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Giannitrapani KF, Holliday JR, McCaa MD, Stockdale S, Bergman AA, Katz ML, Zulman DM, Rubenstein LV, Chang ET. Meeting high-risk patient pain care needs through intensive primary care: a secondary analysis. BMJ Open 2024; 14:e080748. [PMID: 38167288 PMCID: PMC10773401 DOI: 10.1136/bmjopen-2023-080748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Chronic pain disproportionately affects medically and psychosocially complex patients, many of whom are at high risk of hospitalisation. Pain prevalence among high-risk patients, however, is unknown, and pain is seldom a focus for improving high-risk patient outcomes. Our objective is to (1) evaluate pain frequency in a high-risk patient population and (2) identify intensive management (IM) programme features that patients and providers perceive as important for promoting patient-centred pain care within primary care (PC)-based IM. DESIGN Secondary observational analysis of quantitative and qualitative evaluation data from a multisite randomised PC-based IM programme for high-risk patients. SETTING Five integrated local Veterans Affairs (VA) healthcare systems within distinct VA administrative regions. PARTICIPANTS Staff and high-risk PC patients in the VA. INTERVENTION A multisite randomised PC-based IM programme for high-risk patients. OUTCOME MEASURES (a) Pain prevalence based on VA electronic administrative data and (b) transcripts of interviews with IM staff and patients that mentioned pain. RESULTS Most (70%, 2593/3723) high-risk patients had at least moderate pain. Over one-third (38%, 40/104) of the interviewees mentioned pain or pain care. There were 89 pain-related comments addressing IM impacts on pain care within the 40 interview transcripts. Patient-identified themes were that IM improved communication and responsiveness to pain. PC provider-identified themes were that IM improved workload and access to expertise. IM team member-identified themes were that IM improved pain care coordination, facilitated non-opioid pain management options and mitigated provider compassion fatigue. No negative IM impacts on pain care were mentioned. CONCLUSIONS Pain is common among high-risk patients. Future IM evaluations should consider including a focus on pain and pain care, with attention to impacts on patients, PC providers and IM teams.
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Affiliation(s)
- Karleen F Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Jesse R Holliday
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
| | - Matthew D McCaa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Alicia A Bergman
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Marian L Katz
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System Menlo Park Division, Menlo Park, California, USA
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | | | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
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McGowan M, Rose D, Paez M, Stewart G, Stockdale S. Frontline perspectives on adoption and non-adoption of care management tools for high-risk patients in primary care. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100719. [PMID: 37748215 DOI: 10.1016/j.hjdsi.2023.100719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/22/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Population health management tools (PHMTs) embedded within electronic health records (EHR) could improve management of high-risk patients and reduce costs associated with potentially avoidable emergency department visits or hospitalizations. Adoption of PHMTs across the Veterans Health Administration (VA) has been variable and previous research suggests that understaffed primary care (PC) teams might not be using the tools. METHODS We conducted a retrospective content analysis of open-text responses (n = 1804) from the VA's 2018 national primary care personnel survey to, 1) identify system-level and individual-level factors associated with why clinicians are not using the tools, and 2) to document clinicians' recommendations to improve tool adoption. RESULTS We found three themes pertaining to low adoption and/or tool use: 1) IT burden and administrative tasks (e.g., manually mailing letters to patients), 2) staffing shortages (e.g., nurses covering multiple teams), and 3) no training or difficulty using the tools (e.g., not knowing how to access the tools or use the data). Frontline clinician recommendations included automating some tasks, reconfiguring team roles to shift administrative work away from providers and nurses, consolidating PHMTs into a centralized, easily accessible repository, and providing training. CONCLUSIONS Healthcare system-level factors (staffing) and individual-level factors (lack of training) can limit adoption of PHMTs that could be useful for reducing costs and improving patient outcomes. Future research, including qualitative interviews with clinicians who use/don't use the tools, could help develop interventions to address barriers to adoption. IMPLICATIONS Shifting more administrative tasks to clerical staff would free up clinician time for population health management but may not be possible for understaffed PC teams. Additionally, healthcare systems may be able to increase PHMT use by making them more easily accessible through the electronic health record and providing training in their use.
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Affiliation(s)
- Michael McGowan
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA.
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA
| | - Monica Paez
- Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, USA
| | - Gregory Stewart
- Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, USA; Department of Management and Organizations, Tippie College of Business, University of Iowa, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA.
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Bergman AA, Stockdale SE, Zulman DM, Katz ML, Asch SM, Chang ET. Types of Engagement Strategies to Engage High-Risk Patients in VA. J Gen Intern Med 2023; 38:3288-3294. [PMID: 37620722 PMCID: PMC10681963 DOI: 10.1007/s11606-023-08336-8] [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: 01/17/2023] [Accepted: 07/11/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging. OBJECTIVE To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program. METHODS We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. RESULTS The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change. CONCLUSION We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.
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Affiliation(s)
- Alicia A Bergman
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Susan E Stockdale
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Donna M Zulman
- VA HSR&D Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Marian L Katz
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Steven M Asch
- VA HSR&D Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Evelyn T Chang
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Sum G, Sim SYH, Chay J, Ho SH, Ginting ML, Lim ZZB, Yoong J, Wong CH. An Integrated Patient-Centred Medical Home (PCMH) Care Model Reduces Prospective Healthcare Utilisation for Community-Dwelling Older Adults with Complex Needs: A Matched Observational Study in Singapore. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6848. [PMID: 37835116 PMCID: PMC10572627 DOI: 10.3390/ijerph20196848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/04/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (β = -0.85; 95%CI = -1.55 to -0.14) and primary care visits (β = -1.70; 95%CI = -2.17 to -1.22) and a decrease in specialist outpatient visits (β = -0.29; 95%CI = -0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.
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Affiliation(s)
- Grace Sum
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Silvia Yu Hui Sim
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Junxing Chay
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore 169857, Singapore;
| | - Soon Hoe Ho
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Mimaika Luluina Ginting
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Zoe Zon Be Lim
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
| | - Joanne Yoong
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (S.Y.H.S.); (S.H.H.); (M.L.G.); (J.Y.)
- Research for Impact, Singapore 159964, Singapore
| | - Chek Hooi Wong
- Research for Impact, Singapore 159964, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore
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Schuttner L, Guo R, Wong E, Jimenez E, Klein M, Roy S, Rosland AM, Chang ET. High-Risk Patient Experiences Associated With an Intensive Primary Care Management Program in the Veterans Health Administration. J Ambul Care Manage 2023; 46:45-53. [PMID: 36036980 PMCID: PMC9691513 DOI: 10.1097/jac.0000000000000428] [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] [Indexed: 11/25/2022]
Abstract
Intensive management programs may improve health care experiences among high-risk and complex patients. We assessed patient experience among (1) prior enrollees (n = 59) of an intensive management program (2014-2018); (2) nonenrollees (n = 356) at program sites; and (3) nonprogram site patients (n = 728), using a patient survey based on the Consumer Assessment of Healthcare Providers and Systems in 2019. Outcomes included patient ratings of patient-centered care; overall health care experience; and satisfaction with their usual outpatient care provider. In multivariate models, enrollees were more satisfied with their current provider versus nonenrollees within program sites (adjusted odds ratio 2.36; 95% confidence interval 1.15-4.85).
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Affiliation(s)
- Linnaea Schuttner
- Health Systems Research & Development, VA Puget Sound Health Care System, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Rong Guo
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA
- University of California at Los Angeles, David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
| | - Edwin Wong
- Health Systems Research & Development, VA Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA
| | - Elvira Jimenez
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA
- University of California at Los Angeles, David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
| | - Melissa Klein
- VA Northeast Ohio Healthcare System, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sudip Roy
- Salisbury W.G. Hefner VA Medical Center, Salisbury, NC
| | - Ann-Marie Rosland
- VA Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Evelyn T. Chang
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA
- University of California at Los Angeles, David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
- VA Greater Los Angeles Healthcare System, Department of Medicine, Division of General Internal Medicine, Los Angeles, CA
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Stockdale SE, Rose DE, McClean M, Rosland AM, Chang ET, Zulman DM, Stewart G, Nelson KM. Factors Associated With Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients With Complex Needs. J Ambul Care Manage 2022; 45:171-181. [PMID: 35612388 PMCID: PMC9178911 DOI: 10.1097/jac.0000000000000418] [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] [Indexed: 01/03/2023]
Abstract
Using data from a Veterans Health Administration national primary care survey, this study identified the most highly rated tools and care approaches for patients with complex needs and how preferences varied by professional role, staffing, and training. Nurses were significantly more likely to rate most tools as very important as compared with primary care providers. Having a fully staffed team was also significantly associated with a very important rating on all tools. Nurses and fully staffed teams reported a greater likeliness to use most care approaches, and those with perceived need for training reporting a lower likeliness to use.
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Affiliation(s)
- Susan E Stockdale
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California (Drs Stockdale, Rose, and Chang and Mr McClean); Department of Psychiatry and Biobehavioral Sciences (Dr Stockdale), and Department of Medicine, David Geffen School of Medicine (Dr Chang), University of California, Los Angeles; Center for Health Equity Research and Promotion, VA Pittsburgh, Pittsburgh, Pennsylvania (Dr Rosland); Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Rosland); Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles, Los Angeles, California (Dr Chang); Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California (Dr Zulman); Department of Medicine, Stanford University, Stanford, California (Dr Zulman); Department of Management, University of Iowa, Iowa City (Dr Stewart); HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington (Dr Nelson); and Division of General Internal Medicine, University of Washington, Seattle (Dr Nelson)
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Ngoh S, Tang WE, Chng E, Chong PN. Comment on Surendran et al. The Missed Opportunity of Patient-Centered Medical Homes to Thrive in an Asian Context. Int. J. Environ. Res. Public Health 2021, 18, 1817. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084683. [PMID: 35457551 PMCID: PMC9027281 DOI: 10.3390/ijerph19084683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/15/2022] [Accepted: 04/08/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Sharon Ngoh
- Parkway Shenton Pte Ltd., 20 Bendemeer Road #05-04, Singapore 339914, Singapore;
- Correspondence: (S.N.); (W.E.T.)
| | - Wern Ee Tang
- National Healthcare Group Polyclinics, 3 Fusionopolis Link, Nexus@One-North, #05-10, Singapore 138543, Singapore;
- Correspondence: (S.N.); (W.E.T.)
| | - Edwin Chng
- Parkway Shenton Pte Ltd., 20 Bendemeer Road #05-04, Singapore 339914, Singapore;
| | - Phui-Nah Chong
- National Healthcare Group Polyclinics, 3 Fusionopolis Link, Nexus@One-North, #05-10, Singapore 138543, Singapore;
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