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Miller-Rosales C, Lewis VA, Shortell SM, Rodriguez HP. Adoption of Patient Engagement Strategies by Physician Practices in the United States. Med Care 2022; 60:691-699. [PMID: 35833416 PMCID: PMC9378564 DOI: 10.1097/mlr.0000000000001748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally. METHODS We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region. RESULTS We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies. CONCLUSIONS This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.
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Affiliation(s)
| | - Valerie A Lewis
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen M Shortell
- Division of Health Policy and Management, University of California, Berkeley, School of Public Health, Berkeley, CA
| | - Hector P Rodriguez
- Division of Health Policy and Management, University of California, Berkeley, School of Public Health, Berkeley, CA
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Barath D, Amaize A, Chen J. Accountable Care Organizations and Preventable Hospitalizations Among Patients With Depression. Am J Prev Med 2020; 59:e1-e10. [PMID: 32334954 PMCID: PMC7458155 DOI: 10.1016/j.amepre.2020.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Accountable care organizations have been successful in improving quality of care, but little is known about who is benefiting from accountable care organizations and through what mechanism. This study examined variation of potentially preventable hospitalizations for chronic conditions with coexisting depression in adults by hospital accountable care organization affiliation and care coordination strategies by race/ethnicity. METHODS Data files of 11 states from 2015 State Inpatient Databases were used to identify potentially preventable hospitalizations for chronic conditions with coexisting depression by race/ethnicity; the 2015 American Hospital Association's Annual Survey was used to identify hospital accountable care organization affiliation; and American Hospital Association's Survey of Care Systems and Payment (collected from January to August 2016) was used to identify hospital Accountable care organizations affiliation and hospital-based care coordination strategies, such as telephonic outreach, and chronic care management. In 2019, multiple logistic regressions was used to test the probability of potentially preventable hospitalization by accountable care organization affiliation and race/ethnicity. The test was repeated on a subsample analysis of accountable care organization-affiliated hospitals by care coordination strategy. RESULTS Preventable hospitalizations were significantly lower among accountable care organization-affiliated hospitals than accountable care organization-unaffiliated hospitals. Lower preventable hospitalization rates were observed among white, African American, Native American, and Hispanic patients. Effective care coordination strategies varied by patients' race. Results also showed variation of the adoption of specific care coordination strategies among accountable care organization-affiliated hospitals. Analysis further indicated effective care coordination strategies varied by patients' race. CONCLUSIONS Accountable care organizations and specifically designed care coordination strategies can potentially improve preventable hospitalization rates and racial disparities among patients with depression. Findings support the integration of mental and physical health services and provide insights for Centers for Medicare and Medicaid Services risk adjustment efforts across race/ethnicity and socioeconomic status.
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Affiliation(s)
- Deanna Barath
- Department of Health Policy and Management, University of Maryland, College Park, Maryland.
| | - Aitalohi Amaize
- Department of Health Policy and Management, University of Maryland, College Park, Maryland
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland, College Park, Maryland
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3
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Strategies for Delivering Value-Based Care: Do Care Management Practices Improve Hospital Performance? J Healthc Manag 2019; 64:430-444. [PMID: 31725571 DOI: 10.1097/jhm-d-18-00049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
EXECUTIVE SUMMARY Value-based payment has the potential to rein in the volume incentive inherent in fee-for-service payment by holding providers accountable for the quality of patient care they deliver. Success under the new payment structure will depend on how effectively key organizational reforms are embraced by providers in the implementation of quality improvement processes for care delivery. This study examined the relationship between implementation of care management processes (CMPs, the specific tactics that enable the practice of value-based care) and hospital performance under value-based payment. Using the American Hospital Association's Survey of Care Systems and Payment and the Centers for Medicare & Medicaid Services' Hospital Compare, we estimated the relationship between hospital implementation of CMPs and performance as it relates to spending, patient satisfaction, readmission reduction, value-based purchasing, and clinical care outcomes. We found that hospitals increased implementation of CMPs from 2013 to 2014, which has led to modest changes in performance. We concluded that care coordination is associated with greater improvements in hospital performance. However, the long-term effects of resulting changes in care delivery may differ from the short-term effects. Thus, study findings underscore the importance of continued evaluation of care management practice as a strategy for optimizing delivery of high-quality, efficient patient care.
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Martsolf GR, Ashwood S, Friedberg MW, Rodriguez HP. Linking Structural Capabilities and Workplace Climate in Community Health Centers. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 55:46958018794542. [PMID: 30168364 PMCID: PMC6120169 DOI: 10.1177/0046958018794542] [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] [Indexed: 11/26/2022]
Abstract
Many strategies to improve health care quality focus on improving the structural capabilities of primary care practices, including quality infrastructure and registry use, which are critical to managing chronic diseases. However, improving structural capabilities requires practices to expend significant resources and can be especially disruptive to community health centers (CHCs) serving high proportions of socioeconomically vulnerable patients. We explore the relationship between the structural capabilities and workplace climate in CHCs. The final sample for this analysis includes 25 CHC sites that could be matched across CHC site director surveys of structural capabilities and CHC adult primary care clinicians and staff (n = 446). To estimate the association between structural capabilities and dimensions of workplace climate, we estimated multivariate linear regression models that included the climate scales as dependent variables and the 5 structural capability scales as the main independent variables, with the 3 clinic-level and 2 staff-level covariates. More manageable clinic workload was associated with lower electronic record functionality (β = −0.47, P = .007), but positively associated with quality infrastructure (β = 0.92, P = .007). Staff relationships and quality improvement orientation were positively associated with quality infrastructure (β = 1.09, P = .006 and β = 0.87, P = .005). Manager readiness was associated with more robust quality infrastructure (β = 1.35, P = .016), but lower electronic record functionality (β = −0.48, P = .015) and less proactive patient outreach (β = −1.32, P = .025). Complex relationships between structural capabilities and workplace climate were found in CHCs. Further clarification of these complex connections may enable policy makers and practitioners to design and implement nuanced strategies to improve quality of care in CHCs.
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Affiliation(s)
- Grant R Martsolf
- 1 University of Pittsburgh, PA, USA.,2 RAND Corporation, Pittsburgh, PA, USA
| | | | - Mark W Friedberg
- 2 RAND Corporation, Pittsburgh, PA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND The effectiveness of community clinics and health centers' efforts to improve the quality of care might be modified by clinics' workplace climates. Several surveys to measure workplace climate exist, but their relationships to each other and to distinguishable dimensions of workplace climate are unknown. OBJECTIVE To assess the psychometric properties of a survey instrument combining items from several existing surveys of workplace climate and to generate a shorter instrument for future use. MATERIALS AND METHODS We fielded a 106-item survey, which included items from 9 existing instruments, to all clinicians and staff members (n=781) working in 30 California community clinics and health centers, receiving 628 responses (80% response rate). We performed exploratory factor analysis of survey responses, followed by confirmatory factor analysis of 200 reserved survey responses. We generated a new, shorter survey instrument of items with strong factor loadings. RESULTS Six factors, including 44 survey items, emerged from the exploratory analysis. Two factors (Clinic Workload and Teamwork) were independent from the others. The remaining 4 factors (staff relationships, quality improvement orientation, managerial readiness for change, and staff readiness for change) were highly correlated, indicating that these represented dimensions of a higher-order factor we called "Clinic Functionality." This 2-level, 6-factor model fit the data well in the exploratory and confirmatory samples. For all but 1 factor, fewer than 20 survey responses were needed to achieve clinic-level reliability >0.7. CONCLUSIONS Survey instruments designed to measure workplace climate have substantial overlap. The relatively parsimonious item set we identified might help target and tailor clinics' quality improvement efforts.
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Contributions of relational coordination to care management in accountable care organizations: Views of managerial and clinical leaders. Health Care Manage Rev 2016; 41:88-100. [PMID: 25978003 DOI: 10.1097/hmr.0000000000000064] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The accountable care organization (ACO) is a new type of health care organization incentivized to improve quality of care, improve population health, and reduce the cost of care. An ACO's success in meeting these objectives depends greatly upon its ability to improve patient care management. Numerous studies have found relational coordination to be positively associated with key measures of organizational performance in health care organizations, including quality and efficiency. PURPOSE The purpose of this paper is twofold: (a) identify the extent to which ACO leaders are aware of the dimensions of relational coordination, and (b) identify the ways these leaders believe the dimensions influenced care management practices in their organization. METHODOLOGY/APPROACH We performed content analysis of interviews with managerial and clinical leaders from a diverse group of 11 ACOs to assess awareness of relational coordination and identify the ways that dimensions of relational coordination were perceived to influence development of care management practices. FINDINGS ACO leaders mentioned four relational coordination dimensions: shared goals, frequency of communication, timeliness of communication, and problem solving communication. Three dimensions - shared knowledge of team members' tasks, mutual respect, and accuracy of communication - were not mentioned. Our analysis identified numerous ways leaders believed the four mentioned dimensions contributed to the development of care management, including contributions to standardization of care, patient engagement, coordination of care, and care planning. DISCUSSION We propose two hypotheses for future research on relational coordination and care management. PRACTICE IMPLICATIONS If relational coordination is to have a beneficial influence on ACO performance, organizational leaders must become more aware of relational coordination and its various dimensions and become cognizant of relational coordination's influence on care management in their ACO. We suggest a number of means by which ACO leaders could become more aware of relational coordination and its potential effects.
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Abstract
Amid growing focus on individual physician performance, it is timely to examine what evidence exists that physicians can be facilitators and leaders for health care quality improvement in their local health care environments. Despite the importance of governmental policy and national initiatives, change in health care quality must occur in the context of local communities. Therefore, individual physician involvement, working with other local health care leaders and providers, will be crucial to future quality improvement. The objectives of this article are as follows: (1) outline why physicians must be involved in quality improvement, (2) delineate the barriers and facilitators to physician involvement, and (3) discuss how medical certification boards can facilitate greater physician involvement in quality improvement.
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Affiliation(s)
- Eric S Holmboe
- American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106, USA.
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Hussain T, Allen A, Halbert J, Anderson CAM, Boonyasai RT, Cooper LA. Provider perspectives on essential functions for care management in the collaborative treatment of hypertension: the P.A.R.T.N.E.R. framework. J Gen Intern Med 2015; 30:454-61. [PMID: 25515136 PMCID: PMC4370995 DOI: 10.1007/s11606-014-3130-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 08/13/2014] [Accepted: 11/07/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Care management has become a widespread strategy for improving chronic illness care. However, primary care provider (PCP) participation in programs has been poor. Because the success of care management relies on provider engagement, understanding provider perspectives is necessary. OBJECTIVE Our goal was to identify care management functions most valuable to PCPs in hypertension treatment. DESIGN Six focus groups were conducted to discuss current challenges in hypertension care and identify specific functions of care management that would improve care. PARTICIPANTS The study included 39 PCPs (participation rate: 83 %) representing six clinics, two of which care for large African American populations and four that are in underserved locations, in the greater Baltimore metropolitan area. APPROACH This was a qualitative analysis of focus groups, using grounded theory and iterative coding. KEY RESULTS Providers desired achieving blood pressure control more rapidly. Collaborating with care managers who obtain ongoing patient data would allow treatment plans to be tailored to the changing life conditions of patients. The P.A.R.T.N.E.R. framework summarizes the care management functions that providers reported were necessary for effective collaboration: Partner with patients, providers, and the community; Arrange follow-up care; Resolve barriers to adherence; Track treatment response and progress; Navigate the health care system with patients; Educate patients & Engage patients in self-management; Relay information between patients and/or provider(s). CONCLUSIONS The P.A.R.T.N.E.R. framework is the first to offer a checklist of care management functions that may promote successful collaboration with PCPs. Future research should examine the validity of this framework in various settings and for diverse patient populations affected by chronic diseases.
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Affiliation(s)
- Tanvir Hussain
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 2024 E. Monument St. Room 2-604C, Baltimore, MD, 21287, USA,
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Shanahan CW, Sorensen-Alawad A, Carney BL, Persand I, Cruz A, Botticelli M, Pressman K, Adams WG, Brolin M, Alford DP. The implementation of an integrated information system for substance use screening in general medical settings. Appl Clin Inform 2015; 5:878-94. [PMID: 25589904 DOI: 10.4338/aci-2014-03-ra-0025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 09/28/2014] [Indexed: 11/23/2022] Open
Abstract
UNLABELLED The Massachusetts Screening, Brief Intervention and Referral to Treatment (MASBIRT) Program, a substance use screening program in general medical settings, created a web-based, point-of-care (POC), application--the MASBIRT Portal (the "Portal") to meet program goals. OBJECTIVES We report on development and implementation of the Portal. METHODS Five year program process outcomes recorded by an independent evaluator and an anonymous survey of Health Educator's (HEs) adoption, perceptions and Portal use with a modified version of the Technology Readiness Index are described. [8] Specific management team members, selected based on their roles in program leadership, development and implementation of the Portal and supervision of HEs, participated in semi-structured, qualitative interviews. RESULTS At the conclusion of the program 73% (24/33) of the HEs completed a survey on their experience using the Portal. HEs reported that the Portal made recording screening information easy (96%); improved planning their workday (83%); facilitated POC data collection (84%); decreased time dedicated to data entry (100%); and improved job satisfaction (59%). The top two barriers to use were "no or limited wireless connectivity" (46%) and "the tablet was too heavy/bulky to carry" (29%). Qualitative management team interviews identified strategies for successful HIT implementation: importance of engaging HEs in outlining specifications and workflow needs, collaborative testing prior to implementation and clear agreement on data collection purpose, quality requirements and staff roles. DISCUSSION Overall, HEs perceived the Portal favorably with regard to time saving ability and improved workflow. Lessons learned included identifying core requirements early during system development and need for managers to institute and enforce consistent behavioral work norms. CONCLUSION Barriers and HEs' views of technology impacted the utilization of the MASBIRT Portal. Further research is needed to determine best approaches for HIT system implementation in general medical settings.
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Affiliation(s)
- C W Shanahan
- Boston University School of Medicine , Boston, MA ; Boston Medical Center , Boston, MA
| | | | | | | | - A Cruz
- Boston Medical Center , Boston, MA
| | - M Botticelli
- Massachusetts Department of Public Health , Boston, MA
| | - K Pressman
- Massachusetts Department of Public Health , Boston, MA
| | - W G Adams
- Boston University School of Medicine , Boston, MA ; Boston Medical Center , Boston, MA
| | - M Brolin
- Brandeis University , Waltham, MA
| | - D P Alford
- Boston University School of Medicine , Boston, MA ; Boston Medical Center , Boston, MA
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10
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The Design and Acceleration of Healthcare Reform/ACOs: The Fairview Medical Group Case. ACTA ACUST UNITED AC 2014. [DOI: 10.1108/s2045-060520140000004006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Meropol SB, Schiltz NK, Sattar A, Stange KC, Nevar AH, Davey C, Ferretti GA, Howell DE, Strosaker R, Vavrek P, Bader S, Ruhe MC, Cuttler L. Practice-tailored facilitation to improve pediatric preventive care delivery: a randomized trial. Pediatrics 2014; 133:e1664-75. [PMID: 24799539 PMCID: PMC4035588 DOI: 10.1542/peds.2013-1578] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services. METHODS In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods. RESULTS Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need. CONCLUSIONS Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.
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Affiliation(s)
- Sharon B. Meropol
- Departments of Pediatrics,,Epidemiology and Biostatistics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Nicholas K. Schiltz
- Epidemiology and Biostatistics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Kurt C. Stange
- Epidemiology and Biostatistics,,Family Medicine and Community Health,,Oncology,,Sociology
| | - Ann H. Nevar
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Christina Davey
- Departments of Pediatrics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Diana E. Howell
- Departments of Pediatrics,,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Pamela Vavrek
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Samantha Bader
- The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Leona Cuttler
- Departments of Pediatrics,,Bioethics, Case Western Reserve University, Cleveland, Ohio; and,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
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Zallman L, Bearse A, Neal N, VanDeusen Lukas C, Hacker K. Strategies for Aligning Physicians to System Redesign Goals at Eight Safety-Net Systems. Jt Comm J Qual Patient Saf 2014; 40:541-3. [PMID: 26111379 DOI: 10.1016/s1553-7250(14)40070-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Facing recent economic and regulatory pressures, safety-net systems (SNSs) are redesigning their organizations to improve care delivery, remain financially viable, and maintain competitive positions. Aligning physicians with redesign goals is a priority, particularly as many SNSs shift toward patient-centered, population health-focused models. No previous work has examined efforts to align physicians to safety net redesign efforts. METHODS This qualitative study, conducted at eight SNSs, examined challenges faced in a changing health care environment, as well as strategies and resources to address them. RESULTS Strategies clustered in two categories: physician role definition and organizational infrastructure. Physician role definition strategies were (1) changing payment and employment arrangements, (2) changing clinical roles, (3) increasing physician involvement in quality improvement, and (4) strengthening physician leadership in clinical and quality roles. Organizational infrastructure strategies were (1) ensuring medical center leadership support and integration, (2) utilizing data to drive physician behavior, and (3) addressing competing allegiances with academia. All sites reported multifaceted approaches but differed in specific strategies employed, facilitators noted, and challenges encountered. DISCUSSION The findings highlight the need to implement multiple strategies to align physicians in redesign efforts. They suggest that all health systems, whether SNSs or not, can capitalize on qualities of physicians and existing infrastructural and leadership elements to achieve physician alignment. However, they must contend with and address challenges of competing allegiance (for example, academic, physician organization, hospital), as well as resistance to changing clinical roles and payment structures.
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Affiliation(s)
- Leah Zallman
- Institute for Community Health, Cambridge, Massachusetts, USA
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Savarimuthu SM, Jensen AE, Schoenthaler A, Dembitzer A, Tenner C, Gillespie C, Schwartz MD, Sherman SE. Developing a toolkit for panel management: improving hypertension and smoking cessation outcomes in primary care at the VA. BMC FAMILY PRACTICE 2013; 14:176. [PMID: 24261337 PMCID: PMC3840588 DOI: 10.1186/1471-2296-14-176] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/14/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension. METHODS We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team. RESULTS Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas - continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs. CONCLUSIONS Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions. TRIAL REGISTRATION ClinicalTrials.gov, NCT01677533.
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Affiliation(s)
- Stella M Savarimuthu
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Ashley E Jensen
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | | | - Anne Dembitzer
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Craig Tenner
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Colleen Gillespie
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Mark D Schwartz
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Scott E Sherman
- VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA
- New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
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Meehan TP, Meehan TP, Kelvey-Albert M, Van Hoof TJ, Ruth S, Petrillo MK. The Path to Quality in Outpatient Practice: Meaningful Use, Patient-Centered Medical Homes, Financial Incentives, and Technical Assistance. Am J Med Qual 2013; 29:284-91. [PMID: 24006030 DOI: 10.1177/1062860613500334] [Citation(s) in RCA: 3] [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
Adoption and meaningful use of electronic health records is considered an essential step to improve the quality of health care. The authors assessed whether a series of Connecticut primary care providers who achieved Stage I Meaningful Use of electronic health records used quality improvement strategies that are associated with improvements in care. Practice structural characteristics, quality improvement-related electronic health record processes, outcomes, and barriers were assessed in 14 primary care practices. Implementation of quality improvement-related electronic health record processes was variable and barriers were common. Only 4 practices used data consistently to assess their performance, and only 3 reported improvements in care. Practices that were patient-centered medical homes scored higher on all quality improvement domains and received financial rewards more commonly. These findings suggest that primary care quality may be improved by formal alignment of Meaningful Use and Patient-Centered Medical Home criteria and by ongoing technical assistance to practices.
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Affiliation(s)
- Thomas P Meehan
- Qualidigm, Wethersfield, CT Yale University School of Medicine, New Haven, CT
| | | | | | - Thomas J Van Hoof
- Qualidigm, Wethersfield, CT University of Connecticut School of Nursing, Storrs, CT University of Connecticut School of Medicine, Farmington, CT
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Hashim MJ, Prinsloo A, Mirza DM. Quality improvement tools for chronic disease care--more effective processes are less likely to be implemented in developing countries. Int J Health Care Qual Assur 2013; 26:14-9. [PMID: 23534102 DOI: 10.1108/09526861311288604] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Chronic disease services may be improved if care management processes (CMPs), such as disease-specific flowsheets and chronic disease registries, are used. The newly industrialized Gulf state health service has underdeveloped primary care but higher diabetes prevalence. This paper's aim is to investigate care management processes in United Arab Emirates (UAE) primary care clinics to explore these issues. DESIGN/METHODOLOGY/APPROACH A cross-sectional survey using self-administered questionnaires given to family physicians and nurses attending a UAE University workshop was used to collect data. FINDINGS All 38 participants completed the questionnaire: 68 per cent were women and 81 per cent physicians. Care management processes in use included: medical records, 76 per cent; clinical guidelines, 74 per cent; chronic disease care rooms, 74 per cent; disease-specific flowsheets, 61 per cent; medical record audits, 57 per cent; chronic disease nurse-educators, 58 per cent; electronic medical records (EMR), 34 per cent; and incentive plans based on clinical performance, 21 per cent. Only 62 per cent and 48 per cent reported that flowsheets and problem lists, respectively, were completed by physicians. Responses to the open-ended question included using traditional quality improvement (QI) approaches such as continuing education and staff meetings, but not proactive systems such as disease registries and self-management. RESEARCH LIMITATIONS/IMPLICATIONS The study used a small, non-random sample and the survey instrument's psychometric properties were not collected. PRACTICAL IMPLICATIONS Chronic disease care CMPs are present in UAE clinics but use is limited. Quality improvement should include disease registries, reminder-tracking systems, patient self-management support and quality incentives. ORIGINALITY/VALUE This report highlights the lag regarding adopting more effective CMPs in developing countries.
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Mechanic R, Zinner DE. Many large medical groups will need to acquire new skills and tools to be ready for payment reform. Health Aff (Millwood) 2013; 31:1984-92. [PMID: 22949447 DOI: 10.1377/hlthaff.2012.0127] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Federal and state policy makers are now experimenting with programs that hold health systems accountable for delivering care under predetermined budgets to help control health care spending. To assess how well prepared medical groups are to participate in these arrangements, we surveyed twenty-one large, multispecialty groups. We evaluated their participation in risk contracts such as capitation and the degree of operational support associated with these arrangements. On average, about 25 percent of the surveyed groups' patient care revenue stemmed from global capitation contracts and 9 percent from partial capitation or shared risk contracts. Groups with a larger share of revenue from risk contracts were more likely than others to have salaried physicians, advanced data management capabilities, preferred relationships with efficient specialists, and formal programs to coordinate care for high-risk patients. Our findings suggest that medical groups that lack risk contracting experience may need to develop new competencies and infrastructure to successfully navigate federal payment reform programs, including information systems that track performance and support clinicians in delivering good care; physician-level reward systems that are aligned with organizational goals; sound physician leadership; and an organizational commitment to supporting performance improvement. The difficulty of implementing these changes in complex health care organizations should not be underestimated.
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Affiliation(s)
- Robert Mechanic
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA.
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Roberts RG, Gask L, Arndt B, Bower P, Dunbar J, van der Feltz-Cornelis CM, Gunn J, Anderson MIP. Depression and diabetes: the role and impact of models of health care systems. J Affect Disord 2012; 142 Suppl:S80-8. [PMID: 23062862 DOI: 10.1016/s0165-0327(12)70012-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Depression and diabetes often occur together and their comorbidity has a significant and detrimental impact on health outcomes. The aims of this paper are to review the existing international literature on approaches to health care for comorbid depression and diabetes and draw out the key conclusions for both research and future development in health care delivery. METHODS Narrative review of the literature with synthesis by an international team of authors. RESULTS The synthesized findings are discussed under four main headings: specialty and generalist care; models for co-ordinating and integrating care; community approaches to service delivery; and the role of health policy. LIMITATIONS The review only included literature published in English. CONCLUSIONS Translating basic and clinical research findings into improved treatment and outcomes of those with depression and diabetes remains a substantial challenge. There is little research on the difficulties of identifying and implementing best practice into routine health care. Systems need to be designed so that evidence-based interventions are provided in a timely way, with appropriate professional expertise where required.
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Affiliation(s)
- Richard G Roberts
- University of Wisconsin School of Medicine & Public Health, Madison, WI 53715, USA
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Van Hoof TJ, Bisognano M, Reinertsen JL, Meehan TP. Leading quality improvement in primary care: recommendations for success. Am J Med 2012; 125:869-72. [PMID: 22800874 DOI: 10.1016/j.amjmed.2012.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 02/13/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
Leadership is increasingly recognized as a potential factor in the success of primary care quality improvement efforts, yet little is definitively known about which specific leadership behaviors are most important. Until more research is available, the authors suggest that primary care clinicians who are committed to developing their leadership skills should commit to a series of actions. These actions include embracing a theory of leadership, modeling the approach for others, focusing on the goal of improving patient outcomes, encouraging teamwork, utilizing available sources of power, and reflecting on one's approach in order to improve it. Primary care clinicians who commit themselves to such actions will be more effective leaders and will be more prepared as new research becomes available on this important factor.
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Baxter L, Nash DB. Implementing the Patient-Centered Medical Home Model for Chronic Disease Care in Small Medical Practices. Am J Med Qual 2012; 28:113-9. [DOI: 10.1177/1062860612454451] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - David B. Nash
- Jefferson School of Population Health, Philadelphia, PA
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Lauvergeon S, Burnand B, Peytremann-Bridevaux I. Chronic disease management: a qualitative study investigating the barriers, facilitators and incentives perceived by Swiss healthcare stakeholders. BMC Health Serv Res 2012; 12:176. [PMID: 22726820 PMCID: PMC3483191 DOI: 10.1186/1472-6963-12-176] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 06/22/2012] [Indexed: 11/22/2022] Open
Abstract
Background Chronic disease management has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. While Switzerland faces the same challenge, such initiatives have only emerged recently in this country. The aim of this study is to assess their feasibility, in terms of barriers, facilitators and incentives to participation. Methods To meet our aim, we used qualitative methods involving the collection of opinions of various healthcare stakeholders, by means of 5 focus groups and 33 individual interviews. All the data were recorded and transcribed verbatim. Thematic analysis was then performed and five levels were determined to categorize the data: political, financial, organisational/ structural, professionals and patients. Results Our results show that, at each level, stakeholders share common opinions towards the feasibility of chronic disease management in Switzerland. They mainly mention barriers linked to the federalist political organization as well as to financing such programs. They also envision difficulties to motivate both patients and healthcare professionals to participate. Nevertheless, their favourable attitudes towards chronic disease management as well as the fact that they are convinced that Switzerland possesses all the resources (financial, structural and human) to develop such programs constitute important facilitators. The implementation of quality and financial incentives could also foster the participation of the actors. Conclusions Even if healthcare stakeholders do not have the same role and interest regarding chronic diseases, they express similar opinions on the development of chronic disease management in Switzerland. Their overall positive attitude shows that it could be further implemented if political, financial and organisational barriers are overcome and if incentives are found to face the scepticism and non-motivation of some stakeholders.
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Affiliation(s)
- Stéphanie Lauvergeon
- Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.
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Provost S, Pineault R, Tousignant P, Hamel M, Da Silva RB. Evaluation of the implementation of an integrated primary care network for prevention and management of cardiometabolic risk in Montréal. BMC FAMILY PRACTICE 2011; 12:126. [PMID: 22074614 PMCID: PMC3282661 DOI: 10.1186/1471-2296-12-126] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 11/10/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND The goal of this project is to evaluate the implementation of an integrated and interdisciplinary program for prevention and management of cardiometabolic risk (PCMR). The intervention is based on the Chronic Care Model. The study will evaluate the implementation of the PCMR in 6 of the 12 health and social services centres (CSSS) in Montréal, and the effects of the PCMR on patients and the practice of their primary care physicians up to 40 months following implementation, as well as the sustainability of the program. Objectives are: 1-to evaluate the effects of the PCMR and their persistence on patients registered in the program and the practice of their primary care physicians, by implementation site and degree of exposure to the program; 2-to assess the degree of implementation of PCMR in each CSSS territory and identify related contextual factors; 3-to establish the relationships between the effects observed, the degree of PCMR implementation and the related contextual factors; 4-to assess the impact of the PCMR on strengthening local services networks. METHODS/DESIGN The evaluation will use a mixed design that includes two complementary research strategies. The first strategy is similar to a quasi-experimental "before-after" design, based on a quantitative approach; it will look at the program's effects and their variations among the six territories. The effects analysis will use data from a clinical database and from questionnaires completed by participating patients and physicians. Over 3000 patients will be recruited. The second strategy corresponds to a multiple case study approach, where each of the six CSSS constitutes a case. With this strategy, qualitative methods will set out the context of implementation using data from semi-structured interviews with program managers. The quantitative data will be analyzed using linear or multilevel models complemented with an interpretive approach to qualitative data analysis. DISCUSSION Our study will identify contextual factors associated with the effectiveness, successful implementation and sustainability of such a program. The contextual information will enable us to extrapolate our results to other contexts with similar conditions. TRIAL REGISTRATION ClinicalTrials.gov: NCT01326130.
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Affiliation(s)
- Sylvie Provost
- Direction de santé publique de l'Agence de la santé et des services sociaux de Montréal, Canada
- Institut national de santé publique du Québec, Canada
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Canada
| | - Raynald Pineault
- Direction de santé publique de l'Agence de la santé et des services sociaux de Montréal, Canada
- Institut national de santé publique du Québec, Canada
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Canada
| | - Pierre Tousignant
- Direction de santé publique de l'Agence de la santé et des services sociaux de Montréal, Canada
- Institut national de santé publique du Québec, Canada
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Canada
| | - Marjolaine Hamel
- Direction de santé publique de l'Agence de la santé et des services sociaux de Montréal, Canada
- Institut national de santé publique du Québec, Canada
| | - Roxane Borgès Da Silva
- Direction de santé publique de l'Agence de la santé et des services sociaux de Montréal, Canada
- Institut national de santé publique du Québec, Canada
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Kirsh S, Hein M, Pogach L, Schectman G, Stevenson L, Watts S, Radhakrishnan A, Chardos J, Aron D. Improving Outpatient Diabetes Care. Am J Med Qual 2011; 27:233-40. [DOI: 10.1177/1062860611418491] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
More than 20% of patients in the Veterans Health Administration (VHA) have diabetes; therefore, disseminating “best practices” in outpatient diabetes care is paramount. The authors’ goal was to identify such practices and the factors associated with their development. First, a national VHA diabetes registry with 2008 data identified clinical performance based on the percentage of patients with an A1c >9%. Facilities (n = 140) and community-based outpatient clinics (n = 582) were included and stratified into high, mid, and low performers. Semistructured telephone interviews (31) and site visits (5) were conducted. Low performers cited lack of teamwork between physicians and nurses and inadequate time to prepare. Better performing sites reported supportive clinical teams sharing work, time for non-face-to-face care, and innovative practices to address local needs. A knowledge management model informed our process. Notable differences between performance levels exist. “Best practices” will be disseminated across the VHA as the VHA Patient-Centered Medical Home model is implemented.
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Affiliation(s)
- Susan Kirsh
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
- Case Western Reserve University, Cleveland, OH
| | - Michael Hein
- Veterans Affairs Nebraska-Western Iowa Health Care System, Grand Island, NE
| | - Leonard Pogach
- New Jersey Veterans Affairs Healthcare System, Trenton, NJ
- University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - Gordon Schectman
- Clement J. Zablocki Milwaukee Veterans Affairs Medical Center and Medical College of Wisconsin, Milwaukee, WI
| | - Lauren Stevenson
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Sharon Watts
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
- Case Western Reserve University, Cleveland, OH
| | | | - John Chardos
- Palo Alto Veterans Affairs Medical Center, Palo Alto, CA
- Stanford University, Stanford, CA
| | - David Aron
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
- Case Western Reserve University, Cleveland, OH
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Turning on the care coordination switch in rural primary care: voices from the practices--clinician champions, clinician partners, administrators, and nurse care managers. J Ambul Care Manage 2011; 34:304-18. [PMID: 21673531 DOI: 10.1097/jac.0b013e31821c63ee] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.
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Meehan TP, Van Hoof TJ, Galusha D, Barr JK, Curry M, Kelvey-Albert M, Meehan TP. Challenges in Recruiting Minority-Serving Private Practice Primary Care Physicians to a Quality Improvement Project. Am J Med Qual 2011; 26:357-63. [DOI: 10.1177/1062860611401011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Thomas J. Van Hoof
- Qualidigm, Rocky Hill, CT
- University of Connecticut School of Nursing, Storrs, CT
- University of Connecticut School of Medicine, Farmington, CT
| | - Deron Galusha
- Qualidigm, Rocky Hill, CT
- Yale University School of Medicine, New Haven, CT
| | - Judith K. Barr
- Qualidigm, Rocky Hill, CT
- Southern Connecticut State University, New Haven, CT
| | | | | | - Thomas P. Meehan
- Qualidigm, Rocky Hill, CT
- Yale University School of Medicine, New Haven, CT
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Chui MA, Mott DA, Maxwell L. A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach. Res Social Adm Pharm 2011; 8:206-16. [PMID: 21824822 DOI: 10.1016/j.sapharm.2011.06.001] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 06/06/2011] [Accepted: 06/07/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although lack of time, trained personnel, and reimbursement have been identified as barriers to pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies, the underlying contributing factors of these barriers have not been explored. One approach to better understand barriers and facilitators to providing CPS is to use a work system approach to examine different components of a work system and how the components may impact care processes. OBJECTIVES The goals of this study were to identify and describe pharmacy work system characteristics that pharmacists identified and changed to provide CPS in a demonstration program. METHODS A qualitative approach was used for data collection. A purposive sample of 8 pharmacists at 6 community pharmacies participating in a demonstration program was selected to be interviewed. Each semistructured interview was audio recorded and transcribed, and the text was analyzed in a descriptive and interpretive manner by 3 analysts. Themes were identified in the text and aligned with 1 of 5 components of the Systems Engineering Initiative for Patient Safety (SEIPS) work system model (organization, tasks, tools/technology, people, and environment). RESULTS A total of 21 themes were identified from the interviews, and 7 themes were identified across all 6 interviews. The organization component of the SEIPS model contained the most (n=10) themes. Numerous factors within a pharmacy work system appear important to enable pharmacists to provide CPS. Leadership and foresight by the organization to implement processes (communication, coordination, planning, etc.) to facilitate providing CPS was a key finding across the interviews. Expanding technician responsibilities was reported to be essential for successfully implementing CPS. CONCLUSIONS To be successful in providing CPS, pharmacists must be cognizant of the different components of the pharmacy work system and how these components influence providing CPS.
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Affiliation(s)
- Michelle A Chui
- Division of Social and Administrative Sciences, University of Wisconsin-Madison, School of Pharmacy, 777 Highland Avenue, 2513 Rennebohm Hall, Madison, WI 53705, USA.
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Tsiachristas A, Hipple-Walters B, Lemmens KM, Nieboer AP, Rutten-van Mölken MP. Towards integrated care for chronic conditions: Dutch policy developments to overcome the (financial) barriers. Health Policy 2011; 101:122-32. [DOI: 10.1016/j.healthpol.2010.10.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 10/11/2010] [Accepted: 10/13/2010] [Indexed: 11/15/2022]
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Elliott DJ, Robinson EJ, Sanford M, Herrman JW, Riesenberg LA. Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians. Am J Med Qual 2011; 26:284-90. [PMID: 21393616 DOI: 10.1177/1062860610383332] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Primary care providers deliver the majority of care for patients with diabetes. This article presents a qualitative analysis of systemic barriers to primary care diabetes management in the small office setting in Delaware. Grounded theory was used to identify key themes of focus group discussions with 25 Delaware physicians. A total of 6 systemic barriers were identified: (1) a persistent orientation toward acute care; (2) an inability to provide proactive, population-based patient management; (3) an inability to provide adequate self-management education; (4) poor integration of payer-driven disease management activities; (5) lack of universally available clinical information; and (6) lack of public health support. The results suggest that significant systemic barriers limit the ability of primary care providers, particularly those in small practices, to effectively manage diabetes in current practice. Future primary care reform should consider how to support providers, particularly those in small practices, to overcome these barriers.
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Twelve evidence-based principles for implementing self-management support in primary care. Jt Comm J Qual Patient Saf 2011; 36:561-70. [PMID: 21222358 DOI: 10.1016/s1553-7250(10)36084-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recommendations to improve self-management support and health outcomes for people with chronic conditions in primary care settings are provided on the basis of expert opinion supported by evidence for practices and processes. Practices and processes that could improve self-management support in primary care were identified through a nominal group process. In a targeted search strategy, reviews and meta-analyses were then identifed using terms from a wide range of chronic conditions and behavioral risk factors in combination with Self-Care, Self-Management, and Primary Care. On the basis of these reviews, evidence-based principles for self-management support were developed. FINDINGS The evidence is organized within the framework of the Chronic Care Model. Evidence-based principles in 12 areas were associated with improved patient self-management and/or health outcomes: (1) brief targeted assessment, (2) evidence-based information to guide shared decision-making, (3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, (5) collaborative problem solving, (6) self-management support by diverse providers, (7) self-management interventions delivered by diverse formats, (8) patient self-efficacy, (9) active followup, (10) guideline-based case management for selected patients, (11) linkages to evidence-based community programs, and (12) multifaceted interventions. A framework is provided for implementing these principles in three phases of the primary care visit: enhanced previsit assessment, a focused clinical encounter, and expanded postvisit options. CONCLUSIONS There is a growing evidence base for how self-management support for chronic conditions can be integrated into routine health care.
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Fortney JC, Pyne JM, Smith JL, Curran GM, Otero JM, Enderle MA, McDougall S. Steps for implementing collaborative care programs for depression. Popul Health Manag 2010; 12:69-79. [PMID: 19320606 DOI: 10.1089/pop.2008.0023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Numerous studies have demonstrated that collaborative care (care management) for depression improves outcomes, yet few clinics have implemented this evidence-based practice. To promote adoption of this best practice, our objective was to describe the steps needed to tailor collaborative care models for local needs, resources, and priorities while maintaining fidelity to the evidence base. Based on lessons learned from 2 multisite Veterans Affairs implementation studies conducted in 2 different clinical, organizational, and geographic contexts, we describe in detail the steps needed to adapt an evidence-based collaborative care program for depression for local context while maintaining highly fidelity to the research evidence. These steps represent a detailed checklist of decisions and action items that can be used as a tool to plan the implementation of a collaborative care model for depression. We also identify other tools (eg, decision support systems, suicide risk assessment) and resources (eg, training materials) that will support implementation efforts. These implementation tools should help clinicians and administrators develop informed strategies for rolling out collaborative care models for depression.
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Affiliation(s)
- John C Fortney
- Health Services Research and Development (HSR&D), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas 72114, USA.
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Anselmo MI, Nery M, Parisi MCR. The effectiveness of educational practice in diabetic foot: a view from Brazil. Diabetol Metab Syndr 2010; 2:45. [PMID: 20587043 PMCID: PMC2912246 DOI: 10.1186/1758-5996-2-45] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 06/29/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The aim of the present study was to evaluate the prevention and self-inspection behavior of diabetic subjects with foot at ulcer risk, no previous episode, who participated in the routine visits and standardized education provided by the service and who received prescribed footwear. This evaluation was carried out using a questionnaire scoring from 0-10 (high scores reflect worse practice compliance). RESULTS 60 patients were studied (30 of each sex); mean age was 62 years, mean duration of the disease was 17 years. As for compliance, 90% showed a total score </=5, only 8.7% regularly wore the footwear supplied; self foot inspection 65%, 28,3% with additional familiar inspection; creaming 77%; proper washing and drying 88%; proper cutting of toe nails 83%; no cuticle cutting 83%; routine shoe inspection 77%; no use of pumice stones or similar abrasive 70%; no barefoot walking 95%. CONCLUSION the planned and multidisciplinary educational approach enabled high compliance of the ulcer prevention care needed in diabetic patients at risk for complications. In contrast, compliance observed for the use of footwear provided was extremely low, demonstrating that the issue of its acceptability should be further and carefully addressed. In countries of such vast dimensions as Brazil multidisciplinary educational approaches can and should be performed by the services providing care for patients with foot at risk for complications according to the reality of local scenarios. Furthermore, every educational program should assess the learning, results obtained and efficacy in the target population by use of an adequate evaluation system.
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Affiliation(s)
- Maria I Anselmo
- Endocrinology Department, Medical School of the State University of Sao Paulo, Sao Paulo, Brazil
| | - Marcia Nery
- Endocrinology Department, Medical School of the State University of Sao Paulo, Sao Paulo, Brazil
| | - Maria CR Parisi
- Endocrinology Department, Medical School of the State University of Sao Paulo, Sao Paulo, Brazil
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31
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Aagaard EM, Gonzales R, Camargo CA, Auten R, Levin SK, Maselli J, Metlay J. Physician champions are key to improving antibiotic prescribing quality. Jt Comm J Qual Patient Saf 2010; 36:109-16. [PMID: 20235412 DOI: 10.1016/s1553-7250(10)36019-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The previously reported IMPAACT study was a cluster randomized controlled trial of a patient and physician educational intervention designed to reduce antibiotic prescribing for acute respiratory tract infections (ARIs) in emergency departments (EDs) in the United States. On average, the intervention resulted in a modest improvement in antibiotic prescribing behavior at the end of Year 1 and further improvement after Year 2. Yet the intervention's impact was large at some sites but minimal or even negative at others. A study was undertaken to identify organizational factors that influenced the effectiveness (Organizational Effect Modifiers [OEMs]) of the intervention. METHODS Focus groups of nurses and ED staff and semistructured interviews of local project leaders, nurse managers, and quality improvement (QI) officers were performed at seven EDs across the United States. Effectiveness of the local project leader, institutional emphasis on patient satisfaction ratings, and institutional history with and approach to QI were initially identified as key potential OEMs. Two investigators independently read the transcripts for each site and, using prespecified rating scales, rated the presence of each OEM. FINDINGS The perceived effectiveness of the local project leader was most strongly linked to the effectiveness of the intervention. Perceived institutional emphasis on patient satisfaction and institutional history of and approach to QI (top down or bottom up) did not appear to be closely linked with intervention effectiveness. DISCUSSION An effective local leader to serve as a physician champion was key to the success of this project. Organizational factors modify the effectiveness of QI interventions targeting individual physician performance and should be addressed during program implementation.
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Affiliation(s)
- Eva M Aagaard
- University of Colorado, Denver School of Medicine, Aurora, USA.
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Ryan JG. Cost and policy implications from the increasing prevalence of obesity and diabetes mellitus. ACTA ACUST UNITED AC 2009; 6 Suppl 1:86-108. [PMID: 19318221 DOI: 10.1016/j.genm.2009.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2008] [Indexed: 01/07/2023]
Abstract
BACKGROUND The increasing prevalence of obesity and type 2 diabetes mellitus (DM), among children and adults, has posed important policy and budgetary considerations to government, health insurance companies, employers, physicians, and health care delivery systems. OBJECTIVE This article examines issues that are common to obesity and DM, including cost, clinical research, and treatment barriers, and proposes health policies to address these issues. METHOD A manual review was performed of authoritative literature from peer-reviewed medical publications and recently published medical textbooks. RESULTS Obesity has been disproportionately prevalent among women and minorities, accompanied by an increased risk for DM. Women have experienced an increased risk for the metabolic syndrome, DM, and cardiovascular disease after onset of menopause. Obesity has been related to an increased risk for breast cancer among women, and may be a barrier that prevents women from being screened for colon and breast cancers. Maternal obesity has been a risk factor for gestational DM. CONCLUSIONS Obesity and DM represent crises for the health care system and the health of the public, incurring costs and disease burden for adults and children, with increasing costs and prevalence expected unless more coordinated efforts to address the causes of these conditions at the national level are implemented. An investment in infrastructure to promote increased physical activity and reward weight management may be budget neutral in the long term by reducing the costs of morbidity and mortality. About two thirds of the costs from DM complications could be averted with appropriate primary care.
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Affiliation(s)
- John G Ryan
- Division of Primary Care/Health Services Research and Development, Department of Family Medicine and Community Health, University of Miami Miller School of Medicine, Miami, Florida 33101-6700, USA.
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Russell GM, Dahrouge S, Hogg W, Geneau R, Muldoon L, Tuna M. Managing chronic disease in ontario primary care: the impact of organizational factors. Ann Fam Med 2009; 7:309-18. [PMID: 19597168 PMCID: PMC2713154 DOI: 10.1370/afm.982] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care. METHODS We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management. RESULTS Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians. CONCLUSIONS The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario's CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality.
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Affiliation(s)
- Grant M Russell
- C.T. Lamont Primary Health Care Research Centre, Elisabeth Bruyère Research Institute, Ottawa, Ontario, Canada.
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Friedberg MW, Safran DG, Coltin KL, Dresser M, Schneider EC. Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices. J Gen Intern Med 2009; 24:162-9. [PMID: 19050977 PMCID: PMC2629002 DOI: 10.1007/s11606-008-0856-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 10/07/2008] [Accepted: 10/16/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied. OBJECTIVE To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices. DESIGN Cross-sectional analysis. PARTICIPANTS One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database. MEASUREMENTS Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs). MAIN RESULTS Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2-74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics. CONCLUSIONS Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments.
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Affiliation(s)
- Mark W. Friedberg
- Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
- Harvard School of Public Health, Boston, MA USA
| | - Dana G. Safran
- Tufts University Medical School, Blue Cross/Blue Shield of Massachusetts, Boston, MA USA
| | | | | | - Eric C. Schneider
- Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
- Harvard School of Public Health, Boston, MA USA
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Scholle SH, Pawlson LG, Solberg LI, Shih SC, Asche SE, Chou AF, Thoele MJ. Measuring practice systems for chronic illness care: accuracy of self-reports from clinical personnel. Jt Comm J Qual Patient Saf 2008; 34:407-16. [PMID: 18677872 DOI: 10.1016/s1553-7250(08)34051-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Purchasers, plans, and clinical practices involved in quality improvement initiatives are increasingly interested in measuring practice systems, particularly in relation to clinical quality and as part of pay-for-quality initiatives. The validity of self-reports of the use of practice systems was examined. METHODS In 11 medical groups in Minnesota, the Physician Practice Connections Readiness Survey, which was developed on the basis of the concepts and evidence base of the Chronic Care Model, was used to survey office practice personnel about practice systems. Participation rates by medical group ranged from 61% to 94%, with a mean of 76%, yielding surveys from 32 lead physicians and 241 other personnel. Survey results were compared with an on-site audit by trained surveyors. RESULTS Overall agreement with the on-site audit ranged from 40.9% to 96.7% among lead physicians and from 33.9% to 81.9% among other personnel. Mean agreement was high for quality improvement (96.7% for lead physicians and 81.9% for other personnel), moderate for clinical information systems (71.2% for lead physicians and 66.0% for others), and low for the use of care management (less than 50% for both groups). Mean positive predictive value ranged from 55.2% to 100% among lead physicians and from 49.6% to 100% among other personnel. Both the presence of systems and the accuracy of reporting varied across medical groups. DISCUSSION The accuracy of self-reports of practice systems varies by type of system being assessed and by type of respondent. Although self-assessment may be useful for quality improvement purposes, self-reported information on clinical practices systems should not be used for accountability purposes, including pay-for-quality efforts or public reporting unless additional documentation is required to ensure fair comparisons.
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Burns LR, Muller RW. Hospital-physician collaboration: landscape of economic integration and impact on clinical integration. Milbank Q 2008; 86:375-434. [PMID: 18798884 PMCID: PMC2690342 DOI: 10.1111/j.1468-0009.2008.00527.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P). METHODS This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration. FINDINGS The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians. CONCLUSIONS Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.
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Affiliation(s)
- Lawton Robert Burns
- Wharton Center for Health Management and Economics, Wharton School, University of Pennsylvania, Philadelphia, PA 19104-6218, USA.
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Zai AH, Grant RW, Estey G, Lester WT, Andrews CT, Yee R, Mort E, Chueh HC. Lessons from implementing a combined workflow-informatics system for diabetes management. J Am Med Inform Assoc 2008; 15:524-33. [PMID: 18436907 PMCID: PMC2442271 DOI: 10.1197/jamia.m2598] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 04/04/2008] [Indexed: 11/10/2022] Open
Abstract
Shortcomings surrounding the care of patients with diabetes have been attributed largely to a fragmented, disorganized, and duplicative health care system that focuses more on acute conditions and complications than on managing chronic disease. To address these shortcomings, we developed a diabetes registry population management application to change the way our staff manages patients with diabetes. Use of this new application has helped us coordinate the responsibilities for intervening and monitoring patients in the registry among different users. Our experiences using this combined workflow-informatics intervention system suggest that integrating a chronic disease registry into clinical workflow for the treatment of chronic conditions creates a useful and efficient tool for managing disease.
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Affiliation(s)
- Adrian H Zai
- Laboratory of Computer Science, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA.
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Yano EM. The role of organizational research in implementing evidence-based practice: QUERI Series. Implement Sci 2008; 3:29. [PMID: 18510749 PMCID: PMC2481253 DOI: 10.1186/1748-5908-3-29] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2006] [Accepted: 05/29/2008] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Health care organizations exert significant influence on the manner in which clinicians practice and the processes and outcomes of care that patients experience. A greater understanding of the organizational milieu into which innovations will be introduced, as well as the organizational factors that are likely to foster or hinder the adoption and use of new technologies, care arrangements and quality improvement (QI) strategies are central to the effective implementation of research into practice. Unfortunately, much implementation research seems to not recognize or adequately address the influence and importance of organizations. Using examples from the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI), we describe the role of organizational research in advancing the implementation of evidence-based practice into routine care settings. METHODS Using the six-step QUERI process as a foundation, we present an organizational research framework designed to improve and accelerate the implementation of evidence-based practice into routine care. Specific QUERI-related organizational research applications are reviewed, with discussion of the measures and methods used to apply them. We describe these applications in the context of a continuum of organizational research activities to be conducted before, during and after implementation. RESULTS Since QUERI's inception, various approaches to organizational research have been employed to foster progress through QUERI's six-step process. We report on how explicit integration of the evaluation of organizational factors into QUERI planning has informed the design of more effective care delivery system interventions and enabled their improved "fit" to individual VA facilities or practices. We examine the value and challenges in conducting organizational research, and briefly describe the contributions of organizational theory and environmental context to the research framework. CONCLUSION Understanding the organizational context of delivering evidence-based practice is a critical adjunct to efforts to systematically improve quality. Given the size and diversity of VA practices, coupled with unique organizational data sources, QUERI is well-positioned to make valuable contributions to the field of implementation science. More explicit accommodation of organizational inquiry into implementation research agendas has helped QUERI researchers to better frame and extend their work as they move toward regional and national spread activities.
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Affiliation(s)
- Elizabeth M Yano
- Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence for the Study of Healthcare Provider Behaviour, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.
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Lester WT, Zai AH, Chueh HC, Grant RW. Diabetes information technology: designing informatics systems to catalyze change in clinical care. J Diabetes Sci Technol 2008; 2:275-83. [PMID: 19885355 PMCID: PMC2771488 DOI: 10.1177/193229680800200218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Current computerized reminder and decision support systems intended to improve diabetes care have had a limited effect on clinical outcomes. Increasing pressures on health care networks to meet standards of diabetes care have created an environment where information technology systems for diabetes management are often created under duress, appended to existing clinical systems, and poorly integrated into the existing workflow. After defining the components of diabetes disease management, the authors present an eight-step conceptual framework to guide the development of more effective diabetes information technology systems for translating clinical information into clinical action.
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Affiliation(s)
- William T Lester
- Laboratory of Computer Science, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Nutting PA, Gallagher K, Riley K, White S, Dickinson WP, Korsen N, Dietrich A. Care management for depression in primary care practice: findings from the RESPECT-Depression trial. Ann Fam Med 2008; 6:30-7. [PMID: 18195312 PMCID: PMC2203406 DOI: 10.1370/afm.742] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices. METHODS The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis. RESULTS Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician. CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.
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Affiliation(s)
- Paul A Nutting
- The Center for Research Strategies, Denver, Colorado 80203, USA.
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Aron DC, Pogach LM. Harnessing information technologies to improve the delivery of diabetes care to veterans: the future is today. J Diabetes Sci Technol 2008; 2:4-6. [PMID: 19885171 PMCID: PMC2769694 DOI: 10.1177/193229680800200102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although momentum is now building nationally for improved informatics, progress has been incremental in most cases. One notable exception is the Veterans Health Administration, which utilizes one of the most widely used electronic medical record systems in the world. OBJECTIVES The articles in this symposium demonstrate the implementation of technology to move beyond the electronic medical record at the time of the medical encounter to improve timeliness and outcomes of care delivery for veterans with diabetes. RESULTS We report on the use of electronic registries and nurse practitioner-based programs across multiple sites to improve glycemic control; the implementation of a digital retinal imaging system in primary care clinics; the use of health information technology to improve patient self-care; and the development of a research database to move beyond performance measurement to evaluate longitudinal outcomes. CONCLUSIONS While these articles demonstrate the ability of a single national system of care to harness the power of technology to novel strategies for the delivery of care and its evaluation, the technology is scalable from small group practices to regional health care systems.
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Affiliation(s)
- David C Aron
- Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA
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Solberg LI. Improving medical practice: a conceptual framework. Ann Fam Med 2007; 5:251-6. [PMID: 17548853 PMCID: PMC1886486 DOI: 10.1370/afm.666] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 09/28/2006] [Accepted: 10/03/2006] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of this article is to produce a relatively simple conceptual framework for guiding and studying practice improvement. METHODS I summarize the lessons from my experience with a variety of quality improvement research studies during the last 30 years, supplemented with relevant literature from both medicine and other industries about the issues associated with successful quality improvement. RESULTS My experience suggests that organizational leadership with an urgent vision for change, ability to manage the change process, and selection of systematic changes capable of fulfilling the vision are each critical for successful quality improvement. Published literature from other industries emphasizes the importance of a goal-directed change process managed by leaders who recognize the need to engage their employees and other leaders in a disciplined but flexible way that accommodates external and internal factors and uses teams and group learning. It also suggests the importance of organizational context and the level of external and internal barriers and facilitators for change. The resulting model proposes that priority, change process, and care process content are necessary for measurable improvements in quality of care and patient outcomes, although internal and external barriers must also be attended to and addressed. CONCLUSION This framework may provide a guide to those in the front lines of care who would like to make the care transformations that are needed to greatly improve care. It may also be helpful to those who are developing or testing interventions and recruiting medical practices for such change efforts.
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Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, Minneapolis, Minn 55440, USA.
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Wang MC, Hyun JK, Harrison M, Shortell SM, Fraser I. Redesigning health systems for quality: Lessons from emerging practices. Jt Comm J Qual Patient Saf 2007; 32:599-611. [PMID: 17120919 DOI: 10.1016/s1553-7250(06)32078-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND It has been five years since the Institute of Medicine (IOM) report, Crossing the Quality Chasm, proposed systemwide changes to transform our health care system. What progress has been made? What lessons have been learned? How should we move forward? METHODS Semistructured telephone interviews were conducted with 16 health care providers and researchers at organizations involved in system redesign. The findings were supplemented with a focused literature review and discussions from a national expert meeting. RESULTS Many promising and innovative examples of redesign were identified. However, even delivery systems that are redesigning care in pursuit of the six IOM aims face daunting challenges, reflecting the need to align system changes across multiple levels and to integrate redesign efforts with ongoing system features. Four success factors were reported by providers as crucial in overcoming redesign barriers: (1) directly involving top and middle-level leaders, (2) strategically aligning and integrating improvement efforts with organizational priorities, (3) systematically establishing infrastructure, process, and performance appraisal systems for continuous improvement, and (4) actively developing champions, teams, and staff. A framework that integrates these success factors to facilitate a systems approach to redesigning health care organizations and delivery systems for improved performance is provided. CONCLUSIONS Successful system redesign requires coordinating and managing a complex set of changes across multiple levels rather than isolated projects.
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Solberg LI. Recruiting medical groups for research: relationships, reputation, requirements, rewards, reciprocity, resolution, and respect. Implement Sci 2006; 1:25. [PMID: 17067379 PMCID: PMC1630695 DOI: 10.1186/1748-5908-1-25] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Accepted: 10/26/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In order to conduct good implementation science research, it will be necessary to recruit and obtain good cooperation and comprehensive information from complete medical practice organizations. The goal of this paper is to report an effective example of such a recruitment effort for a study of the organizational aspects of depression care quality. METHODS There were 41 medical groups in the Minnesota region that were eligible for participation in the study because they had sufficient numbers of patients with depression. We documented the steps required to both recruit their participation in this study and obtain their completion of two questionnaire surveys and two telephone interviews. RESULTS All 41 medical groups agreed to participate and consented to our use of confidential data about their care quality. In addition, all 82 medical directors and quality improvement coordinators completed the necessary questionnaires and interviews. The key factors explaining this success can be summarized as the seven R's: Relationships, Reputation, Requirements, Rewards, Reciprocity, Resolution, and Respect. CONCLUSION While all studies will not have all of these factors in such good alignment, attention to them may be important to other efforts to add to our knowledge of implementation science.
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Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, PO Box 1524, MS#21111R, Minneapolis, MN 55440-1524, USA.
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Leeman J. Interventions to improve diabetes self-management: utility and relevance for practice. DIABETES EDUCATOR 2006; 32:571-83. [PMID: 16873595 DOI: 10.1177/0145721706290833] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to review publications of research on diabetes self-management interventions and assess whether the interventions are relevant for practice. METHODS A content analysis was performed on research reports published between 1993 and 2004 of interventions designed to improve patients' diabetes self-management. Information was abstracted relevant to the intervention's generalizability to other settings and its compatibility and feasibility in practice. RESULTS Publications included only limited information relevant to an intervention's generalizability across populations and settings. Many of the interventions tested were not designed to be compatible with the realities of current practice or to be delivered in the settings in which most diabetes care is provided. Many of the interventions were very complex, requiring multiple delivery modes and contacts, proactive scheduling, and coordination across disciplines. CONCLUSIONS In view of the prevalence of diabetes, it is critical that effective self-management interventions be adopted and implemented. Interventions need to be designed so that their findings have greater relevance and utility for practice and can be generalized across practice settings.
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Affiliation(s)
- Jennifer Leeman
- School of Nursing, CB#7460, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7460, USA.
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Kilbourne AM, McGinnis GF, Belnap BH, Klinkman M, Thomas M. The role of clinical information technology in depression care management. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2006; 33:54-64. [PMID: 16215661 DOI: 10.1007/s10488-005-4236-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We examine the literature on the growing application of clinical information technology in managing depression care and highlight lessons learned from Robert Wood Johnson Foundation's national program "Depression in Primary Care-Incentives Demonstrations." Several program sites are implementing depression care registries. Key issues discussed about implementing registries include using a simple yet functional format, designing registries to track multiple conditions versus depression alone (i.e., patient-centric versus disease-centric registries) and avoiding violations of patient privacy with the advent of more advanced information technologies (e.g., web-based formats). Finally, we discuss some implications of clinical information technology for health care practices and policy makers.
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Affiliation(s)
- Amy M Kilbourne
- Center for Health Equity Research and Promotion, School of Medicine, VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA 15240, USA.
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Bachman J, Pincus HA, Houtsinger JK, Unützer J. Funding mechanisms for depression care management: opportunities and challenges. Gen Hosp Psychiatry 2006; 28:278-88. [PMID: 16814626 DOI: 10.1016/j.genhosppsych.2006.03.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Revised: 03/03/2006] [Accepted: 03/06/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Inconsistent third-party reimbursement for depression care management is a significant economic barrier to the utilization and sustainability of the chronic illness care model in primary care practice settings. We review common mechanisms used to procure payment for depression care management services, discuss obstacles encountered and suggest future directions. METHOD We describe several extant models for funding depression care management services in use at the demonstration sites of the Robert Wood Johnson Foundation funded "Depression in Primary Care" project and similar programs. We derived this information from ongoing discussions with the sites' project directors and through an extensive electronic literature search on "care management, funding mechanisms and depression." RESULTS Funding mechanisms include (a) practice-based care management on a fee-for-service basis, (b) practice-based care management under contract to health plans, (c) global capitation, (d) flexible infrastructure support for chronic care management, (e) health-plan-based care management, (f) third-party-based care management under contract to health plans and (g) hybrid models. CONCLUSIONS While substantial obstacles remain in the way of fully implementing these depression care management funding mechanisms (e.g., variations in care managers' credentials and work locations and third-party payer concerns about overutilization and transaction costs), several recent policy advances provide some optimism for the potential adoption of financial mechanisms to support and disseminate these evidence-based practices.
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Affiliation(s)
- John Bachman
- Depression in Primary Care: Linking Clinical and Systems Strategies, National Program Office, Pittsburgh, PA 15213, USA.
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Casalino LP. The Federal Trade Commission, clinical integration, and the organization of physician practice. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2006; 31:569-85. [PMID: 16785298 DOI: 10.1215/03616878-2005-007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
This article examines Federal Trade Commission (FTC) policy--in particular, the agency's controversial 1996 statements on clinical integration--toward joint negotiations for nonrisk contracts with health plans by physicians organized into independent practice associations (IPAs) and (with hospitals) into physician-hospital organizations (PHOs). The article concludes that the policy is consistent with anti-trust principles, consistent with current thinking on the use of organized processes to improve medical care quality, specific enough to provide guidance to physicians wanting to integrate clinically, and general enough to encourage ongoing innovations in physician organization. The FTC should consider stronger sanctions for IPAs and PHOs whose clinical integration is nothing more than a sham intended to provide cover for joint negotiations, should give the benefit of the doubt to organizations whose clinical integration appears to be reasonably consonant with the statements, and should clarify several ambiguities in the statements. Health plans should facilitate IPA and PHO efforts to improve care by rewarding quality and efficiency and by providing clinically integrated organizations with claims information on individual patients. Though creating clinically integrated organizations is difficult and expensive, physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patients.
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Solberg LI, Hroscikoski MC, Sperl-Hillen JM, Harper PG, Crabtree BF. Transforming medical care: case study of an exemplary, small medical group. Ann Fam Med 2006; 4:109-16. [PMID: 16569713 PMCID: PMC1467006 DOI: 10.1370/afm.424] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 08/02/2005] [Accepted: 08/25/2005] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Most published descriptions of organizations providing or improving quality of care concern large medical groups or systems; however, 90% of the medical care in the United States is provided by groups of no more than 20 physicians. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality. METHODS A 15-family physician medical group was identified from comparative public performance scores of 27 medical groups providing most of the primary care in our metropolitan area. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents were reviewed. Four primary care physician researchers and a consultant then reviewed transcriptions, field notes, and materials during semistructured sessions to identify the main attributes of this group and their probable origins. RESULTS This medical group ranked first in a composite measure of preventive services and fourth and sixth, respectively, in composite scores for coronary artery disease and diabetes care. Our analysis identified 12 attributes of this group that seemed to be associated with its good care quality, with patient-centeredness being the foundational attribute for most of the others. Historical factors important to most of these attributes included small size, physician ownership, and a high value on practice consistency among the clinicians in the group. CONCLUSIONS The identified 12 attributes of this medical group seem to be associated with its superior care quality, and most of them might be replicable by other small groups if they choose to work toward that end.
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Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, Minneapolis, Minn 55440-1524, USA.
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Schmittdiel JA, Shortell SM, Rundall TG, Bodenheimer T, Selby JV. Effect of primary health care orientation on chronic care management. Ann Fam Med 2006; 4:117-23. [PMID: 16569714 PMCID: PMC1467016 DOI: 10.1370/afm.520] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Revised: 09/07/2005] [Accepted: 09/21/2005] [Indexed: 11/09/2022] Open
Abstract
PURPOSE It has been suggested that the best way to improve chronic illness care is through a redesign of primary care emphasizing comprehensive, coordinated care as espoused by the Chronic Care Model (CCM). This study examined the relationship between primary care orientation and the implementation of the CCM in physician organizations. METHODS The relationship between measures of primary care orientation and the CCM was examined in a sample of 957 physician organizations from the National Study of Physician Organizations, a cross-sectional telephone survey of all US medical groups and independent practice associations with 20 or more physicians (response rate, 70%). RESULTS After adjusting for potential confounders, 6 of 8 measures of primary care orientation were associated with physician organizations' adoption of 11 elements of CCM chronic care management. These 6 measures were severity of chronic illness treated in primary care, health promotion activity, health education activity, any accepted financial risk for hospitalization, required reporting, and presence of an electronic standardized problem list. Presence of an electronic medical record and the 5-year primary care physician turnover rate were not associated. CONCLUSIONS Organizations that have adopted 6 core attributes of primary care, representing comprehensive health service delivery and a commitment to overall patient health, appear to use more chronic care management practices. Policy makers and other stakeholders may wish to focus on creating an improved primary care home in their quest to close the "quality chasm" in chronic illness care.
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Affiliation(s)
- Julie A Schmittdiel
- Kaiser Permanente Northern California Division of Research, Oakland, Calif 94612, USA.
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