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Cerdeña JP. The prenatal care color line and Latina migrant motherhood. Med Anthropol Q 2023; 37:325-340. [PMID: 37354543 DOI: 10.1111/maq.12782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 04/21/2023] [Indexed: 06/26/2023]
Abstract
Drawing from ethnographic research with Latin American migrant mothers seeking prenatal care at a safety net clinic in southern Connecticut, I describe the racial dynamics of a medical hierarchy that situates White providers and nurses above Black and Brown medical assistants and patients, terming this the prenatal care color line. I characterize three segments of the prenatal care color line: through (1) onerous enrollment in prenatal care support that strips rights from migrant mothers; (2) differences in racialized embodiment that harden essentialist and stereotyped notions surrounding Latinx reproduction, making the experience of pregnancy and birth a process of race-making; and (3) obstetric racism manifest through both denying or delaying critical medical care to Latinx pregnant patients while also overmedicalizing their uncomplicated births. I argue that the presence of the prenatal care color line-in my study clinic as in other safety net clinics-permits the harsher racialization of Latinx birthers.
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Affiliation(s)
- Jessica P Cerdeña
- Institute for Collaboration on Health, Intervention, and Policy (InCHIP), University of Connecticut
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Cordova-Ramos EG, Burke J, Sileo N, McGean M, Torrice V, Mantri S, Parker MG, Drainoni ML. "We Don't Want to Screen for the Sake of Screening": A Qualitative Evaluation of a Social Needs Screening and Referral Intervention in the NICU. J Perinat Neonatal Nurs 2023:00005237-990000000-00016. [PMID: 37773583 DOI: 10.1097/jpn.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Low uptake of social determinants of health (SDH) screening and referral interventions within neonatal intensive care units (NICUs) is partly due to limited understanding of the best procedures to integrate this practice into routine clinical workflows. PURPOSE To examine the feasibility and acceptability of an SDH screening and referral intervention in the NICU from the perspective of neonatal nurses; and to identify factors affecting implementation outcomes. METHODS We conducted 25 semistructured interviews with NICU nurses. We used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to guide interview questions and codebook development for directed content analysis. Themes were mapped onto the 3 PARiHS domains of context, evidence, and facilitation. FINDINGS Analysis yielded 8 themes. Context: Nurses felt that stressors experienced by NICU families are magnified in a safety net environment. Nurses shared varying viewpoints of the roles and responsibilities for social care in the NICU, and feared that scarcity of community resources would make it difficult to address families' needs. Evidence: The intervention was perceived to increase identification of adverse SDH and provision of resources; and to potentially jump-start better caregiver and infant health trajectories. Facilitation: Procedures that improved acceptability included dynamic training and champion support, regular feedback on intervention outcomes, and strategies to reduce stigma and bias. CONCLUSION We identified contextual factors, concrete messaging, and training procedures that may inform implementation of SDH screening and referral in NICU settings.
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Affiliation(s)
- Erika G Cordova-Ramos
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts (Dr Cordova-Ramos and Ms Burke); Department of Medicine, Evans Center for Implementation and Improvement Sciences (Drs Cordova-Ramos and Drainoni), Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts (Mss Sileo, McGean, and Mantri); Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York (Dr Torrice); Department of Pediatrics, UMass Memorial Medical Center, Worcester, Massachusetts (Dr Parker); Section of Infectious Diseases, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts (Dr Drainoni); and Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts (Dr Drainoni)
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Nouri S, Lyles CR, Sherwin EB, Kuznia M, Rubinsky AD, Kemper KE, Nguyen OK, Sarkar U, Schillinger D, Khoong EC. Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation. JAMA Netw Open 2023; 6:e2333944. [PMID: 37713198 PMCID: PMC10504619 DOI: 10.1001/jamanetworkopen.2023.33944] [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: 05/22/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023] Open
Abstract
Importance Telehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient-clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions. Objective To evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics. Design, Setting, and Participants This retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed. Exposure Telehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021). Main Outcomes and Measures The main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES). Results Of 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P < .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03). Conclusions and Relevance In this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.
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Affiliation(s)
- Sarah Nouri
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco
| | - Courtney R. Lyles
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco
- UCSF Center for Vulnerable Populations, University of California San Francisco
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Elizabeth B. Sherwin
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | | | - Anna D. Rubinsky
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Kathryn E. Kemper
- UCSF Center for Vulnerable Populations, University of California San Francisco
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Oanh K. Nguyen
- UCSF Center for Vulnerable Populations, University of California San Francisco
- Division of Hospital Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco
| | - Urmimala Sarkar
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco
- UCSF Center for Vulnerable Populations, University of California San Francisco
| | - Dean Schillinger
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco
- UCSF Center for Vulnerable Populations, University of California San Francisco
| | - Elaine C. Khoong
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, Department of Medicine, University of California San Francisco
- UCSF Center for Vulnerable Populations, University of California San Francisco
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Sotelo Guerra LJ, Ortiz J, Liljenquist K, Szilagyi PG, Fiscella K, Porras-Javier L, Johnson G, Friesema L, Coker TR. Implementation of a community health worker-focused team-based model of care: What modifications do clinics make? FRONTIERS IN HEALTH SERVICES 2023; 3:989157. [PMID: 36926506 PMCID: PMC10012691 DOI: 10.3389/frhs.2023.989157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/09/2023] [Indexed: 01/31/2023]
Abstract
Background Team-based care offers potential for integrating non-clinicians, such as community health workers (CHWs), into the primary care team to ensure that patients and families receive culturally relevant care to address their physical, social, and behavioral health and wellness needs. We describe how two federally qualified health center (FQHC) organizations adapted an evidence-based, team-based model of well-child care (WCC) designed to ensure that the parents of young children, aged 0-3, have their comprehensive preventive care needs met at WCC visits. Methods Each FQHC formed a Project Working Group composed of clinicians, staff, and parents to determine what adaptations to make in the process of implementation of PARENT (Parent-Focused Redesign for Encounters, Newborns to Toddlers), a team-based care intervention that uses a CHW in the role of a preventive care coach. We use the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) to chronicle the various intervention modifications and the adaptation process, focusing on when and how modifications occurred, whether it was planned or unplanned, and the reasons and goals for the modification. Results The Project Working Groups adapted several elements of the intervention in response to clinic priorities, workflow, staffing, space, and population need. Modifications were planned and proactive, and were made at the organization, clinic, and individual provider level. Modification decisions were made by the Project Working Group and operationalized by the Project Leadership Team. Examples of modifications include the following: (1) changing the parent coach educational requirement from a Master's degree to a bachelor's degree or equivalent experience to reflect the needs of the coach role; (2) the use of FQHC-specific templates for the coach's documentation of the pre-visit screening in the electronic health record; and (3) the use of electronic social needs referral tools to help the coach track and follow up on social need referrals. The modifications did not change the core elements (i.e., parent coach provision of preventive care services) or intervention goals. Conclusions For clinics implementing team-based care interventions, the engagement of key clinical stakeholders early and often in the intervention adaptation and implementation process, and planning for intervention modifications at both at an organizational level and at a clinical level are critical for local implementation.
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Affiliation(s)
- Laura J. Sotelo Guerra
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Janette Ortiz
- Department of Pediatrics, University of California, Los Angeles, CA, United States
| | - Kendra Liljenquist
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Peter G. Szilagyi
- Department of Pediatrics, University of California, Los Angeles, CA, United States
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester, Rochester, NY, United States
| | - Lorena Porras-Javier
- Department of Pediatrics, University of California, Los Angeles, CA, United States
| | - Gina Johnson
- Northeast Valley Health Corporation, San Fernando, CA, United States
| | | | - Tumaini R. Coker
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
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Dwyer M, Prior SJ, Van Dam PJ, O’Brien L, Griffin P. Development and Evaluation of a Massive Open Online Course on Healthcare Redesign: A Novel Method for Engaging Healthcare Workers in Quality Improvement. NURSING REPORTS 2022; 12:850-860. [PMID: 36412801 PMCID: PMC9680403 DOI: 10.3390/nursrep12040082] [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: 10/10/2022] [Revised: 10/29/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Healthcare workers are under increasing pressure to use limited resources more efficiently and improve patient outcomes. Healthcare redesign, a quality improvement methodology derived from the automotive industry, is a proven means of achieving these goals. Continuing Professional Development (CPD) opportunities for nurses seeking to build their capacity for healthcare redesign often come in the form of university courses, which can be costly and prohibitively time-consuming. We developed a Massive Open Online Course (MOOC) with a view to increasing the number of healthcare workers undertaking CPD in healthcare redesign and subsequently using these principles in their workplaces. The aim of the current study is to describe the development of our MOOC and its initial feedback from users. Materials and Methods: The theoretical and practical components of an existing postgraduate award course unit were made fit for purpose by being arranged into six weekly modules, before being transposed to an established learning management platform for MOOCs. Related quizzes, videos and interactive activities were then developed and included in each of these modules. Peer review of this content was completed by subject matter and teaching and learning experts prior to the MOOC being launched. Results: After running for nine months, 578 participants had enrolled in the MOOC, of whom 118 (20%) had followed through to completion. Participants were overwhelmingly from Australia (89%) and identified as female (78%). Preliminary feedback obtained from participants was positive, with 81% of respondents agreeing that they were satisfied with their experience, and 82% intending to apply their knowledge in practice. Conclusions: The MOOC has addressed a learning need by providing a brief and free form of education; learning from its development will help others seeking similar educational solutions. Initial feedback suggests the MOOC has been well-received and is likely to be translated into practice.
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Affiliation(s)
- Mitchell Dwyer
- Tasmanian School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia
- Correspondence:
| | - Sarah J. Prior
- Tasmanian School of Medicine, Rural Clinical School, University of Tasmania, Burnie, TAS 7320, Australia
| | - Pieter Jan Van Dam
- School of Nursing, Cradle Coast Campus, University of Tasmania, Burnie, TAS 7320, Australia
| | - Lauri O’Brien
- Tasmanian School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia
| | - Phoebe Griffin
- Tasmanian School of Medicine, University of Tasmania, Launceston, TAS 7000, Australia
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Pérez Jolles M, Fernández ME, Jacobs G, De Leon J, Myrick L, Aarons GA. Using Implementation Mapping to develop protocols supporting the implementation of a state policy on screening children for Adverse Childhood Experiences in a system of health centers in inland Southern California. Front Public Health 2022; 10:876769. [PMID: 36091515 PMCID: PMC9459376 DOI: 10.3389/fpubh.2022.876769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/25/2022] [Indexed: 01/21/2023] Open
Abstract
Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accidents, harsh migration experiences, or violence. Screening for ACEs includes asking questions about an individual's early exposure to these types of events. ACEs screenings have potential value in identifying children exposed to chronic and significant stress that produces elevated cortisol levels (i.e., toxic stress), and its associated physical and mental health conditions, such as heart disease, diabetes, depression, asthma, ADHD, anxiety, and substance dependence. However, ACEs screenings are seldom used in primary care settings. The Surgeon General of California has addressed this care gap by introducing ACEs Aware, an ACEs screening fee-for-service healthcare policy signed into law by Gov. Gavin Newsom. Since January 2020, Medi-Cal, California's Medicaid health care program, has reimbursed primary care providers for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children and adults for ACEs during wellness visits. To achieve the goals set by the ACEs Aware state policy, it is essential to develop and test implementation strategies that are informed by the values, priorities, and resources of clinical settings, healthcare professionals, and end-users. To address this need, we partnered with a system of federally qualified health centers in Southern California on a pilot study to facilitate the implementation of ACEs screenings in five community-based clinics. The health centers had broad ideas for an implementation strategy, as well as best practices to improve adoption of screenings, such as focusing on staff training to improve clinic workflow. This knowledge was incorporated into the development of an implementation strategy template, used at the outset of this study. We used the Exploration, Preparation, Implementation and Sustainment (EPIS) framework to guide the study and inform a participatory planning process called Implementation Mapping. In this paper, we describe how Implementation Mapping was used to engage diverse stakeholders and guide them through a systematic process that resulted in the development of the implementation strategy. We also detail how the EPIS framework informed each Implementation Mapping Task and provide recommendations for developing implementation strategies using EPIS and Implementation Mapping in health-care settings.
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Affiliation(s)
- Mónica Pérez Jolles
- ACCORDS Dissemination and Implementation Science Program, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Gehr Family Center for Health Systems Science and Innovation, Keck Medicine, University of Southern California, Los Angeles, CA, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, United States
| | - María E. Fernández
- Department of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States
| | - Gabrielle Jacobs
- ACCORDS Dissemination and Implementation Science Program, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jessenia De Leon
- Suzanne Dworak Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Leslie Myrick
- Suzanne Dworak Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Gregory A. Aarons
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States
- Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, University of California, San Diego, La Jolla, CA, United States
- Child and Adolescent Services Research Center, San Diego, CA, United States
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Access to neurorehabilitation interdisciplinary outpatient programs in British Columbia. Neurol Sci 2022; 50:450-452. [PMID: 35357302 DOI: 10.1017/cjn.2022.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This survey explored access to British Columbia (BC) hospital-based neurorehabilitation outpatient programs (HB-NROPs). Fifteen rehabilitation-focused healthcare providers were interviewed. Wait times for HB-NROPs were up to 3 months for initial appointments, and inclusion criteria were variable. Two HB-NROPs had occasional access to specialized physicians. Informal communication methods were preferred modes of collaboration. BC HB-NROPs varied in access, use of interdisciplinary care, and outcome measures used to measure performance. The lack of coverage for nonphysician services may be a barrier to collaborative care in the community. Future projects should explore solutions to improve funding and equal access to BC HB-NROPs.
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Silva LDLT, Dias FCDS, Maforte NTP, Menezes AC. Segurança do paciente na Atenção Primária à Saúde: percepção da equipe de enfermagem. ESCOLA ANNA NERY 2022. [DOI: 10.1590/2177-9465-ean-2021-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo compreender a percepção da equipe de enfermagem da Atenção Primária à Saúde sobre a segurança do paciente. Método estudo exploratório e descritivo com abordagem qualitativa com 22 profissionais da enfermagem atuantes na Atenção Primária à Saúde. Os dados foram coletados por meio de entrevistas semiestruturadas gravadas e analisados segundo a análise temática de conteúdo proposto por Bardin. Resultados emergiram três unidades temáticas: “O significado de segurança do paciente”, “Fatores contribuintes para a ocorrência de erros na assistência à saúde” e “Estratégias para a segurança do paciente”. A equipe de enfermagem desconhecia o Programa Nacional de Segurança do Paciente, mas destacaram ações de cuidado seguro e fatores que levam a ocorrência de erro, além de reconhecerem a necessidade de uma educação formal sobre a temática e melhoria do processo de trabalho e da comunicação com a alta gestão. Considerações finais e implicações para a prática o desconhecimento da equipe de enfermagem indica a necessidade de capacitá-la acerca da temática para subsidiar alterações no processo de trabalho com a incorporação de protocolos e de estratégias de mitigação e prevenção de eventos adversos na Atenção Primária à Saúde que garantam uma assistência mais capacitada e segura ao usuário.
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Morgan S, Pullon S, McKinlay E, Garrett S, Kennedy J, Watson B. Collaborative Care in Primary Care: The Influence of Practice Interior Architecture on Informal Face-to-Face Communication-An Observational Study. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2020; 14:190-209. [PMID: 32705904 DOI: 10.1177/1937586720939665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Quality patient care in primary care settings, especially for patients with complex long-term health needs, is improved by interprofessional collaborative practice. Effective collaboration is achieved in large part by frequent informal face-to-face "on-the-fly" communication between team members. Research undertaken in hospitals shows that interior architecture influences informal communication and collaboration between staff. However, little is known about how the interior architecture of primary care practices might facilitate or hinder informal communication and collaboration among primary care staff. OBJECTIVES This research explores the influence of primary care practice interior architecture on face-to-face on-the-fly communication for collaborative care. METHODS An observational study was undertaken to compare face-to-face informal interactions between staff in three primary care practices of differing interior architecture. Data collected from practices included: direct observations floor plans, photographs, interviews, and surveys. RESULTS Most primary care staff engaged in frequent, brief face-to-face interactions, which appeared to be key to the delivery of effective collaboration. Features of primary care practice designs that were associated with increased frequency of staff interaction included shared spaces, staff proximity/visibility, and the presence of convenient circulatory and transitional spaces where staff were able to easily engage in timely on-the-fly communication with colleagues. CONCLUSIONS The interior architecture of primary care practices has an important impact on staff collaboration. Although more research is needed to investigate further details in more practices, close attention should nevertheless be paid to maximizing opportunities for brief face-to-face communication in well-designed shared spaces in primary care practices.
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Affiliation(s)
- Sonya Morgan
- Department of Primary Health Care and General Practice, University of Otago Wellington, New Zealand
| | - Susan Pullon
- Department of Primary Health Care and General Practice, University of Otago Wellington, New Zealand
| | - Eileen McKinlay
- Department of Primary Health Care and General Practice, University of Otago Wellington, New Zealand
| | - Susan Garrett
- Department of Primary Health Care and General Practice, University of Otago Wellington, New Zealand
| | - Jonathan Kennedy
- Department of Primary Health Care and General Practice, University of Otago Wellington, New Zealand
| | - Bruce Watson
- Faculty of Built Environment, 7800University of New South Wales, Sydney, Australia
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Crable EL, Biancarelli D, Walkey AJ, Drainoni ML. Barriers and facilitators to implementing priority inpatient initiatives in the safety net setting. Implement Sci Commun 2020; 1:35. [PMID: 32885192 PMCID: PMC7427845 DOI: 10.1186/s43058-020-00024-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 02/28/2020] [Indexed: 02/03/2023] Open
Abstract
Background Safety net hospitals, which serve vulnerable and underserved populations and often operate on smaller budgets than non-safety net hospitals, may experience unique implementation challenges. We sought to describe common barriers and facilitators that affect the implementation of improvement initiatives in a safety net hospital, and identify potentially transferable lessons to enhance implementation efforts in similar settings. Methods We interviewed leaders within five inpatient departments and asked them to identify the priority inpatient improvement initiative from the last year. We then conducted individual, semi-structured interviews with 25 stakeholders across the five settings. Interviewees included individuals serving in implementation oversight, champion, and frontline implementer roles. The Consolidated Framework for Implementation Research informed the discussion guide and a priori codes for directed content analysis. Results Despite pursuing diverse initiatives in different clinical departments, safety net hospital improvement stakeholders described common barriers and facilitators related to inner and outer setting dynamics, characteristics of individuals involved, and implementation processes. Implementation barriers included (1) limited staffing resources, (2) organizational recognition without financial investment, and (3) the use of implementation strategies that did not adequately address patients’ biopsychosocial complexities. Facilitators included (1) implementation approaches that combined passive and active communication styles, (2) knowledge of patient needs and competitive pressure to perform well against non-SNHs, (3) stakeholders’ personal commitment to reduce health inequities, and (4) the use of multidisciplinary task forces to drive implementation activities. Conclusion Inner and outer setting dynamics, individual’s characteristics, and process factors served as implementation barriers and facilitators within the safety net. Future work should seek to leverage findings from this study toward efforts to enact positive change within safety net hospitals.
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Affiliation(s)
- Erika L Crable
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA
| | - Dea Biancarelli
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA
| | - Allan J Walkey
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA.,The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA USA
| | - Mari-Lynn Drainoni
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA USA.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA USA
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Levis-Peralta M, González MDR, Stalmeijer R, Dolmans D, de Nooijer J. Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients-A Scoping Review. Front Endocrinol (Lausanne) 2020; 11:352. [PMID: 32760344 PMCID: PMC7375199 DOI: 10.3389/fendo.2020.00352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/05/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Team-based care models (TBC) have demonstrated effectiveness to improve health outcomes for vulnerable diabetes patients but have proven difficult to implement in low income settings. Organizational conditions have been identified as influential on the implementation of TBC. This scoping review aims to answer the question: What is known from the scientific literature about how organizational conditions enable or inhibit TBC for diabetic patients in primary care settings, particularly settings that serve low-income patients? Methods: A scoping review study design was selected to identify key concepts and research gaps in the literature related to the impact of organizational conditions on TBC. Twenty-six articles were finally selected and included in this review. This scoping review was carried out following a directed content analysis approach. Results: While it is assumed that trained health professionals from diverse disciplines working in a common setting will sort it out and work as a team, co-location, and health professions education alone do not improve patient outcomes for diabetic patients. Health system, organization, and/or team level factors affect the way in which members of a care team, including patients and caregivers, collaborate to improve health outcomes. Organizational factors span across seven categories: governance and policies, structure and process, workplace culture, resources, team skills and knowledge, financial implications, and technology. These organizational factors are cited throughout the literature as important to TBC, however, research on the organizational conditions that enable and inhibit TBC for diabetic patients is extremely limited. Dispersed organizational factors are cited throughout the literature, but only one study specifically assesses the effect of organizational factors on TBC. Thematic analysis was used to categorize organizational factors in the literature about TBC and diabetes and a framework for analysis and definitions for key terms is presented. Conclusions: The review identified significant gaps in the literature relating to the study of organizational conditions that enable or inhibit TBC for low-income patients with diabetes. Efforts need to be carried out to establish unifying terminology and frameworks across the field to help explain the relationship between organizational conditions and TBC for diabetes. Gaps in the literature include research be based on organizational theories, research carried out in low-income settings and low and middle income countries, research explaining the difference between the organizational conditions that impact the implementation of TBC vs. maintaining or sustaining TBC and the interaction between organizational factors at the micro, meso and macro level and their impact on TBC. Few studies include information on patient outcomes, and fewer include information on low income settings. Further research is necessary on the impact of organizational conditions on TBC and diabetic patient outcomes.
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Affiliation(s)
| | | | - Renée Stalmeijer
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Diana Dolmans
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Jascha de Nooijer
- Department of Health Promotion, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
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Gibson SJ. Addressing the unique needs of training primary care-based educators. MEDICAL EDUCATION 2019; 53:754-756. [PMID: 31243780 DOI: 10.1111/medu.13921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Simone J Gibson
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia
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