veterans Health Administration, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Psychology Field Group, Pitzer College, Claremont, CA, United States
| | - Julie E Volkman
- Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
- Department of Communication, Bryant University, Smithfield, RI, United States
| | - Mary Rocheleau
- Center for Evaluating Patient-Centered Care in the Veterans Health Administration, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
| | - Nora Mueller
- Center for Evaluating Patient-Centered Care in the Veterans Health Administration, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
| | - Anna M Barker
- Center for Evaluating Patient-Centered Care in the Veterans Health Administration, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
| | - Kim M Nazi
- Veterans and Consumers Health Informatics Office, Office of Connected Care, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, United States
| | - Thomas K Houston
- Center for Evaluating Patient-Centered Care in the Veterans Health Administration, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Barbara G Bokhour
- Center for Evaluating Patient-Centered Care in the Veterans Health Administration, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States
- Department of Health, Law, Policy & Management, School of Public Health, Boston University, Boston, MA, United States
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14
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Giannitrapani KF, Ahluwalia SC, Day RT, Pisciotta M, Dobscha S, Lorenz K. Challenges to teaming for pain in primary care. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:23-27. [PMID: 28711504 DOI: 10.1016/j.hjdsi.2017.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 01/24/2017] [Accepted: 06/28/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA.
| | | | - R Thomas Day
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Maura Pisciotta
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, USA
| | - Steven Dobscha
- Department of Psychiatry, Oregon Health & Science University, USA
| | - Karl Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; The RAND Corporation, USA; Stanford School of Medicine, USA
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15
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Ball S, Montpetite M, Kowalski C, Gerdes Z, Graham G, Kirsh S, Lowery J. Care coordination agreements in the Veterans Healthcare Administration. JOURNAL OF INTEGRATED CARE 2017. [DOI: 10.1108/jica-11-2016-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The Veterans Healthcare Administration (VHA) has promoted Specialty Care Neighborhoods (SCN) to enhance the coordination of services between primary and specialty care. Care coordination agreements (CCAs) were included as a critical element in the SCN program. The purpose of this paper is to examine the role of these documents in the successful implementation of SCNs.
Design/methodology/approach
Content, quality, and perceived usefulness of CCAs from 19 SCN sites were evaluated. CCA content was defined as the presence or absence of eight key components: contact information, process for urgent consults, process for e-consults, content of consults, primary and specialty care responsibilities, expected response time, discharge criteria, and review criteria. CCA quality was based on a qualitative assessment of CCA content; and perceived usefulness was based on a qualitative assessment of interview responses from CCA users. CCA characteristics were compared to SCN implementation levels using descriptive statistics. SCN implementation level was defined and measured by VHA Specialty Care Services.
Findings
Participating sites with medium-high or high SCN implementation levels had CCAs with more key components and of higher quality than sites with medium-low to medium SCN implementation levels. Perceived usefulness of CCAs was not associated with implementation level.
Research limitations/implications
Since this study built on a quality improvement effort to facilitate care coordination, a rigorous research approach was not used. Specific CCA components could not be examined nor could specific hypotheses be tested due to the small and diverse sample. Findings presented are only preliminary.
Practical implications
The examination of CCAs suggests that these documents may be helpful to improve communication among primary and specialty care providers by explicitly stating agreed upon processes, mechanisms and criteria for referrals, roles and responsibilities for the co-management of patients, and timelines for review of CCAs.
Originality/value
This small study suggests that high-quality CCAs, which include a number of key components, can facilitate the implementation of coordinated care. Key characteristics of CCAs are identified in this study, including measures of CCA content, quality, and usefulness, which can be used in future efforts to develop and evaluate efforts to improve care coordination.
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16
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Chuang E, Brunner J, Mak S, Hamilton AB, Canelo I, Darling J, Rubenstein LV, Yano EM. Challenges with Implementing a Patient-Centered Medical Home Model for Women Veterans. Womens Health Issues 2017; 27:214-220. [PMID: 28063848 PMCID: PMC6824838 DOI: 10.1016/j.whi.2016.11.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 11/23/2016] [Accepted: 11/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) Patient Aligned Care Team (PACT) initiative aims to ensure that all patients receive care consistent with medical home principles. Women veterans' unique care needs and minority status within the VA pose challenges to delivery of equitable, comprehensive primary care for this population. Currently, little is known about whether and/or how PACT should be tailored to better meet women veterans' needs. METHODS In 2014, we conducted semistructured interviews with 73 primary care providers and staff to examine facilitators and barriers encountered in providing PACT-principled care to women veterans. Respondents were located in eight VA medical centers in eight different states across the United States. RESULTS Respondents perceived PACT as improving continuity of care for patients and as increasing ability of nursing staff to practice at the top of their license. However, the implementation of core medical home features and team huddles was inconsistent and varied both within and across medical centers. Short staffing, inclusion of part-time providers on teams, balancing performance requirements for continuity and same-day access, and space constraints were identified as ongoing barriers to PACT implementation. Challenges unique to care of women veterans included a higher prevalence of psychosocial needs, the need for specialized training of primary care personnel, and short staffing owing to additional sharing of primary care support staff with specialist providers. CONCLUSION Providers and staff face unique challenges in delivering comprehensive primary care to women veterans that may require special policy, practice, and management action if benefits of PACT are to be fully realized for this population.
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Affiliation(s)
- Emmeline Chuang
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California.
| | - Julian Brunner
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Selene Mak
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Alison B Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Ismelda Canelo
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Jill Darling
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Lisa V Rubenstein
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California; HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Elizabeth M Yano
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California; HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Health Care System, Los Angeles, California
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17
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Appenheimer AB, Bokhour B, McInnes DK, Richardson KK, Thurman AL, Beck BF, Vaughan-Sarrazin M, Asch SM, Midboe AM, Taylor T, Dvorin K, Gifford AL, Ohl ME. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open Forum Infect Dis 2017; 4:ofx005. [PMID: 28480278 DOI: 10.1093/ofid/ofx005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/19/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care. METHODS We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics. RESULTS Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68). CONCLUSIONS Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.
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Affiliation(s)
- A Ben Appenheimer
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Barbara Bokhour
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - D Keith McInnes
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Kelly K Richardson
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Andrew L Thurman
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Brice F Beck
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Mary Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Steven M Asch
- Division of General Medical Science, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Amanda M Midboe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Thom Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Allen L Gifford
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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18
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Bouldin ED, Littman AJ, Wong E, Liu CF, Taylor L, Rice K, Reiber GE. Medicare-VHA dual use is associated with poorer chronic wound healing. Wound Repair Regen 2016; 24:913-922. [PMID: 27292283 DOI: 10.1111/wrr.12454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 05/29/2016] [Indexed: 11/30/2022]
Abstract
Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.
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Affiliation(s)
- Erin D Bouldin
- VHA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington. .,Department of Epidemiology, and. .,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington.
| | - Alyson J Littman
- VHA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington.,Department of Epidemiology, and.,Department of Veterans Affairs Puget Sound Health Care System, Seattle Epidemiologic Research and Information Center, Seattle, Washington
| | - Edwin Wong
- VHA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Chuan-Fen Liu
- VHA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Leslie Taylor
- VHA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington
| | - Kenneth Rice
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Gayle E Reiber
- VHA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington.,Department of Epidemiology, and.,Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
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19
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Chartier M, Maier M. Engagement Along the HIV Care Continuum and the Potential Role f Mental Health and Substance Use Disorders. Fed Pract 2015; 32:10S-14S. [PMID: 30766106 PMCID: PMC6375506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Increasing access to mental health and substance use services, particularly through integrated care models, as well as addressing issues of HIV-related stigma, may positively impact engagement in HIV clinical care.
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Affiliation(s)
- Maggie Chartier
- is a national public health clinical psychologist for the HIV, Hepatitis and Public Health Pathogens Programs in the VHA Office of Public Health, a staff psychologist at the San Francisco VAMC, and assistant clinical professor in the Department of Psychiatry, University of California, San Francisco. is a national public health infectious disease officer for the HIV, Hepatitis, and Public Health Pathogens Program in the VHA Office of Public Health and a staff physician at the Portland VAMC, and is an assistant professor at Oregon Health and Sciences University in Portland
| | - Marissa Maier
- is a national public health clinical psychologist for the HIV, Hepatitis and Public Health Pathogens Programs in the VHA Office of Public Health, a staff psychologist at the San Francisco VAMC, and assistant clinical professor in the Department of Psychiatry, University of California, San Francisco. is a national public health infectious disease officer for the HIV, Hepatitis, and Public Health Pathogens Program in the VHA Office of Public Health and a staff physician at the Portland VAMC, and is an assistant professor at Oregon Health and Sciences University in Portland
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