The Patient-Centered Medical Home: transforming primary care

Comparing quality of care in medical specialties between nurse practitioners and physicians

BACKGROUND

The American health care system is facing a growing health care provider shortage in primary and specialty care settings. Research has established that nurse practitioners (NPs) match or exceed their physician colleagues in providing quality care in primary care settings.

OBJECTIVE

This systematic review aimed to compare the quality of NP versus physician-led care in outpatient specialty care setting for clinical outcomes patient satisfaction.

DATA SOURCES

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided the literature search (CINAHL, PubMed, and Cochrane Library) and interpretation of findings. Of the 228 articles that met the inclusion/exclusion criteria, 11 were selected for further review.

CONCLUSIONS

Studies were conducted from 1995 to 2016 across four countries and spanned 10 distinct medical specialties. As a whole, these studies demonstrated that NPs in specialty settings perform as well as physicians terms of clinical safety and positive patient outcomes. Nurse practitioners matched or exceeded their physician counterparts in patient education and satisfaction.

IMPLICATIONS FOR PRACTICE

Nurse practitioners are a feasible option for addressing specialty care shortages. Further research should investigate whether NPs and physicians are equally prepared to provide equivalent care immediately following their respective postbaccalaureate programs. If not, studies should explore specific training duration and elements NPs require to provide equivalent care.

Fibromyalgia: management strategies for primary care providers

AIMS

Fibromyalgia (FM), a chronic disorder defined by widespread pain, often accompanied by fatigue and sleep disturbance, affects up to one in 20 patients in primary care. Although most patients with FM are managed in primary care, diagnosis and treatment continue to present a challenge, and patients are often referred to specialists. Furthermore, the lack of a clear patient pathway often results in patients being passed from specialist to specialist, exhaustive investigations, prescription of multiple drugs to treat different symptoms, delays in diagnosis, increased disability and increased healthcare resource utilisation. We will discuss the current and evolving understanding of FM, and recommend improvements in the management and treatment of FM, highlighting the role of the primary care physician, and the place of the medical home in FM management.

METHODS

We reviewed the epidemiology, pathophysiology and management of FM by searching PubMed and references from relevant articles, and selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements.

RESULTS

The implementation of a framework for chronic pain management in primary care would limit unnecessary, time-consuming, and costly tests, reduce diagnostic delay and improve patient outcomes.

DISCUSSION

The patient-centred medical home (PCMH), a management framework that has been successfully implemented in other chronic diseases, might improve the care of patients with FM in primary care, by bringing together a team of professionals with a range of skills and training.

CONCLUSION

Although there remain several barriers to overcome, implementation of a PCMH would allow patients with FM, like those with other chronic conditions, to be successfully managed in the primary care setting.

Lung cancer care: the impact of facilities and area measures

Lung cancer is the leading cause of cancer related mortality in the US, and while treatment disparities by race and class have been well described in the literature, the impact of social determinates of health, and specific characteristics of the treatment centers have been less well characterized. As the treatment of lung cancer relies more upon a precision and personalized medicine approach, where patients obtain treatment has an impact on outcomes and could be a major factor in treatment disparities. The purpose of this manuscript is to discuss the manner in which lung cancer care can be impacted by poor access to high quality treatment centers, and how the built environment can be a mitigating factor in the pursuit of treatment equity.

Teamwork and delegation in medical homes: primary care staff perspectives in the Veterans Health Administration

BACKGROUND

The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential.

OBJECTIVE

To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation.

DESIGN

Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States.

PARTICIPANTS

A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates.

APPROACH

Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation.

KEY RESULTS

We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation.

CONCLUSIONS

Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

Clinical nurse specialists: then, now, and the future of the profession

PURPOSE

The role of the clinical nurse specialist (CNS) has evolved significantly over time and will continue to do so. Future students, faculty, and practicing CNSs should be aware of their roots, current status, and what the future may entail.

RATIONALE

An accurate understanding and reflection of the past, present, and future of this specific advanced practice nursing specialty could ensure its continued success as a predominate force in health restoration and the promotion of the health and well-being of people.

DESCRIPTION

A review of the literature yielded a lack of cohesive information about the evolution of the CNS role, prompting an investigation into the historical, current, and future aspects of the CNS.

OUTCOME

This article compiles information related to the evolution of the CNS role and what the future may entail.

CONCLUSION

An understanding of how the CNS role evolved, where it stands currently, and future considerations may help clarify the role, improve utilization of the CNS in a variety of settings, improve standards for CNS education and certifications, and advance this nursing practice specialty.