How Preferences for Continuity and Access Differ Between Multimorbidity and Healthy Patients in a Team Care Setting

Association of Continuity of Care With Health Care Utilization and Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack

OBJECTIVES

To examine the association of prestroke continuity of care (COC) with postdischarge health care utilization and expenditures.

STUDY POPULATION

The study population included 2233 patients with a diagnosis of stroke or a transient ischemic attack hospitalized in one of 41 hospitals in North Carolina between March 2016 and July 2019 and discharged directly home from acute care.

METHODS

COC was assessed from linked Centers for Medicare and Medicaid Services Medicare claims using the Modified, Modified Continuity Index. Logistic regressions and 2-part models were used to examine the association of prestroke primary care COC with postdischarge health care utilization and expenditures.

RESULTS

Relative to patients in the first (lowest) COC quartile, patients in the second and third COC quartiles were more likely [21% (95% CI: 8.5%, 33.5%) and 33% (95% CI: 20.5%, 46.1%), respectively] to have an ambulatory care visit within 14 days. Patients in the highest COC quartile were more likely to visit a primary care provider but less likely to see a stroke specialist. Highest as compared with lowest primary care COC quartile was associated with $45 lower (95% CI: $14, $76) average expenditure for ambulatory care visits within 30 days postdischarge. Patients in the highest, as compared with the lowest, primary care COC quartile were 36% less likely (95% CI: 8%, 64%) to be readmitted within 30 days postdischarge and spent $340 less (95% CI: $2, $678) on unplanned readmissions.

CONCLUSIONS

These findings underscore the importance of primary care COC received before stroke hospitalization to postdischarge care and expenditures.

Team-Based Care Model Improves Timely Access to Care and Patient Satisfaction in General Cardiology

ABSTRACT

Appointment wait times have increased nationally since 2014, especially in cardiology. At a mid-Atlantic academic medical center, access to care in the general cardiology clinic was below national standards, which can negatively affect patient outcomes and satisfaction. Adopting a team-based care (TBC) model, advanced practice providers (APPs) were added to care teams with general cardiologists to provide timely outpatient management of cardiac conditions. This aimed to increase access to care and, consequently, patient satisfaction. A formative program evaluation using the Agency for Clinical Innovation framework assessed TBC's impact on these outcomes. Access to care and patient satisfaction measures for TBC and nonteam providers were compared with one another and national benchmarks. Nine months after implementation, the average time to new patient appointment for TBC providers was 31 days (47% decrease) and for nonteam providers was 41 days (20% decrease). TBC had a higher percentage of new patient appointments within 14 days than nonteam providers (39% and 20%, respectively). Patient satisfaction improved to the 98th percentile nationally for TBC but decreased to the 71st percentile for nonteam. These findings suggest that a TBC model using APPs can improve access to care and patient satisfaction in the outpatient general cardiology setting.

Continuity of Care: A Primer for Family Medicine Residencies

Continuity of care has been an identifying characteristic of family medicine since its inception and is an essential ingredient for high-functioning health care teams. Many benefits, including the quadruple aim of enhancing patient experience, improving population health, reducing costs, and improving care team well-being, are ascribed to continuity of care. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) added two new continuity requirements-annual patient-sided continuity and annual resident-sided continuity-in family medicine training programs. This article reviews continuity of care as it applies to family medicine training programs. We discuss the various types of continuity and issues surrounding the measurement of continuity. A generally agreed upon definition of patient-sided and resident-sided continuity is presented to allow programs to begin to collect the necessary data. Especially within resident training programs, intricacies associated with maintaining continuity of care, such as empanelment, resident turnover, and scheduling, are discussed. The importance of right-sizing resident panels is highlighted, and a mechanism for accomplishing this is presented. The recent ACGME requirements represent a cultural shift from measuring resident experience based on volume to measuring resident continuity. This cultural shift forces family medicine training programs to adapt their various systems, policies, and procedures to emphasize continuity. We hope this manuscript's review of several facets of contuinuity, some unique to training programs, helps programs ensure compliance with the ACGME requirements.

Self-scheduling Medical Visits in a Multispecialty, Multisite Medical Practice: Complexity, Challenges, and Successes

Background

Self-scheduling of medical visits is becoming more common but the complexity of applying multiple requirements for self-scheduling has hampered implementation. Mayo Clinic implemented self-scheduling in 2019 and has been increasing its portfolio of self-schedulable visits since then. Our aim was to show measures quantifying the complexity associated with medical visit scheduling and to describe how opportunities and challenges of scheduling complexity apply in self-scheduling.

Methods

We examined scheduled visits from January 1, 2022, through August 24, 2023. For seven visit categories, we counted all unique visit types that were scheduled, for both staff-scheduled and self-scheduled. We examined counts of self-scheduled visit types to identify those with highest uptake during the study period.

Results

There were 9555 unique visit types associated with 20.8 M (million) completed visits. Self-scheduled visit types accounted for 4.0% (838,592/20,769,699) of the completed total visits. Of seven visit categories, self-scheduled established patient visits, testing visits, and procedure visits accounted for 93.5% (784,375/838,592) of all self-scheduled visits. Established patient visits in primary care (10 visit types) accounted for 273,007 (32.6%) of all self-scheduled visits. Testing visits (blood and urine testing, 2 visit types) accounted for 183,870 (21.9%) of all self-scheduled visits. Procedure visits for screening mammograms, bone mineral density, and immunizations (8 visit types) accounted for 147,358 (17.6%) of all self-scheduled visits.

Conclusion

Large numbers of unique visit types comprise a major challenge for self-scheduling. Some visit types are more suitable for self-scheduling. Guideline-based procedure visits such as screening mammograms, bone mineral density exams, and immunizations are examples of visits that have high volumes and can be standardized for self-scheduling. Established patient visits and laboratory testing visits also can be standardized for self-scheduling. Despite the successes, there remain thousands of specific visit types that may need some staff-scheduler intervention to properly schedule.

Modeling Family Medicine Provider Care Team Design to Improve Patient Care Continuity

BACKGROUND AND OBJECTIVES

Continuity of care is an integral aspect of high-quality patient care in primary care settings. In the Department of Family Medicine at Mayo Clinic, providers have multiple responsibilities in addition to clinical duties or panel management time (PMT). These competing time demands limit providers' clinical availability. One way to mitigate the impact on patient access and care continuity is to create provider care teams to collectively share the responsibility of meeting patients' needs.

METHODS

This study presents a descriptive characterization of patient care continuity based on provider types and PMT. Care continuity was measured by the percentage of patient a ppointments s een by a provider in their o wn c are t eam (ASOCT) with the aim of reducing the variability of provider care team continuity. The prediction method is iteratively developed to illustrate the importance of the individual independent components. An optimization model is then used to determine optimal provider mix in a team.

RESULTS

The ASOCT percentage in current practice among care teams ranges from 46% to 68% and the per team number of MDs varies from 1 to 5 while the number of nurse practitioners and physician assistants (NP/PAs) ranges from 0 to 6. The proposed methods result in the optimal provider assignment, which has an ASOCT percentage consistently at 62% for all care teams and 3 or 4 physicians (MDs) and NP/PAs in each care team.

CONCLUSIONS

The predictive model combined with assignment optimization generates a more consistent ASOCT percentage, provider mix, and provider count for each care team.

Patient perspectives on primary care for multimorbidity: An integrative review

INTRODUCTION

Improving healthcare for people with multiple chronic or ongoing conditions is receiving increased attention, particularly due to the growing number of people experiencing multimorbidity (MM) and concerns about the sustainability of the healthcare system. Primary care has been promoted as an important resource for supporting people with MM to live well with their conditions and to prevent unnecessary use of health care services. However, traditional primary care has been criticized for not centring the needs and preferences of people with MM themselves. Our aim was to conduct a review that centred on the perspective of people with MM in multiple ways, including having patient partners co-lead the design, conduct and reporting of findings, and focusing on literature that reported the perspective of people with MM, irrespective of it being experimental or nonexperimental.

METHODS

We searched for published literature in CINAHL with Full Text (EBSCOhost) and MEDLINE All (Ovid). Findings from experimental and nonexperimental studies were integrated into collaboration with patient partners.

RESULTS

Twenty-nine articles were included in the review. Findings are described in five categories: (1) Care that is tailored to my unique situation; (2) meaningful inclusion in the team; (3) a healthcare team that is ready and able to address my complex needs; (4) supportive relationships and (5) access when and where I need it.

CONCLUSION

This review supports a reorientation of primary care systems to better reflect the experiences and perspectives of people with MM. This can be accomplished by involving patient partners in the design and evaluation of primary care services and incentivizing collaboration among health and social supports and services for people with MM.

PATIENT OR PUBLIC CONTRIBUTION

Patient partners were involved in the design and conduct of this review, and in the preparation of the manuscript. Their involvement is further elucidated in the manuscript text.

Revising the advanced access model pillars: a multimethod study

BACKGROUND

The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care.

METHODS

This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content.

RESULTS

The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model ("Appointment system" and "Interprofessional practice"), 1 was merged with a revised pillar ("Develop contingency plans" with "Planning of needs and supply") and 1 underwent major transformations ("Backlog reduction" to "Continuous adjustment"). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content.

INTERPRETATION

The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Assessing the experience of person-centred coordinated care of people with chronic conditions in the Netherlands: Validation of the Dutch P3CEQ

BACKGROUND

Countries are adapting their health and social care systems to better meet the needs of growing populations with (multiple) chronic conditions. To guide this process, assessment of the 'patient experience' is becoming increasingly important. For this purpose, the Person-Centred Coordinated Care Experience Questionnaire (P3CEQ) was developed in the United Kingdom, and translated into several languages.

AIM

This study aimed to assess the internal and construct validity of the Dutch P3CEQ to capture the experience of person-centred coordinated care of people with chronic conditions in the Netherlands.

PARTICIPANTS AND METHODS

Adults with chronic conditions (N = 1098) completed the Dutch P3CEQ, measures of health literacy and patient activation, and reported the use and perceived quality of care services. Data analysis included Principal Component and reliability analysis (internal validity), analysis of variance and Student's T-tests (construct validity).

RESULTS

The two-component structure found was pretty much the same as in the UK validation study. Sociodemographic correlates also resembled those found in the United Kingdom. Women, persons who were less educated, less health-literate or less activated experienced less person-centred coordinated care. P3CEQ scores correlated positively with general practitioner performance scores and quality ratings of the total care received.

CONCLUSION

The Dutch P3CEQ is a valid instrument to assess the experience of person-centred coordinated care among people with chronic conditions in the Netherlands. Awareness of inequity and more attention to communication skills in professional training are needed to ensure that care professionals better recognize the needs of women, lower educated or less health-literate persons, and improve their experiences of care.

PATIENT CONTRIBUTION

The P3CEQ has been developed in collaboration with a range of stakeholders. Eighteen persons with (multiple) chronic conditions participated as patient representatives and codesign experts in (four) codesign workshops. Other patient representatives participated in cognitive testing of the English-language instrument. The usability of the P3CEQ to capture the experience of person-centred coordinated care of older persons has been examined by interviewing 228 older European service users, including 13 living in the Netherlands, as part of the SUSTAIN project. More than a thousand persons with chronic conditions participated in the validation study of the Dutch P3CEQ.

Priorities and preferences for care of people with multiple chronic conditions

Background

To guide the development of high‐quality care for people with multiple chronic conditions, partners of the European Joint Action CHRODIS developed the Integrated Multimorbidity Care Model. To assess its suitability for improving care for people with multimorbidity in the Netherlands, the model was piloted in a primary care setting with both patients and care providers.

Aim

This paper reports on the patient perspective, and aims to explore the priorities, underlying values and preferences for care of people with multimorbidity.

Participants and methods

Twenty persons with multimorbidity (selected from general practice registries) participated in a focus group or telephone interview. Subsequently, a questionnaire was completed by 863 persons with multimorbidity registered with 14 general practices. Qualitative data were thematically analysed and quantitative data by means of descriptive statistics.

Results

Frequently prioritized elements of care were the use of shared electronic health records, regular comprehensive assessments, self‐management support and shared decision making, and care coordination. Preferences for how these elements should be specifically addressed differed according to individual values (eg weighing safety against privacy) and needs (eg ways of coping with multimorbidity).

Conclusion

The JA‐CHRODIS Integrated Multimorbidity Care Model reflects the priorities and preferences for care of people with multimorbidity in the Netherlands, which supports its relevance to guide the development of person‐centred integrated care for people with multiple chronic conditions in the Netherlands.

Patient contribution

European patient experts contributed to the development and applicability assessment of the JA‐CHRODIS Integrated Multimorbidity Care Model; Dutch patients participated in focus groups, interviews and a survey.

Frequent attenders' experiences of encounters with healthcare personnel: A systematic review of qualitative studies

Rather than measure demographic factors such as socioeconomics, the aim of this study was to examine the lived experience of frequent attenders by synthesizing findings on their encounters with healthcare personnel. The Scopus, CINAHL, PsycARTICLES, and PubMed (Medline) databases were searched in May 2020 in order to screen studies by title and abstract (n = 1794) and full-text (n = 20). Findings from the included studies (n = 6) were then pooled using meta-aggregation, yielding the following results: difficulties in resolving frequent attenders' situations may create "service circles," frustrating patients with their situation; frequent attenders' own expertise regarding their condition should be recognized and valued alongside that of healthcare professionals when performing collaborative care; a lack of empathy and disparagement may make frequent attenders feel misunderstood and unappreciated; frequent attenders should be recognized as individuals by taking their circumstances into account and providing support accordingly. Frequent attenders' experiences demonstrate the importance of shared decision-making, continuity of care, and acknowledging these patients' individual circumstances. Identifying the variety of frequent attenders' service needs by synthesizing their experiences is a practical way of organizing patient-centered healthcare services.

Association between continuity and access in primary care: a retrospective cohort study

BACKGROUND

Continuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care.

METHODS

We conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department.

RESULTS

We analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access.

INTERPRETATION

Changes in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.

Multimorbidity and consultation time: a systematic review

BACKGROUND

Multimorbidity (MM) is one of the major challenges health systems currently face. Management of time length of a medical consultation with a patient with MM is a matter of concern for doctors.

METHODS

A systematic review was performed to describe the impact of MM on the average time of a medical consultation considering the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. The systematic online searches of the Embase and PubMed databases were undertaken, from January 2000 to August 2018. The studies were independently screened by two reviewers to decide which ones met the inclusion criteria. (Kappa = 0.84 and Kappa = 0.82). Differing opinions were solved by a third person. This systematic review included people with MM criteria as participants (two or more chronic conditions in the same individual). The type of outcome included was explicitly defined - the length of medical appointments with patients with MM. Any strategies aiming to analyse the impact of MM on the average consultation time were considered. The length of time of medical appointment for patients without MM was the comparator criteria. Experimental and observational studies were included.

RESULTS

Of 85 articles identified, only 1 observational study was included, showing a clear trend for patients with MM to have longer consultations than patients without MM criteria (p < 0.001).

CONCLUSIONS

More studies are required to better assess allocation length-time for patients with MM and to measure other characteristics like doctors' workload.

Health-related preferences of older patients with multimorbidity: an evidence map

OBJECTIVES

To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence.

DESIGN

Evidence map (systematic review variant).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018.

STUDY SELECTION

Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions).

DATA EXTRACTION

Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software.

RESULTS

The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies.

CONCLUSION

Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences.

TRIAL REGISTRATION NUMBER

Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.