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Felizzola J, Pinho V, Funk D, Del Río-González AM, Zea MC, Sol C, Barker S. Transforming Latinx HIV Care: Mixed-Methods Evaluation of a Patient-Centered HIV Practice Transformation. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2022; 34:131-141. [PMID: 35438539 DOI: 10.1521/aeap.2022.34.2.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We conducted a mixed-method longitudinal evaluation of an HIV primary care practice transformation project in Washington, D.C. The project aimed to enhance organizational capacity to deliver culturally appropriate and patient-centered care for Latinxs living with HIV. Quantitative and qualitative data were simultaneously collected to capture the complex interactions among care providers, staff, and patients as well as to monitor practice changes that occurred as a result of the project implementation. The practice transformation intervention consisted of core competency workforce training, workflow redesign, and data-driven quality improvement strategies utilized to guide the intervention and to gather data from providers and patients. The mixed-methods approach facilitated meaningful change within the clinic that resulted in improved patient outcomes, patient experiences of care, and increases in staff's perceived level of knowledge of patient-centered care and improved efficiencies in HIV health care service delivery.
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Affiliation(s)
| | | | - Danielle Funk
- The Fenway Institute, Fenway Health, Boston, Massachusetts
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2
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Arabadjis SD, Sullivan EE. Data and HIT systems in primary care settings: an analysis of perceptions and use. J Health Organ Manag 2021; ahead-of-print. [PMID: 33354961 DOI: 10.1108/jhom-03-2020-0071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Electronic Health Records (EHRs) and other Health Information Technologies (HITs) pose significant challenges for clinicians, administrators and managers in the field of primary care. While there is an abundance of literature on the challenges of HIT systems in primary care, there are also practices where HITs are well-integrated and useful for care delivery. This study aims to (1) understand how exemplary primary care practices conceptualized data and HIT system use in their care delivery and (2) describe components that support and promote data and HIT system use in care delivery. DESIGN/METHODOLOGY/APPROACH This paper is a sub-analysis of a larger qualitative data set on exemplary primary care in which data was collected using in-depth interviews, observations, field notes and primary source documents from week-long site visits at each organization. Using a combination of qualitative analysis methods including elements of thematic analysis, discourse analysis, and qualitative comparison analysis, we examined HIT-related data across six exemplary primary care organizations. FINDINGS Three key components were identified that underlie engagement with data and HIT systems: data audience identification, defined data purpose and structures for participation in both data design and maintenance. ORIGINALITY/VALUE Within the context of primary care, these findings have implications for effective integration of HIT systems into primary care delivery.
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Affiliation(s)
- Sophia D Arabadjis
- Geography, University of California Santa Barbara, Santa Barbara, California, USA
| | - Erin E Sullivan
- Sawyer Business School, Suffolk University, Boston, Massachusetts, USA.,Center for Primary Care, Harvard Medical School, Boston, Massachusetts, USA
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Metusela C, Dijkmans-Hadley B, Mullan J, Gow A, Bonney A. Implementation of a patient centred medical home (PCMH) initiative in general practices in New South Wales, Australia. BMC FAMILY PRACTICE 2021; 22:120. [PMID: 34148554 PMCID: PMC8215740 DOI: 10.1186/s12875-021-01485-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND With an ageing population and an increase in chronic disease burden in Australia, Patient Centred Medical Home (PCMH) models of care have been identified as potential options for primary care reform and improving health care outcomes. Adoption of PCMH models are not well described outside of North America. We examined the experiences of seven general practices in an Australian setting that implemented projects aligned with PCMH values and goals supported by their local Primary Health Network (PHN). METHOD Qualitative and quantitative data were collected over a twelve month period, including semi-structured interviews, participant observation, and practice data to present a detailed examination of a subject of study; the implementation of PCMH projects in seven general practices. We conducted 49 interviews (24 pre and 25 post) with general practitioners, practice managers, practice nurses and PHN staff. Framework analysis deploying the domains of a logic model was used to synthesis and analyse the data. RESULTS Facilitators in implementing successful, sustainable change included the capacity and willingness of practices to undertake change; whole of practice engagement with a shared vision towards PCMH change; engaged leadership; training and support; and structures and processes required to provide team-based, data driven care. Barriers to implementation included change fatigue, challenges of continued engaged leadership and insufficient time to implement PCMH change. CONCLUSIONS Our study examined the experiences of implementing PCMH initiatives in an Australian general practice setting, describing facilitators and barriers to PCMH change. Our findings provide guidance for PHNs and practices within Australia, as well as general practice settings internationally, that are interested in undertaking similar quality improvement projects.
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Affiliation(s)
- Christine Metusela
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
| | | | - Judy Mullan
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
| | - Andrew Gow
- South Eastern New South Wales Primary Health Network, Wollongong, Australia
| | - Andrew Bonney
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
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4
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Grembowski D. Burnout and Patient Referral Among Primary Care Providers in Veterans Affairs Patient Aligned Care Teams (VA PACTs). J Ambul Care Manage 2021; 44:126-137. [PMID: 33394816 DOI: 10.1097/jac.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Using the Veterans Health Administration's 2018 national provider and staff survey, this study describes the practice patterns of 1453 primary care providers for specialty care consults, program referrals, secure messaging, and telephone visits; and examines whether the practice patterns are associated with provider burnout in primary care teamlets. About 51% of providers experienced moderate to severe burnout and 22% had severe burnout. Providers who embraced all 4 practice approaches had lower odds of severe burnout than providers endorsing none of the approaches (odds ratio range, 0.35-0.39). Associations were weaker for providers with moderate to severe burnout.
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Affiliation(s)
- David Grembowski
- Department of Health Services, School of Public Health, University of Washington, Seattle; and VA Puget Sound Health Care System, Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, US Department of Veterans Affairs, Seattle, Washington
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5
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Do Teams Improve the Quality of Ambulatory Care? J Ambul Care Manage 2021; 44:89-100. [PMID: 33394817 DOI: 10.1097/jac.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Using data from the National Ambulatory Medical Care Survey, we examined team composition in office-based practices and compared their relative quality of care. We found that, compared with physician-only teams, patients seen by physician and nurse practitioner/nurse midwife teams and those seen by physician and nurse teams were more likely to receive statins for hyperlipidemia and blood pressure screening, respectively. We also found that patients seen by physician and physician assistant teams were less likely to receive recommended care for all 4 quality indicators, and patients seen by any interprofessional team were less likely to receive recommended depression treatment than physician-only teams.
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Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
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Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
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Stockdale SE, Hamilton AB, Bergman AA, Rose DE, Giannitrapani KF, Dresselhaus TR, Yano EM, Rubenstein LV. Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration. Implement Sci 2020; 15:18. [PMID: 32183873 PMCID: PMC7079486 DOI: 10.1186/s13012-020-0979-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 03/04/2020] [Indexed: 12/25/2022] Open
Abstract
Background Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants’ fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity. Methods Nine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010–2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis. Results Seven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity. Conclusions This study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.
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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, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA. .,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA.
| | - Alison B Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Alicia A Bergman
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA
| | - Danielle E Rose
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA
| | - Karleen F Giannitrapani
- HSR&D Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Department of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | | | - Elizabeth M Yano
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA.,Department of Health Policy & Management Fielding School of Public Health, University of California, Los Angeles, USA
| | - Lisa V Rubenstein
- Department of Health Policy & Management Fielding School of Public Health, University of California, Los Angeles, USA.,Department of Medicine David Geffen School of Medicine, University of California, Los Angeles, USA.,RAND Corporation, Santa Monica, CA, USA
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Liss DT, Peprah YA, Brown T, Ciolino JD, Jackson K, Kho AN, Murakami L, Walunas TL, Persell SD. Using Electronic Health Records to Measure Quality Improvement Efforts: Findings from a Large Practice Facilitation Initiative. Jt Comm J Qual Patient Saf 2020; 46:11-17. [PMID: 31704159 PMCID: PMC9884429 DOI: 10.1016/j.jcjq.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Federal incentives for electronic health record (EHR) use typically require quality measure reporting over calendar year or 90-day periods. However, required reporting periods may not align with time frames of real-world quality improvement (QI) efforts. This study described primary care practices' ability to obtain measures with reporting periods aligning with a large QI initiative. METHODS Researchers conducted a substudy of a randomized trial testing practice facilitation strategies for preventive cardiovascular care. Three quality measures (aspirin for ischemic vascular disease; blood pressure control for hypertension; smoking screening/cessation) were collected quarterly over one year. The primary outcome was a binary indicator of whether a practice facilitator obtained all three measures with "rolling 12-month" reporting periods (that is, the year preceding each study quarter). RESULTS The study included 107 practices, 63 (58.9%) of which met the primary outcome of obtaining all measures with rolling 12-month reporting periods. Smaller practices were less likely to meet the primary outcome (p < 0.001). Practices used 11 different EHRs, 3 of which were unable to consistently produce rolling 12-month measures; at 33 practices (30.8%) using these 3 EHRs, facilitators met a secondary outcome of obtaining prior calendar year and rolling 3-month measures. Facilitators reported barriers to data collection such as practices lacking optional EHR features, and EHRs' inability to produce reporting periods across two calendar years. CONCLUSION EHR vendors' compliance with federal reporting requirements is not necessarily sufficient to support real-world QI work. Improvements are needed in the flexibility and usability of EHRs' quality measurement functions, particularly for smaller practices.
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Affiliation(s)
- David T. Liss
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine (NUFSM), Chicago
| | - Yaw A. Peprah
- Division of General Internal Medicine and Geriatrics, NUFSM
| | | | | | | | | | - Linda Murakami
- Quality Improvement, American Medical Association, Chicago
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Kim B, Bolton RE, Hyde J, Fincke BG, Drainoni ML, Petrakis BA, Simmons MM, McInnes DK. Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders. HEALTH & JUSTICE 2019; 7:18. [PMID: 31832790 PMCID: PMC6909453 DOI: 10.1186/s40352-019-0099-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 11/20/2019] [Indexed: 05/05/2023]
Abstract
BACKGROUND Between 12,000 and 16,000 veterans leave incarceration annually. As is known to be the case for justice-involved populations in general, mental health disorders (MHDs) and substance use disorders (SUDs) are highly prevalent among incarcerated veterans, and individuals with MHDs and SUDs reentering the community are at increased risk of deteriorating health and recidivism. We sought to identify opportunities to better coordinate care/services across correctional, community, and VA systems for reentry veterans with MHDs and SUDs. METHODS We interviewed 16 veterans post-incarceration and 22 stakeholders from reentry-involved federal/state/community organizations. We performed a grounded thematic analysis, and recognizing consistencies between the emergent themes and the evidence-based Collaborative Chronic Care Model (CCM), we mapped findings to the CCM's elements - work role redesign (WRR), patient self-management support (PSS), provider decision support (PDS), clinical information systems (CIS), linkages to community resources (LCR), and organizational/leadership support (OLS). RESULTS Emergent themes included (i) WRR - coordination challenges among organizations involved in veterans' reentry; (ii) PSS - veterans' fear of reentering society; (iii) PDS - uneven knowledge by reentry support providers regarding available services when deciding which services to connect a reentry veteran to and whether he/she is ready and/or willing to receive services; (iv) CIS - lapses in MHD/SUD medications between release and a first scheduled health care appointment, as well as challenges in transfer of medical records; (v) LCR - inconsistent awareness of existing services and resources available across a disparate reentry system; and (vi) OLS - reentry plans designed to address only immediate transitional needs upon release, which do not always prioritize MHD/SUD needs. CONCLUSIONS Applying the CCM to coordinating cross-system health care and reentry support may contribute to reductions in mental health crises and overdoses in the precarious first weeks of the reentry period.
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Affiliation(s)
- Bo Kim
- VA Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Rendelle E. Bolton
- VA Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA USA
- Brandeis University The Heller School for Social Policy and Management, Waltham, MA USA
| | - Justeen Hyde
- VA Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA USA
- Boston University School of Medicine, Boston, MA USA
| | - B. Graeme Fincke
- VA Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA USA
- Boston University School of Public Health, Boston, MA USA
| | - Mari-Lynn Drainoni
- VA Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA USA
- Boston University School of Medicine, Boston, MA USA
- Boston University School of Public Health, Boston, MA USA
| | - Beth Ann Petrakis
- VA Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA USA
| | | | - D. Keith McInnes
- VA Center for Healthcare Organization and Implementation Research, Bedford/Boston, MA USA
- Boston University School of Public Health, Boston, MA USA
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10
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Abstract
The Patient-Centered Medical Home (PCMH) now defines excellent primary care. Recent literature has begun to elucidate the components of PCMHs that improve care and reduce costs, but there is little empiric evidence that helps practices, payers, or policy makers understand how high-performing practices have improved outcomes. We report the findings from 38 such practices that fill this gap. We describe how they execute 8 functions that collectively meet patient needs. They include managing populations, providing self-management support coaching, providing integrated behavioral health care, and managing referrals. The functions provide a more actionable perspective on the work of primary care.
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Parchman ML, Anderson ML, Coleman K, Michaels LA, Schuttner L, Conway C, Hsu C, Fagnan LJ. Assessing quality improvement capacity in primary care practices. BMC FAMILY PRACTICE 2019; 20:103. [PMID: 31345167 PMCID: PMC6657073 DOI: 10.1186/s12875-019-1000-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/18/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Healthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation. METHODS To guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors. RESULTS The QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2-5 clinicians had lower QICA scores.. CONCLUSIONS The QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality. TRIAL REGISTRATION This trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.
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Affiliation(s)
- Michael L. Parchman
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Melissa L. Anderson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Katie Coleman
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Le Ann Michaels
- Oregon Rural Practice Research Network, Oregon Health Sciences University, Portland, OR USA
| | | | - Cullen Conway
- Oregon Rural Practice Research Network, Oregon Health Sciences University, Portland, OR USA
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Lyle J. Fagnan
- Oregon Rural Practice Research Network, Oregon Health Sciences University, Portland, OR USA
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12
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Establishing Teams: How Does It Change Practice Configuration, Size, and Composition? J Ambul Care Manage 2019; 41:146-155. [PMID: 29474254 DOI: 10.1097/jac.0000000000000229] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg, job licenses, titles, and team assignment) and practice manager surveys. All personnel (physician and nonphysician) worked within 18 Massachusetts academic primary care practices participating in a 2-year learning collaborative aimed at establishing team-based care. We found that establishing team-based care can involve changing practice configurations and composition without substantially changing practice size.
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Suriyawongpaisal P, Aekplakorn W, Leerapan B, Lakha F, Srithamrongsawat S, von Bormann S. Assessing system-based trainings for primary care teams and quality-of-life of patients with multimorbidity in Thailand: patient and provider surveys. BMC FAMILY PRACTICE 2019; 20:85. [PMID: 31208358 PMCID: PMC6580542 DOI: 10.1186/s12875-019-0951-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 04/26/2019] [Indexed: 11/16/2022]
Abstract
Background Strengthening primary care is considered a global strategy to address non-communicable diseases and their comorbidity. However, empirical evidence of the longer-term benefits of capacity building programmes for primary care teams contextualised for low- and middle-income countries is scanty. In Thailand, a series of system-based capacity building programmes for primary care teams have been implemented for a decade. An analysis of the relationship between these systems-based trainings in diverse settings of primary care and quantified patient outcomes was needed. Methods Facility-based and community-based cross-sectional surveys were used to obtain data on exposure of primary care team members to 11 existing training programmes in Thailand, and health profiles and health-related quality of life of their patients measured in EuroQol-5 Dimension (EQ-5D) scale. Using a multilevel modelling, the associations between primary care provider’s training and patient’s EQ-5D score were estimated by a generalized linear mixed model (GLMM). Results While exposure to training programmes varied among primary care teams nationwide, District Health Management Learning (DHML) and Contracting Unit of Primary Care (CUP) Leadership Training Programmes, which put more emphasis on bundling of competencies and contextualising of applying such competencies, were positively associated with better health-related quality of life of their multimorbid patients. Conclusions Our report provides systematic feedback to a decade-long investment on system-based capacity building for primary care teams in Thailand, and can be considered as new evidence on the value of human resource development in primary care systems in low- and middle-income countries. Building multiple competencies helps members of primary care teams collaboratively manage district health systems and address complex health problems in different local contexts. Coupling contextualised training with ongoing programme implementation could be a key entity to the sustainable development of primary care teams in low and middle income countries which can then be a leverage for improving patients outcomes. Electronic supplementary material The online version of this article (10.1186/s12875-019-0951-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paibul Suriyawongpaisal
- Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wichai Aekplakorn
- Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Borwornsom Leerapan
- Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Fatim Lakha
- NHS Lothian, Edinburgh, Scotland, UK.,The University of Edinburgh, Edinburgh, Scotland, UK
| | - Samrit Srithamrongsawat
- Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Goldman RE, Brown J, Stebbins P, Parker DR, Adewale V, Shield R, Roberts MB, Eaton CB, Borkan JM. What matters in patient-centered medical home transformation: Whole system evaluation outcomes of the Brown Primary Care Transformation Initiative. SAGE Open Med 2018; 6:2050312118781936. [PMID: 29977548 PMCID: PMC6024270 DOI: 10.1177/2050312118781936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/17/2018] [Indexed: 01/17/2023] Open
Abstract
Objectives: Patient-centered medical home transformation initiatives for enhancing
team-based, patient-centered primary care are widespread in the United
States. However, there remain large gaps in our understanding of these
efforts. This article reports findings from a contextual, whole system
evaluation study of a transformation intervention at eight primary care
teaching practice sites in Rhode Island. It provides a picture of system
changes from the perspective of providers, staff, and patients in these
practices. Methods: Quantitative/qualitative evaluation methods include patient, provider, and
staff surveys and qualitative interviews; practice observations; and focus
groups with the intervention facilitation team. Results: Patient satisfaction in the practices was high. Patients could describe
observable elements of patient-centered medical home functioning, but they
lacked explicit awareness of the patient-centered medical home model, and
their activation decreased over time. Providers’ and staff’s emotional
exhaustion and depersonalization increased slightly over the course of the
intervention from baseline to follow-up, and personal accomplishment
decreased slightly. Providers and staff expressed appreciation for the
patient-centered medical home as an ideal model, variously implemented some
important patient-centered medical home components, increased their
understanding of patient-centered medical home as more than specific
isolated parts, and recognized their evolving work roles in the medical
home. However, frustration with implementation barriers and the added work
burden they associated with patient-centered medical home persisted. Conclusion: Patient-centered medical home transformation is disruptive to practices,
requiring enduring commitment of leadership and personnel at every level,
yet the model continues to hold out promise for improved delivery of
patient-centered primary care.
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Affiliation(s)
- Roberta E Goldman
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Center for Primary Care & Prevention, Brown University, Pawtucket, RI, USA
| | - Joanna Brown
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Patricia Stebbins
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Donna R Parker
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Center for Primary Care & Prevention, Brown University, Pawtucket, RI, USA.,Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Victoria Adewale
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Renee Shield
- School of Public Health, Brown University, Providence, RI, USA
| | - Mary B Roberts
- Center for Primary Care & Prevention, Brown University, Pawtucket, RI, USA
| | - Charles B Eaton
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Center for Primary Care & Prevention, Brown University, Pawtucket, RI, USA.,Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - Jeffrey M Borkan
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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15
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Miller-Day M, Applequist J, Zabokrtsky K, Dalton A, Kellom K, Gabbay R, Cronholm PF. A tale of four practices. J Health Organ Manag 2018; 31:630-646. [PMID: 29034825 DOI: 10.1108/jhom-01-2017-0015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. This transformation presents a challenge to many care delivery organizations. The purpose of this paper is to describe attributes shaping successful and unsuccessful practice transformation within four medical practice groups. Design/methodology/approach As part of a larger study of 25 practices transitioning into a PCMH, the current study focused on diabetes care and identified high- and low-improvement medical practices in terms of quantitative patient measures of glycosylated hemoglobin and qualitative assessments of practice performance. A subset of the top two high-improvement and bottom two low-improvement practices were identified as comparison groups. Semi-structured interviews were conducted with diverse personnel at these practices to investigate their experiences with practice transformation and data were analyzed using analytic induction. Findings Results show a variety of key attributes facilitating more successful PCMH transformation, such as empanelment, shared goals and regular meetings, and a clear understanding of PCMH transformation purposes, goals, and benefits, providing care/case management services, and facilitating patient reminders. Several barriers also exist to successful transformation, such as low levels of resources to handle financial expense, lack of understanding PCMH transformation purposes, goals, and benefits, inadequate training and management of technology, and low team cohesion. Originality/value Few studies qualitatively compare and contrast high and low performing practices to illuminate the experience of practice transformation. These findings highlight the experience of organizational members and their challenges in practice transformation while providing quality diabetes care.
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Affiliation(s)
- Michelle Miller-Day
- Department of Health and Strategic Communication, Chapman University , Orange, California, USA
| | - Janelle Applequist
- The Zimmerman School of Advertising, University of South Florida , Tampa, Florida, USA
| | | | - Alexandra Dalton
- Department of Clinical Research and Leadership, George Washington University , Washington, District of Columbia, USA
| | - Katherine Kellom
- Department of Family Medicine and Community Health, Center for Public Health Initiatives, Leonard Davis Institute of Health Economics, University of Pennsylvania , Philadelphia, Pennsylvania, USA
| | - Robert Gabbay
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter F Cronholm
- Department of Family Medicine and Community Health, Center for Public Health Initiatives, Leonard Davis Institute of Health Economics, University of Pennsylvania , Philadelphia, Pennsylvania, USA
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16
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Measuring and improving comprehensive pediatric cardiac care: Learning from continuous quality improvement methods and tools. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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Chung S, Panattoni L, Chi J, Palaniappan L. Can Secure Patient-Provider Messaging Improve Diabetes Care? Diabetes Care 2017; 40:1342-1348. [PMID: 28807977 DOI: 10.2337/dc17-0140] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/09/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Internet-based secure messaging between patients and providers through a patient portal is now common in the practice of modern medicine. There is limited evidence on how messaging is associated with use and clinical quality measures among patients with type 2 diabetes. We examine whether messaging with physicians for medical advice is associated with fewer face-to-face visits and better diabetes management. RESEARCH DESIGN AND METHODS Patients with diabetes who were enrolled in an online portal of an outpatient health care organization in 2011-2014 were studied (N = 37,762 patient-years). Messages from/to primary care physicians or diabetes-related specialists for medical advice were considered. We estimated the association of messaging with diabetes quality measures, adjusting for patient and provider characteristics and patient-level clustering. RESULTS Most patients (72%) used messaging, and those who made frequent visits were also more likely to message. Given visit frequency, no (vs. any) messaging was negatively associated with the likelihood of meeting an HbA1c target of <8% (64 mmol/mol) (odds ratio [OR] 0.83 [95% CI 0.77, 0.90]). Among message users, additional messages (vs. 1) were associated with better outcome (two more messages: OR 1.17 [95% CI 1.06, 1.28]; three more messages: 1.38 [1.25, 1.53]; four more messages: 1.55 [1.43, 1.69]). The relationship was stronger for noninsulin users. Message frequency was also positively associated, but to a smaller extent, with process measures (e.g., eye examination). Physician-initiated messages had effects similar to those for patient-initiated messages. CONCLUSIONS Patients with diabetes frequently used secure messaging for medical advice in addition to routine visits to care providers. Messaging was positively associated with better diabetes management in a large community outpatient practice.
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Affiliation(s)
- Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Laura Panattoni
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeffrey Chi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Latha Palaniappan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
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18
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Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project. Med Care 2017. [PMID: 28650922 DOI: 10.1097/mlr.0000000000000759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. STUDY SETTING In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. STUDY DESIGN Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools. DATA COLLECTION METHODS Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites. PRINCIPAL FINDINGS Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES. CONCLUSIONS A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.
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19
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Schiff GD, Bearden T, Hunt LS, Azzara J, Larmon J, Phillips RS, Singer S, Bennett B, Sugarman JR, Bitton A, Ellner A. Primary Care Collaboration to Improve Diagnosis and Screening for Colorectal Cancer. Jt Comm J Qual Patient Saf 2017. [PMID: 28648219 DOI: 10.1016/j.jcjq.2017.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer death, reducible by screening and early diagnosis, yet many patients fail to receive recommended screening. As part of an academic improvement collaborative, 25 primary care practices worked to improve CRC screening and diagnosis. METHODS The project featured triannual learning sessions, monthly conference calls, practice coach support, and monthly reporting. The project phases included literature review and interviews with national leaders/organizations, development of driver diagrams to identify key factors and change ideas, project launch and practice team planning, and a practice improvement phase. RESULTS The project activities included (1) inventory of barriers and best practices, (2) driver diagram to drive improvements, (3) list of changes to try, (4) compilation of lessons learned, and (5) five key changes to optimize screening and follow-up. Practices leveraged prior transformation efforts to track patients for screening and follow-up during and between office visits. By mapping processes, testing changes, and collecting data, sites targeted opportunities to improve quality, safety, efficiency, and patient and care team experience. Successful change interventions centered around partnering with gastroenterology, engaging leadership, leveraging registries and health information technology, promoting alternative screening options, and partnering with and supporting patients. Several practices achieved improvement in screening rates, while others demonstrated no change from baseline during the 10-month testing and implementation phase (July 2014-April 2015). CONCLUSION The collaborative effectively engaged teams in a broad set of process improvements with key lessons learned related to barriers, information technology challenges, outreach challenges/strategies, and importance of stakeholder and patient engagement.
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20
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Rodriguez HP, Henke RM, Bibi S, Ramsay PP, Shortell SM. The Exnovation of Chronic Care Management Processes by Physician Organizations. Milbank Q 2017; 94:626-53. [PMID: 27620686 DOI: 10.1111/1468-0009.12213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
UNLABELLED Policy Points The rate of adoption of chronic care management processes (CMPs) by physician organizations has been fairly slow in spite of demonstrated effectiveness of CMPs in improving outcomes of chronic care. Exnovation (ie, removal of innovations) by physician organizations largely explains the slow population-level increases in practice use of CMPs over time. Expanded health information technology functions may aid practices in retaining CMPs. Low provider reimbursement by Medicaid programs, however, may contribute to disinvestment in CMPs by physician organizations. CONTEXT Exnovation is the process of removal of innovations that are not effective in improving organizational performance, are too disruptive to routine operations, or do not fit well with the existing organizational strategy, incentives, structure, and/or culture. Exnovation may contribute to the low overall adoption of care management processes (CMPs) by US physician organizations over time. METHODS Three national surveys of US physician organizations, which included common questions about organizational characteristics, use of CMPs, and health information technology (HIT) capabilities for practices of all sizes, and Truven Health Insurance Coverage Estimates were integrated to assess organizational and market influences on the exnovation of CMPs in a longitudinal cohort of 1,048 physician organizations. CMPs included 5 strategies for each of 4 chronic conditions (diabetes, asthma, congestive heart failure, and depression): registry use, nurse care management, patient reminders for preventive and care management services to prevent exacerbations of chronic illness, use of nonphysician clinicians to provide patient education, and quality of care feedback to physicians. FINDINGS Over one-third (34.1%) of physician organizations exnovated CMPs on net. Quality of care data feedback to physicians and patient reminders for recommended preventive and chronic care were discontinued by over one-third of exnovators, while nurse care management and registries were largely retained. Greater proportions of baseline Medicaid practice revenue (incidence rate ratio [IRR] = 1.44, p < 0.001) and increasing proportions of revenue from Medicaid (IRR = 1.02, p < 0.05) were associated with greater CMP exnovation by physician organizations on net. Practices with greater expansion of HIT functionality exnovated fewer CMPs (IRR = 0.91, p < 0.001) compared to practices with less expansion of HIT functionality. CONCLUSIONS Exnovation of CMPs is an important reason why the population-level adoption of CMPs by physician organizations has remained low. Expanded HIT functions and changes to Medicaid reimbursement and incentives may aid the retention of CMPs by physician organizations.
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Affiliation(s)
- Hector P Rodriguez
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley. .,Division of Health Policy and Management, UC Berkeley School of Public Health.
| | | | - Salma Bibi
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley
| | - Patricia P Ramsay
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley
| | - Stephen M Shortell
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley.,Division of Health Policy and Management, UC Berkeley School of Public Health
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21
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Schamess A, Foraker R, Kretovics M, Barnes K, Beatty S, Bose-Brill S, Tayal N. Reduced emergency room and hospital utilization in persons with multiple chronic conditions and disability receiving home-based primary care. Disabil Health J 2017; 10:326-333. [DOI: 10.1016/j.dhjo.2016.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/14/2016] [Accepted: 10/07/2016] [Indexed: 02/04/2023]
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22
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Wagner EH, Flinter M, Hsu C, Cromp D, Austin BT, Etz R, Crabtree BF, Ladden MD. Effective team-based primary care: observations from innovative practices. BMC FAMILY PRACTICE 2017; 18:13. [PMID: 28148227 PMCID: PMC5289007 DOI: 10.1186/s12875-017-0590-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/22/2017] [Indexed: 11/22/2022]
Abstract
Background Team-based care is now recognized as an essential feature of high quality primary care, but there is limited empiric evidence to guide practice transformation. The purpose of this paper is to describe advances in the configuration and deployment of practice teams based on in-depth study of 30 primary care practices viewed as innovators in team-based care. Methods As part of LEAP, a national program of the Robert Wood Johnson Foundation, primary care experts nominated 227 innovative primary care practices. We selected 30 practices for intensive study through review of practice descriptive and performance data. Each practice hosted a 3-day site visit between August, 2012 and September, 2013, where specific advances in team configuration and roles were noted. Advances were identified by site visitors and confirmed at a meeting involving representatives from each of the 30 practices. Results LEAP practices have expanded the roles of existing staff and added new personnel to provide the person power and skills needed to perform the tasks and functions expected of a patient-centered medical home (PCMH). LEAP practice teams generally include a rich array of staff, especially registered nurses (RNs), behavioral health specialists, and lay health workers. Most LEAP practices organize their staff into core teams, which are built around partnerships between providers and specific Medical Assistants (MAs), and often include registered nurses (RNs) and others such as health coaches or receptionists. MAs, RNs, and other staff are heavily involved in the planning and delivery of preventive and chronic illness care. The care of more complex patients is supported by behavioral health specialists, RN care managers, and pharmacists. Standing orders and protocols enable staff to act independently. Conclusions The 30 LEAP practices engage health professional and lay staff in patient care to the maximum extent, which enables the practices to meet the expectations of a PCMH and helps free up providers to focus on tasks that only they can perform. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0590-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edward H Wagner
- MacColl Center for Health Care Innovation, Group Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA, 98101, USA.
| | | | - Clarissa Hsu
- Center for Community Health and Evaluation, Group Health Research Institute, Seattle, WA, USA
| | - DeAnn Cromp
- Center for Community Health and Evaluation, Group Health Research Institute, Seattle, WA, USA
| | - Brian T Austin
- MacColl Center for Health Care Innovation, Group Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA, 98101, USA
| | - Rebecca Etz
- Department of Family Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers-Robert Wood Johnson Medical School, Piscataway Township, NJ, USA
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23
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Abstract
BACKGROUND Patient navigation refers to a direct patient care role that links patients with clinical providers and their support system and provides individualized support during cancer care, ensuring that patients have access to the knowledge and resources necessary to complete recommended treatment. While most reports have studied the role of patient navigators during the cancer screening or diagnostic process, emerging evidence indicates the benefits of patient navigation during active cancer treatment. DISCUSSION Reports in the literature are conflicting on the impact of patient navigation during cancer care and on the benefits to timely or quality care in all populations. Recent sub-analyses of the Patient Navigation Research Program data demonstrated specifically the benefits of targeting patient navigation to the most vulnerable populations, including those with low educational attainment, low income and unstable housing, less social support, multiple comorbidities, and minority race/ethnicity. CONCLUSION The implications of the Patient Navigation Research Program are that this resource is best utilized when directed to support the care of patients at locations with known challenges to timely care and for specific patients with risk factors for delays in care, including comorbidities, low educational attainment and low income. Implementation of patient navigation programs requires the following processes: needs assessment, selection of a navigator to meet the community and care needs, supervision and integration of the navigator into clinical processes, and systems support to facilitate the identification and tracking of those patients requiring patient navigation. There is a need for ongoing research on methods to fund and sustain patient navigation programs.
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Affiliation(s)
- Karen M Freund
- a Institute of Clinical Research and Health Policy Studies, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine , Boston , Massachusetts , USA
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24
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Chang E, Buist DS, Handley M, Pardee R, Gundersen G, Reid RJ. Physician Service Attribution Methods for Examining Provision of Low-Value Care. EGEMS 2017; 4:1276. [PMID: 28203612 PMCID: PMC5302861 DOI: 10.13063/2327-9214.1276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objectives: There has been significant research on provider attribution for quality and cost. Low-value care is an area of heightened focus, with little of the focus being on measurement; a key methodological decision is how to attribute delivered services and procedures. We illustrate the difference in relative and absolute physician- and panel-attributed services and procedures using overuse in cervical cancer screening. Study Design: A retrospective, cross-sectional study in an integrated health care system. Methods: We used 2013 physician-level data from Group Health Cooperative to calculate two utilization attributions: (1) panel attribution with the procedure assigned to the physician’s predetermined panel, regardless of who performed the procedure; and (2) physician attribution with the procedure assigned to the performing physician. We calculated the percentage of low-value cervical cancer screening tests and ranked physicians within the clinic using the two utilization attribution methods. Results: The percentage of low-value cervical cancer screening varied substantially between physician and panel attributions. Across the whole delivery system, median panel- and physician-attributed percentages were 15 percent and 10 percent, respectively. Among sampled clinics, panel-attributed percentages ranged between 10 percent and 17 percent, and physician-attributed percentages ranged between 9 percent and 13 percent. Within a clinic, median panel-attributed screening percentage was 17 percent (range 0 percent–27 percent) and physician-attributed percentage was 11 percent (range 0 percent–24 percent); physician rank varied by attribution method. Conclusions: The attribution method is an important methodological decision when developing low-value care measures since measures may ultimately have an impact on national benchmarking and quality scores. Cross-organizational dialogue and transparency in low-value care measurement will become increasingly important for all stakeholders.
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Affiliation(s)
| | - Diana Sm Buist
- Group Health Research Institute, Group Health Cooperative
| | | | - Roy Pardee
- Group Health Research Institute, Group Health Cooperative
| | | | - Robert J Reid
- Group Health Research Institute, Group Health Cooperative; Trillium Health Partners - Institute for Better Health
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25
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Barriers and facilitators to team-based care in the context of primary care transformation. J Ambul Care Manage 2016; 38:125-33. [PMID: 25748261 DOI: 10.1097/jac.0000000000000056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The patient-centered medical home model relies on team-based care for meaningful practice transformation. This article adds to the literature on the importance of teams in primary care by exploring the barriers and facilitators to establishing high functioning teams during a patient-centered medical home transformation process.
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26
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Edwards ST, Bitton A, Hong J, Landon BE. Patient-centered medical home initiatives expanded in 2009-13: providers, patients, and payment incentives increased. Health Aff (Millwood) 2016; 33:1823-31. [PMID: 25288429 DOI: 10.1377/hlthaff.2014.0351] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient-centered medical home initiatives are central to many efforts to reform the US health care delivery system. To better understand the extent and nature of these initiatives, in 2013 we performed a nationwide cross-sectional survey of initiatives that included payment reform incentives in their models, and we compared the results to those of a similar survey we conducted in 2009. We found that the number of initiatives featuring payment reform incentives had increased from 26 in 2009 to 114 in 2013. The number of patients covered by these initiatives had increased from nearly five million to almost twenty-one million. We also found that the proportion of time-limited initiatives--those with a planned end date--was 20 percent in 2013, a decrease from 77 percent in 2009. Finally, we found that the dominant payment model for patient-centered medical homes remained fee-for-service payments augmented by per member per month payments and pay-for-performance bonuses. However, those payments and bonuses were higher in 2013 than they were in 2009, and the use of shared-savings models was greater. The patient-centered medical home model is likely to continue both to become more common and to play an important role in delivery system reform.
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Affiliation(s)
- Samuel T Edwards
- Samuel T. Edwards is a fellow at the Veterans Affairs Boston Healthcare System and Harvard Medical School, both in Boston, Massachusetts
| | - Asaf Bitton
- Asaf Bitton is an assistant professor of medicine and health care policy at Harvard Medical School and Brigham and Women's Hospital, in Boston. He is also a core faculty member at Harvard Medical School's Center for Primary Care
| | - Johan Hong
- Johan Hong is a research assistant in the Department of Health Care Policy, Harvard Medical School
| | - Bruce E Landon
- Bruce E. Landon is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School, and in the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, in Boston
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27
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Olfson M. The Rise of Primary Care Physicians in the Provision of US Mental Health Care. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2016; 41:559-583. [PMID: 27127264 DOI: 10.1215/03616878-3620821] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Primary care physicians have assumed an increasingly important role in US outpatient mental health care. They are providing an increasing volume of outpatient mental health services, prescribing a growing number and variety of psychotropic medications, and treating patients with a broader array of mental health conditions. These trends, which run counter to a general trend toward specialization and subspecialization within US health care, place new strains on the clinical competencies of primary care physicians. They also underscore the importance of implementing more effective models of collaboration between primary care physicians and mental health specialists. Several elements of the Affordable Care Act provide options for financing and organizing the delivery of integrated general medical and behavioral services. Such integrated services have the potential to improve access and quality of outpatient mental health care for a range of psychiatric disorders. Because people with severe and persisting mental disorders commonly require a higher-level medical expertise than is readily available within primary care as well as a complex array of social services, separate specialized mental health will likely continue to play a vitally important role in caring for this population.
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28
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Lanham HJ, Palmer RF, Leykum LK, McDaniel RR, Nutting PA, Stange KC, Crabtree BF, Miller WL, Jaén CR. Trust and Reflection in Primary Care Practice Redesign. Health Serv Res 2016; 51:1489-514. [PMID: 26611650 PMCID: PMC4946034 DOI: 10.1111/1475-6773.12415] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). DATA SOURCES/STUDY SETTING Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. STUDY DESIGN We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. DATA COLLECTION/EXTRACTION METHODS We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. PRINCIPAL FINDINGS Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection. CONCLUSIONS Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.
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Affiliation(s)
- Holly Jordan Lanham
- Department of Medicine/Hospital Medicine & Department of Family and Community MedicineThe University of Texas Health Science CenterSan AntonioTX
- South Texas Veterans Health Care SystemSan AntonioTX
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
| | - Raymond F. Palmer
- Department of Family and Community MedicineThe University of Texas Health Science CenterSan AntonioTX
| | - Luci K. Leykum
- South Texas Veterans Health Care SystemSan AntonioTX
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
- Department of Medicine/Hospital MedicineThe University of Texas Health Science CenterSan AntonioTX
| | - Reuben R. McDaniel
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
| | | | - Kurt C. Stange
- Departments of Family Medicine, Epidemiology and Biostatistics, and SociologyCase Comprehensive Cancer CenterCase Western Reserve UniversityClevelandOH
| | - Benjamin F. Crabtree
- Department of Family Medicine & Community HealthRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - William L. Miller
- Department of Family MedicineLehigh Valley Health NetworkAllentownPA
| | - Carlos Roberto Jaén
- Departments of Family & Community Medicine, and Epidemiology and BiostatisticsResearch to Advance Community Health CenterThe University of Texas Health Sciences CenterSan AntonioTX
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29
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Abstract
As America experiences the largest health care revolution of the past 50 years, clinicians and administrators are refocusing their attention on the goals of the Quadruple Aim. Motivation and capabilities among stakeholders vary as practical tools and an adequate workforce remain elusive. At the same time, the patient-centered medical home (PCMH) model is spreading rapidly but demonstrating variable results. Positive PCMH outcomes seem to reflect high-quality teamwork. A primary care physician shortage is looming, and increasing numbers of health professionals are being pushed into the PCMH, mandated to provide "integrated" care. Even now, the majority of our Graduate Medical Education programs do not train clinicians in team-based workflow models and interaction skills. Consequently, PCMH teams will only optimize and realize the model's true potential if they learn to coordinate, communicate, and collaborate effectively. This means all PCMH staff members achieve solid teamwork skills and work at the top of their license. The authors discuss resources for improving coordination, communication, and collaboration among members of PCMH teams, and strategies for including other professionals.
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Abstract
BACKGROUND Disparities in health care and health outcomes are a significant problem in the United States. Delivery system reforms such as the patient-centered medical home (PCMH) could have important implications for disparities. OBJECTIVES To investigate what role disparities play in current PCMH initiatives and how their set-up might impact on disparities. RESEARCH DESIGN We selected 4 state-based PCMH initiatives (Colorado, Massachusetts, Pennsylvania, and Rhode Island), 1 regional initiative in New Orleans, and 1 multistate initiative. We interviewed 30 key actors in these initiatives and 3 health policy experts on disparities in the context of PCMH. Interview data were coded using the constant comparative method. RESULTS We find that disparities are not an explicit priority in PCMH initiatives. Nevertheless, many policymakers, providers, and initiative leaders believe that the model has the potential to reduce disparities. However, because of the funding structure of initiatives and the lack of adjustment of quality metrics, health policy experts do not share this optimism and safety-net providers report concerns and frustration. CONCLUSION Even though disparities are currently not a priority in the PCMH community, the design of initiatives has important implications for disparities.
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Abstract
OBJECTIVE The experiences of RNs and licensed practical nurses (LPNs) implementing a patient-centered medical home (PCMH) in the Department of Veterans Affairs (VA) primary care clinics were examined to understand model implications for nursing practice and professional identity. BACKGROUND National implementation of the PCMH model, called patient-aligned care teams (PACTs) in VA, emphasizes areas of nursing expertise, yet little is known about the effect of medical homes on the day-to-day work of nurses. METHODS As part of a formative evaluation to identify barriers and facilitators to PACT implementation, we interviewed 18 nurses implementing PACT. RESULTS Challenges to nurse's organizational and professional roles were experienced differently by RNs and LPNs in the following areas: (1) diversified modes of care and expanded clinical duties, (2) division of labor among PACT nurses, and (3) interprofessional status in the team. CONCLUSIONS Healthcare managers implementing PCMH should consider its inherent cultural and practice transformations.
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Wu LT, Brady KT, Spratt SE, Dunham AA, Heidenfelder B, Batch BC, Lindblad R, VanVeldhuisen P, Rusincovitch SA, Killeen TK, Ghitza UE. Using electronic health record data for substance use Screening, Brief Intervention, and Referral to Treatment among adults with type 2 diabetes: Design of a National Drug Abuse Treatment Clinical Trials Network study. Contemp Clin Trials 2016; 46:30-38. [PMID: 26563446 PMCID: PMC4695300 DOI: 10.1016/j.cct.2015.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/31/2015] [Accepted: 11/07/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND The Affordable Care Act encourages healthcare systems to integrate behavioral and medical healthcare, as well as to employ electronic health records (EHRs) for health information exchange and quality improvement. Pragmatic research paradigms that employ EHRs in research are needed to produce clinical evidence in real-world medical settings for informing learning healthcare systems. Adults with comorbid diabetes and substance use disorders (SUDs) tend to use costly inpatient treatments; however, there is a lack of empirical data on implementing behavioral healthcare to reduce health risk in adults with high-risk diabetes. Given the complexity of high-risk patients' medical problems and the cost of conducting randomized trials, a feasibility project is warranted to guide practical study designs. METHODS We describe the study design, which explores the feasibility of implementing substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) among adults with high-risk type 2 diabetes mellitus (T2DM) within a home-based primary care setting. Our study includes the development of an integrated EHR datamart to identify eligible patients and collect diabetes healthcare data, and the use of a geographic health information system to understand the social context in patients' communities. Analysis will examine recruitment, proportion of patients receiving brief intervention and/or referrals, substance use, SUD treatment use, diabetes outcomes, and retention. DISCUSSION By capitalizing on an existing T2DM project that uses home-based primary care, our study results will provide timely clinical information to inform the designs and implementation of future SBIRT studies among adults with multiple medical conditions.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
| | - Kathleen T Brady
- South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, Charleston, SC, USA
| | - Susan E Spratt
- Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | - Ashley A Dunham
- Duke Translational Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Brooke Heidenfelder
- Duke Translational Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Bryan C Batch
- Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | | | | | | | - Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Udi E Ghitza
- National Institute on Drug Abuse, Bethesda, MD, USA
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Reciprocal Peer Support for Post-partum Patients with Diabetes: A Needs Assessment for the Diabetes Buddy Program. J Community Health 2015; 41:354-8. [DOI: 10.1007/s10900-015-0103-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fort MP, Castro M, Peña L, López Hernández SH, Arreola Camacho G, Ramírez-Zea M, Martínez H. Opportunities for involving men and families in chronic disease management: a qualitative study from Chiapas, Mexico. BMC Public Health 2015; 15:1019. [PMID: 26438195 PMCID: PMC4595112 DOI: 10.1186/s12889-015-2361-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/28/2015] [Indexed: 12/03/2022] Open
Abstract
Background A healthy lifestyle intervention was implemented in primary care health centers in urban parts of Tuxtla Gutiérrez, Chiapas, Mexico with an aim of reducing cardiovascular disease risk for patients with type 2 diabetes and/or hypertension. During implementation, research questions emerged. Considerably fewer men participated in the intervention than women, and an opportunity was identified to increase the reach of activities aimed at improving disease self-management through strategies involving family members. A qualitative study was conducted to identify strategies to involve men and engage family members in disease management and risk reduction. Methods Nine men with hypertension and/or type 2 diabetes with limited to no participation in disease self-management and health promotion activities, six families in which at least one family member had a diagnosis of one or both conditions, and nine health care providers from four different government health centers were recruited for the study. Participants took part in semi-structured interviews. During interviews with families, genograms and eco-maps were used to diagram family composition and structure, and capture the nature of patients’ relationships to the extended family and community resources. Transcripts were coded and a general inductive analytic approach was used to identify themes related to men’s limited participation in health promotion activities, family support and barriers to disease management, and health care providers’ recommendations. Results Participants reported barriers to men’s participation in chronic disease management and healthy lifestyle education activities that can be grouped into two categories: internal and external factors. Internal factors are those for which they are able to make the decision on their own and external factors are those that are not related solely to their decision to take part or not. Four primary aspects were identified related to families’ relationships with disease: different roles within the family, types of support provided to patients, the opportunity to prevent disease among family members without a diagnosis, and - in some cases - lack of family support or stress-induced by other family members. There was an overlap in recommended strategies for engaging men and family members in chronic disease management activities. Conclusions There is an opportunity to increase the reach of interventions aimed at improving disease self-management by engaging men and family members. The proposed strategies presented by patients, family members, and providers have implications for health education and service provision at primary care health centers and for future research.
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Affiliation(s)
- Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,Department of Family Medicine, University of Colorado - Denver, Denver, CO, USA.
| | - Maricruz Castro
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | - Liz Peña
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | | | - Gabriel Arreola Camacho
- School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | - Manuel Ramírez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala.
| | - Homero Martínez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. .,Hospital Infantil de México, "Dr. Federico Gómez", Mexico City, Mexico.
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Lamb KD, Baker JW, McFarland MS. Implementation of a pharmacotherapy clinic into the patient centered medical home model by a second year pharmacy resident. Am J Health Syst Pharm 2015; 72:S83-9. [DOI: 10.2146/sp150015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Spenceley SM, Sedgwick N, Keenan J. Dementia care in the context of primary care reform: an integrative review. Aging Ment Health 2015; 19:107-20. [PMID: 24901364 DOI: 10.1080/13607863.2014.920301] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this review was to determine the influence of the growing body of evidence about the attributes of high-performing primary care systems on the literature related to the primary care of people living with dementia. METHODS In this integrative review, we examined a broad range of published and grey literature (2000-2013) about the primary care of dementia, using a systematic approach set up in advance of the literature search. The review was guided by two questions: What are the evident models of primary care for dementia? How do the models line up with the other attributes of high-performing primary care? RESULTS Three models were noted: carved-out, co-managed, and integrative-hub, all informed by different assumptions about the role of primary care in dementia. The models varied in alignment with the attributes of high-performing primary care, although we found very little attention to accessibility, relational continuity or comprehensiveness of care. CONCLUSIONS We know what we need to pay attention to in building our primary care system - and no population will put the performance of primary care more to the test over the next two decades than the rapidly growing number of people who will be living with complex chronic conditions like dementia. Recent literature around primary care and dementia shows promise in attending to some of the attributes of high-performing primary care, yet much more work is needed if we are to truly leverage the potential value of primary care in addressing the needs of these complex and numerous future patients.
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Affiliation(s)
- Shannon M Spenceley
- a Faculty of Health Sciences (Nursing) , University of Lethbridge , Alberta , Canada
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Baffert S, Hoang HL, Brédart A, Asselain B, Alran S, Berseneff H, Huchon C, Trichot C, Combes A, Alves K, Koskas M, Nguyen T, Roulot A, Rouzier R, Héquet D. The patient-breast cancer care pathway: how could it be optimized? BMC Cancer 2015; 15:394. [PMID: 25963161 PMCID: PMC4430872 DOI: 10.1186/s12885-015-1417-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 05/05/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND A care pathway is defined as patient-focused global care that addresses temporal (effective and coordinated management throughout the illness) and spatial issues (treatment is provided near the health territory in or around the patient's home). Heterogeneity of the care pathways in breast cancer (BC) is presumed but not well evaluated. The OPTISOINS01 study aims to assess every aspect of the care pathway for early BC patients using a temporal and spatial scope. METHODS/DESIGN An observational, prospective, multicenter study in a regional health territory (Ile-de-France, France) in different types of structures: university or local hospitals and comprehensive cancer centers. We will include and follow during 1 year 1,000 patients. The study consists of 3 work-packages: - Cost of pathway The aim of this WP is to calculate the overall costs of the early BC pathway at 1 year from different perspectives (society, health insurance and patient) using a cost-of-illness analysis. Using a bottom-up method, we will assess direct costs, including medical direct costs and nonmedical direct costs (transportation, home modifications, home care services, and social services), and indirect costs (loss of production). - Patient satisfaction and work reintegration Three questionnaires will assess the patients' satisfaction and possible return to work: the occupational questionnaire for employed women; the questionnaire on the need for supportive care, SCNS-SF34 ('breast cancer' module, SCNS-BR8); and the OUTPASSAT-35 questionnaire. - Quality, coordination and access to innovation Quality will be evaluated based on visits and treatment within a set period, whether the setting offers a multidisciplinary consultative framework, the management by nurse coordinators, the use of a personalized care plan, the provision of information via documents about treatments and the provision of supportive care. The coordination between structures and caregivers will be evaluated at several levels. Day surgery, home hospitalization and one-stop breast clinic visits will be recorded to assess the patient's access to innovation. DISCUSSION The assessment of care pathways encourages the implementation of new payment models. Our approach could help health care professionals and policymakers to establish other cost-of-illness studies and plan the allocation of resources on a patient basis rather than a visit basis.
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Affiliation(s)
- Sandrine Baffert
- Department of Health Economy, Institut Curie, 26 rue d'Ulm, 75005, Paris, France.
| | - Huong Ly Hoang
- Department of Health Economy, Institut Curie, 26 rue d'Ulm, 75005, Paris, France.
| | - Anne Brédart
- Department of Supportive Care, Institut Curie, 26 rue d'Ulm, 75005, Paris, France.
| | - Bernard Asselain
- Department of Biostatistics, Institut Curie, 26 rue d'Ulm, 75005, Paris, France.
| | - Séverine Alran
- Department of Surgical Oncology, Institut Curie, 26 rue d'Ulm, 75005, Paris, France.
| | - Hélène Berseneff
- Department of Gynecology, René Dubos Hospital, 6, avenue de L'Ile de France, 95303, Pontoise, France.
| | - Cyrille Huchon
- Department of Gynecology, Poissy-St Germain hospital, 10 Rue du Champ Gaillard, 78300, Poissy, France.
| | - Caroline Trichot
- Department of Gynecology, Antoine Béclère Hospital, 157 rue de la Porte de Trivaux, 92140, Clamart, France.
| | - Aline Combes
- Department of Gynecology, André Mignot Hospital, 50 rue Berthier, 78000, Versailles, France.
| | - Karine Alves
- Department of Gynecology, Argenteuil Hospital, 69 Rue Lt Colonel Prudhon, 95100, Argenteuil, France.
| | - Martin Koskas
- Department of Gynecology, Bichat Hospital, 46 rue Henri Huchard, 75018, Paris, France.
| | - Thuy Nguyen
- Department of Gynecology, Louis Mourier Hospital, 178 rue des Renouillers, 92700, Colombes, France.
| | - Aurélie Roulot
- Department of Surgical Oncology, Institut Curie-René Huguenin, 35 rue Dailly, 92210, St Cloud, France.
| | - Roman Rouzier
- Department of Surgical Oncology, Institut Curie-René Huguenin, 35 rue Dailly, 92210, St Cloud, France.
- Equipe d'Accueil 7285, Risk and safety in clinical medicine for women and perinatal health, University Versailles-Saint-Quentin, Montigny-le-Bretonneux, France.
| | - Delphine Héquet
- Department of Surgical Oncology, Institut Curie-René Huguenin, 35 rue Dailly, 92210, St Cloud, France.
- Equipe d'Accueil 7285, Risk and safety in clinical medicine for women and perinatal health, University Versailles-Saint-Quentin, Montigny-le-Bretonneux, France.
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Using a facilitation model to achieve patient-centered medical home recognition. Health Care Manag (Frederick) 2015; 34:93-105. [PMID: 25909396 DOI: 10.1097/hcm.0000000000000059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article describes how a facilitation model that included a partnership between a Community Care of North Carolina network and undergraduates at a regional university supported rural primary care practices in transforming their practices to become National Committee for Quality Assurance-recognized patient-centered medical homes. Health care management and preprofessional undergraduate students worked with 14 rural primary care practices to redesign practice processes and complete the patient-centered medical home application. Twelve of the practices participated in the evaluation of the student contribution. A semistructured interview guide containing questions about practice characteristics, student competencies, and the value of the student's contribution to their practice's achievement of patient-centered medical home recognition was used to interview practice managers or their designee. Analysis included item-descriptive statistics and qualitative analysis of narrative content. All 12 participating practices achieved 2011 National Committee for Quality Assurance patient-centered medical home recognition, with 4 practices achieving level 3, 5 practices achieving level 2, and 3 practices achieving level 1. The facilitation model using partnerships between health care agencies and universities might be an option for enhancing a practice's internal capacity for successful transformation and should be explored further.
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Tu SP, Young V, Coombs LJ, Williams R, Kegler M, Kimura A, Risendal B, Friedman DB, Glenn B, Pfeiffer DJ, Fernandez M. Practice adaptive reserve and colorectal cancer screening best practices at community health center clinics in 7 states. Cancer 2015; 121:1241-8. [PMID: 25524651 PMCID: PMC4393345 DOI: 10.1002/cncr.29176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/14/2014] [Accepted: 11/04/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Enhancing the capability of community health centers to implement best practices (BPs) may mitigate health disparities. This study investigated the association of practice adaptive reserve (PAR) with the implementation of patient-centered medical home (PCMH) colorectal cancer (CRC) screening BPs at community health center clinics in 7 states. METHODS A convenience sample of clinic staff participated in a self-administered, online survey. Eight PCMH CRC screening BPs were scored as a composite ranging from 0 to 32. The PAR composite score was scaled from 0 to 1 and then categorized into 3 levels. Multilevel analyses examined the relation between PAR and self-reported implementation of PCMH BPs. RESULTS There were 296 respondents, and 59% reported 6 or more PCMH BPs at their clinics. The mean PAR score was 0.66 (standard deviation, 0.18), and the PCMH BP mean scores were significantly higher for respondents who reported higher clinic PAR categories. In comparison with the lowest PAR level, adjusted PCMH BP means were 25.0% higher at the middle PAR level (difference, 3.2; standard error, 1.3; t = 2.44; P = .015) and 63.2% higher at the highest PAR level (difference, 8.0; standard error, 1.9; t = 4.86; P < .0001). CONCLUSIONS A higher adaptive reserve, as measured by the PAR score, was positively associated with self-reported implementation of PCMH CRC screening BPs by clinic staff. Future research is needed to determine the PAR levels most conducive to implementing CRC screening and to develop interventions that enhance PAR in primary care settings.
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Affiliation(s)
- Shin-Ping Tu
- Virginia Commonwealth University, Department of Medicine, Richmond, VA
- University of Washington, Department of Health Services, Seattle, WA
| | - Vicki Young
- South Carolina Primary Health Care Association, Columbia, SC
| | - Letoynia J. Coombs
- University of Colorado Denver, Department of Family Medicine, Denver, CO
| | - Rebecca Williams
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Michelle Kegler
- Emory University, Department of Behavioral Sciences and Medical Education, Atlanta, GA
| | - Amanda Kimura
- University of Washington, Department of Health Services, Seattle, WA
| | - Betsy Risendal
- University of Colorado Cancer Center, Colorado School of Public Health, Aurora, CO
| | - Daniela B. Friedman
- University of South Carolina, Department of Health Promotion, Education, and Behavior, Columbia, SC
| | - Beth Glenn
- University of California, Center for Cancer Prevention and Control Research, Los Angeles, CA
| | | | - Maria Fernandez
- University of Texas Health Science Center, School of Public Health, Houston, TX
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Goldman RE, Parker DR, Brown J, Walker J, Eaton CB, Borkan JM. Recommendations for a mixed methods approach to evaluating the patient-centered medical home. Ann Fam Med 2015; 13:168-75. [PMID: 25755039 PMCID: PMC4369592 DOI: 10.1370/afm.1765] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 12/16/2014] [Accepted: 01/05/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE There is a strong push in the United States to evaluate whether the patient-centered medical home (PCMH) model produces desired results. The explanatory and contextually based questions of how and why PCMH succeeds in different practice settings are often neglected. We report the development of a comprehensive, mixed qualitative-quantitative evaluation set for researchers, policy makers, and clinician groups. METHODS To develop an evaluation set, the Brown Primary Care Transformation Initiative convened a multidisciplinary group of PCMH experts, reviewed the PCMH literature and evaluation strategies, developed key domains for evaluation, and selected or created methods and measures for inclusion. RESULTS The measures and methods in the evaluation set (survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation, and process evaluation) are meant to be used together. PCMH evaluation must be sufficiently comprehensive to assess and explain both the context of transformation in different primary care practices and the experiences of diverse stakeholders. In addition to commonly assessed patient outcomes, quality, and cost, it is critical to include PCMH components integral to practice culture transformation: patient and family centeredness, authentic patient activation, mutual trust among practice employees and patients, and transparency, joy, and collaboration in delivering and receiving care in a changing environment. CONCLUSIONS This evaluation set offers a comprehensive methodology to enable understanding of how PCMH transformation occurs in different practice settings. This approach can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality, and cost-effective sustainable change among diverse primary care practices.
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Affiliation(s)
- Roberta E Goldman
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Donna R Parker
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joanna Brown
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Judith Walker
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Charles B Eaton
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jeffrey M Borkan
- Department of Family Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Development of a facilitation curriculum to support primary care transformation: the "coach medical home" curriculum. Med Care 2014; 52:S26-32. [PMID: 25310635 DOI: 10.1097/mlr.0000000000000240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In an effort to improve patient care, retain high-quality primary care providers, and control costs, primary care practices across the United States are transforming to patient-centered medical homes. This is no small task. Practice facilitation, also called "coaching," is increasingly being used to support system change; however, there is limited guidance for these programs. OBJECTIVE To develop an evidence-based curriculum to help practice coaches guide broad-scale transformation efforts in primary care. METHODS We gathered evidence about effective practice transformation coaching from 25 published programs and 8 expert interviews. Given limited published information, we drew extensively on our experience as leaders and coaches in the Safety Net Medical Home Initiative. Using these data, and with input from a User Group, we identified 6 curricular topics and created learning objectives and curricular content related to these topics. RESULTS The Coach Medical Home curriculum guides coaches in the following areas: getting started with a practice; recognition and payment; sequencing changes; measurement; learning communities; and sustainability and spread. CONCLUSIONS Coach Medical Home is a publically available web-based curriculum that provides tools, resources, and guidance for practice transformation support programs, including practice facilitators and learning community organizers.
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Associations between medical home characteristics and support for patient activation in the safety net: understanding differences by race, ethnicity, and health status. Med Care 2014; 52:S48-55. [PMID: 25310638 DOI: 10.1097/mlr.0000000000000198] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few studies have evaluated whether the patient-centered medical home (PCMH) supports patient activation and none have evaluated whether support for patient activation differs among racial and ethnic groups or by health status. This is critical because activation is lower on average among minority patients and those in poorer health. OBJECTIVE To assess the association between clinic PCMH characteristics and patient perception of clinic support for patient activation, and whether that association varies by patients' self-reported race/ethnicity or health status. PARTICIPANTS A total of 214 providers/staff and 735 patients in 24 safety net clinics across 5 states. MEASURES Provider/staff surveys produced a 0-100 score for PCMH characteristics. Patient surveys used the patient activation subscale of the Patient Assessment of Chronic Illness Care to produce a 0-100 score for patient perception of clinic support for patient activation. RESULTS Across all patients, we did not find a statistically significant association between PCMH score and clinic support for patient activation. However, among the subgroup of minority patients in fair or poor health, a 10-point higher PCMH score was associated with a 14.5-point (CI, 4.4, 24.5) higher activation score. CONCLUSIONS In a population of safety net patients, higher-rated PCMH characteristics were not associated with patients' perception of clinic support for activation among the full study population; however, we found a strong association between PCMH characteristics and clinic support for activation among minority patients in poor/fair health status. The PCMH may be promising for reducing disparities in patient activation for ill minority patients.
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Abstract
BACKGROUND Although coordinating care is a defining characteristic of primary care, evidence suggests that both patients and providers perceive failures in communication and care when care is received from multiple sources. OBJECTIVES To examine the utility of a newly developed Care Coordination Model in improving care coordination among participating practices in the Safety Net Medical Home Initiative (SNMHI). RESEARCH DESIGN In this paper, we used correlation analysis to evaluate whether application of the elements of the Care Coordination Model by SNMHI sites, as measured by the Key Activities Checklist (KAC), was associated with more effective care coordination as measured by another instrument, the PCMH-A. MEASURES SNMHI measures are practice self-assessments based on the 8 change concepts that define a PCMH, one of which is Care Coordination. For this study, we correlated 12 KAC items that describe activities felt to improve coordination of care with 5 PCMH-A items that indicate the extent to which a practice has developed the capability to effectively coordinate care. Practice staff indicated whether any of the KAC activities were being test, implemented, sustained, or not on 4 occasions. RESULTS The Care Coordination Model elements-assume accountability, build relationships with care partners, support patients through the referral or transition process, and create connections to support information exchange-were positively correlated with some PCMH-A care coordination items but not others. Activities related to the model were most strongly correlated with following up patients seen in the Emergency Department or discharged from hospital. CONCLUSIONS The analysis provides suggestive evidence that activities consistent with the 4 elements of the Care Coordination Model may enable safety net primary care to better coordinate care for its patients, but further study is clearly needed.
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Abstract
BACKGROUND Transformation of primary care to patient-centered medical homes (PCMH) is challenging. Progress in transformation varied widely among practices involved in the Safety Net Medical Home Initiative. OBJECTIVE To study 3 successful practices to identify common characteristics and approaches. RESEARCH DESIGN We selected 3 diverse practices based on their improvement on the PCMH-A, a self-assessment instrument measuring progress toward becoming a PCMH. We interviewed 2-3 leaders from the each of 3 practices seeking information about their motivations for transforming, the methods used to make changes, and challenges and facilitators. Interview data were coded, themes developed, and conclusions drawn using qualitative research methods. RESULTS For these successful practices, the major motivators were a desire to improve quality of care, patient experience, or provider experience. Financial incentives played a minor role. All practices had engaged, visible leaders driving change, and all ultimately developed an effective quality improvement/practice change strategy that included the provision of trusted performance data at the provider level and an explicit process change strategy. Sequencing the work of PCMH transformation was important, and developing defined provider patient panels and building effective clinical teams facilitated making improvements to access and care delivery. CONCLUSIONS Practice transformation is disruptive. To be successful, organizations need to have the will or motivation to change, explicit ideas or models on which to base change, and a culture and infrastructure that enables the execution of system changes.
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Grace SM, Rich J, Chin W, Rodriguez HP. Fidelity of implementation to a care team redesign and improved outcomes of diabetes care. Int J Qual Health Care 2014; 27:60-6. [PMID: 25431469 DOI: 10.1093/intqhc/mzu088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We assessed fidelity of implementation (FOI) to the intended features of a primary care team redesign that integrated registered nurse care managers and patient health coaches onto existing care teams. The relation of FOI ranking and improvements in intermediate outcomes of diabetes care was examined. DESIGN We assessed FOI by interviewing frontline primary care team members (n = 20). We explored the relation of FOI and outcomes of diabetes care (n = 10 206 patients) over a 3-year period (2010-12). Multilevel, multivariate regression estimated the relation of FOI and improvements in outcomes of diabetes care. SETTING Five primary care practices in greater Los Angeles, CA, USA. PARTICIPANTS Ten thousand, two hundred and six adult patients with diabetes; 20 frontline primary care clinicians and staff. MAIN OUTCOME MEASURES Blood pressure, hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) control among adult diabetic patients. RESULTS All practices improved diabetic patients' LDL-C control over time. In adjusted analyses, the practice with the highest FOI achieved the largest improvement in blood pressure and HbA1c control among diabetic patients. In contrast, the practice with the lowest FOI had the least improvements in blood pressure, HbA1c and LDL-C control. FOI was an inconsistent predictor of intermediate outcomes of diabetes care for other practices. CONCLUSIONS FOI assessment can be useful for identifying low FOI to a redesign so that technical assistance and resources can be provided to improve team functioning and patient outcomes. High FOI can enable greater improvements in patient outcomes in the context of primary care practice redesign.
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Affiliation(s)
- Sherry M Grace
- Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E Young Drive South, Los Angeles, CA 90095, USA
| | - Jeremy Rich
- HealthCare Partners Institute for Applied Research and Education, 19191 South Vermont Avenue, Suite 200, Torrance, CA 90502, USA
| | - William Chin
- HealthCare Partners Medial Group and Affiliated Physicians, 19191 South Vermont Avenue, Suite 200, Torrance, CA 90502, USA
| | - Hector P Rodriguez
- Division of Health Policy and Management, University of California, Berkeley School of Public Health, 50 University Hall, Room 245, Berkeley, CA 94720, USA
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Collaborative interaction points in post-discharge stroke care. Int J Integr Care 2014; 14:e032. [PMID: 25414623 PMCID: PMC4238053 DOI: 10.5334/ijic.1549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 10/10/2014] [Accepted: 10/20/2014] [Indexed: 11/22/2022] Open
Abstract
Introduction Lack of appropriate electronic tools for supporting patient involvement and
collaboration with care professionals is a problem in health care. Methods Care and rehabilitation processes of post-discharge stroke patients were analysed
using the concept of interaction points where patients, next-of-kin and care
professionals interact and exchange information. Thirteen interviews with care
professionals and five non-participatory observations were performed. Data were
analysed using content analysis and modelling of interaction points in the patient
journey. Results Patient participation and interaction patterns vary; patients requiring home care
have a passive role and next-of-kin or nurses become advocates by coordinating
care on behalf of the patient, whereas patients who are able to visit primary care
coordinate their own care by initiating interactions. Important categories of
participation include the following: participation in care planning, in monitoring
risk factors and in rehabilitation planning. Conclusions Designing a supportive electronic tool requires understanding the interactions and
patients’ activity levels at each interaction point. A tool for patients
with higher activity level should support them to coordinate their own care,
whereas for a less-active patient group, the tool could focus on supporting
next-of-kin and care professionals in motivating, guiding and including passive
patients in their care and rehabilitation processes.
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Helfrich CD, Dolan ED, Fihn SD, Rodriguez HP, Meredith LS, Rosland AM, Lempa M, Wakefield BJ, Joos S, Lawler LH, Harvey HB, Stark R, Schectman G, Nelson KM. Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2014; 2:238-44. [PMID: 26250630 DOI: 10.1016/j.hjdsi.2014.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 08/22/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. MATERIAL AND METHODS We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. RESULTS 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001). CONCLUSIONS Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. IMPLICATIONS Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.
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Affiliation(s)
- Christian D Helfrich
- VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA; Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
| | - Emily D Dolan
- VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA
| | - Stephan D Fihn
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA, USA
| | - Hector P Rodriguez
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, CA, USA
| | - Lisa S Meredith
- RAND Corporation, Santa Monica, CA, USA; Veterans Health Administration Health Services Research & Development Center of Excellence, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Ann-Marie Rosland
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA; University of Michigan Medical School, Department of Internal Medicine, USA
| | - Michele Lempa
- Philadelphia VA Medical Center, US Department of Veterans Affairs, Philadelphia, PA, USA
| | - Bonnie J Wakefield
- VA Iowa City Health Services Research & Development Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, IA, USA
| | - Sandra Joos
- Portland VA Medical Center, VISN 20 PACT Demonstration Laboratory, US Department of Veterans Affairs, Portland, OR, USA
| | - Lauren H Lawler
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | - Henry B Harvey
- Office of Analytics and Business Intelligence, US Department of Veterans Affairs, Seattle, WA, USA
| | - Richard Stark
- VA Office of Clinical Operations, Washington, DC, USA
| | | | - Karin M Nelson
- VA Center of Innovation for Veteran-Centered and Value-Driven Care, US Department of Veterans Affairs, Seattle, WA, USA
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Rumball-Smith J, Wodchis WP, Koné A, Kenealy T, Barnsley J, Ashton T. Under the same roof: co-location of practitioners within primary care is associated with specialized chronic care management. BMC FAMILY PRACTICE 2014; 15:149. [PMID: 25183554 PMCID: PMC4171578 DOI: 10.1186/1471-2296-15-149] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/13/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND International and national bodies promote interdisciplinary care in the management of people with chronic conditions. We examine one facilitative factor in this team-based approach - the co-location of non-physician disciplines within the primary care practice. METHODS We used survey data from 330 General Practices in Ontario, Canada and New Zealand, as a part of a multinational study using The Quality and Costs of Primary Care in Europe (QUALICOPC) surveys. Logistic and linear multivariable regression models were employed to examine the association between the number of disciplines working within the practice, and the capacity of the practice to offer specialized and preventive care for patients with chronic conditions. RESULTS We found that as the number of non-physicians increased, so did the availability of special sessions/clinics for patients with diabetes (odds ratio 1.43, 1.25-1.65), hypertension (1.20, 1.03-1.39), and the elderly (1.22, 1.05-1.42). Co-location was also associated with the provision of disease management programs for chronic obstructive pulmonary disease, diabetes, and asthma; the equipment available in the centre; and the extent of nursing services. CONCLUSIONS The care of people with chronic disease is the 'challenge of the century'. Co-location of practitioners may improve access to services and equipment that aid chronic disease management.
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Affiliation(s)
- Juliet Rumball-Smith
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St, Suite 425, Toronto, ON M5T 3M6, Canada.
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