Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project

Enhancing Primary Care and Mental Health Integration for Women Veterans with Complex Healthcare Needs Using Evidence-Based Quality Improvement

BACKGROUND

Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach to implementing new care models that can address care gaps for women Veterans.

OBJECTIVE

This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs.

DESIGN

Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans.

PARTICIPANTS

Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team.

MAIN MEASURES

We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution.

KEY RESULTS

The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges.

CONCLUSIONS

Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems.

Strategic use of resources to enhance colorectal cancer screening for patients with diabetes (SURE: CRC4D) in federally qualified health centers: a protocol for hybrid type ii effectiveness-implementation trial

BACKGROUND

Persons with diabetes have 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from priority health disparities populations. Federally qualified health centers (FQHCs) struggle to implement CRC screening programs for average risk patients. Strategies to effectively prioritize and optimize CRC screening for patients with diabetes in the primary care safety-net are needed.

METHODS

Guided by the Exploration, Preparation, Implementation and Sustainment Framework, we conducted a stakeholder-engaged process to identify multi-level change objectives for implementing optimized CRC screening for patients with diabetes in FQHCs. To identify change objectives, an implementation planning group of stakeholders from FQHCs, safety-net screening programs, and policy implementers were assembled and met over a 7-month period. Depth interviews (n = 18-20) with key implementation actors were conducted to identify and refine the materials, methods and strategies needed to support an implementation plan across different FQHC contexts. The planning group endorsed the following multi-component implementation strategies: identifying clinic champions, development/distribution of patient educational materials, developing and implementing quality monitoring systems, and convening clinical meetings. To support clinic champions during the initial implementation phase, two learning collaboratives and bi-weekly virtual facilitation will be provided. In single group, hybrid type 2 effectiveness-implementation trial, we will implement and evaluate these strategies in a in six safety net clinics (n = 30 patients with diabetes per site). The primary clinical outcomes are: (1) clinic-level colonoscopy uptake and (2) overall CRC screening rates for patients with diabetes assessed at baseline and 12-months post-implementation. Implementation outcomes include provider and staff fidelity to the implementation plan, patient acceptability, and feasibility will be assessed at baseline and 12-months post-implementation.

DISCUSSION

Study findings are poised to inform development of evidence-based implementation strategies to be tested for scalability and sustainability in a future hybrid 2 effectiveness-implementation clinical trial. The research protocol can be adapted as a model to investigate the development of targeted cancer prevention strategies in additional chronically ill priority populations.

TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov (NCT05785780) on March 27, 2023 (last updated October 21, 2023).

Quality and team care response to the pandemic stresses in high performing primary care practices: A qualitative study

OBJECTIVE

To learn how high performing primary care practices organized care for patients with diabetes during the initial months of the COVID-19 pandemic.

PARTICIPANTS AND METHODS

Semi-structured interviews were conducted between August 10 and December 10, 2020 with 16 leaders from 11 practices that had top quartile performance measures for diabetes outcomes pre-COVID. Each clinic had completed a similar interview and a survey about the existence of care management systems associated with quality outcomes before the pandemic. Transcript analysis utilized a theoretical thematic analysis at the semantic level.

RESULTS

The pandemic disrupted the primary care practices' operations and processes considered important for quality prior to the pandemic, particularly clinic reliance on proactive patient care. Safety concerns resulted from the shift to virtual visits, which produced documentation gaps and led practices to reorder their use of proactive patient care processes. Informal interactions with patients also declined. These practices' challenges were mitigated by technical, informational and operational help from the larger organizations of which they were a part. Care management processes had to accommodate both in-person and virtual visits.

CONCLUSION

These high performing practices demonstrated an ability to adapt their use of proactive patient care processes in pursuing quality outcomes for patients with diabetes during the pandemic. Continued clinic transformation and improvements in quality within primary care depend on the ability to restructure the responsibilities of care team members and their interactions with patients.

Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study

PURPOSE

Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness.

METHODS

We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators.

RESULTS

Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators.

CONCLUSIONS

Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.

Developing indicators and measures of high-quality for Australian general practice

BACKGROUND

Rising health costs and health inequity are major challenges in Australia, as internationally. Strong primary health care is well evidenced to address these challenges. Primary Health Networks (PHNs) work with general practices to collect data and support quality improvement; however, there is no consensus regarding what defines high quality. This paper describes the development of an evidence-based suite of indicators and measures of high-quality general practice for the Australian context.

METHODS

We reviewed the literature to develop a suitable framework and revise quality assurance measures currently in use, then reviewed these in three workshops with general practitioners, practice managers, nurses, consumers and PHN staff in western Sydney. We used a descriptive qualitative research approach to analyse the data.

RESULTS

A total of 125 evidence-based indicators were agreed to be relevant, and 80 were deemed both relevant and feasible. These were arranged across a framework based on the Quadruple Aim, and include structure, process and outcome measures.

CONCLUSIONS

The agreed suite of indicators and measures will be further validated in collaboration with PHNs across Australia. This work has the potential to inform health systems innovation both nationally and internationally.

Transforming Latinx HIV Care: Mixed-Methods Evaluation of a Patient-Centered HIV Practice Transformation

We conducted a mixed-method longitudinal evaluation of an HIV primary care practice transformation project in Washington, D.C. The project aimed to enhance organizational capacity to deliver culturally appropriate and patient-centered care for Latinxs living with HIV. Quantitative and qualitative data were simultaneously collected to capture the complex interactions among care providers, staff, and patients as well as to monitor practice changes that occurred as a result of the project implementation. The practice transformation intervention consisted of core competency workforce training, workflow redesign, and data-driven quality improvement strategies utilized to guide the intervention and to gather data from providers and patients. The mixed-methods approach facilitated meaningful change within the clinic that resulted in improved patient outcomes, patient experiences of care, and increases in staff's perceived level of knowledge of patient-centered care and improved efficiencies in HIV health care service delivery.

How Type of Practice Ownership Affects Participation with Quality Improvement External Facilitation: Findings from EvidenceNOW

BACKGROUND

Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives.

OBJECTIVE

Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation.

STUDY DESIGN

We used an iterative mixed-methods design.

PARTICIPANTS, APPROACH, AND MEASURES

We collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation.

KEY RESULTS

In the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: - 2.83, p < 0.01 for number of encounters, and - 2.04, p < 0.01 for number of months with encounters). Qualitative data showed that Health System and FQHC ownership influenced types of practices enrolled in EvidenceNOW, and suggested that in these practices lower autonomy and greater complexity compared to clinician-owned ownership influenced facilitation participation patterns.

CONCLUSIONS

Practice ownership shaped how but not how much practices participated in external facilitation. This finding highlights the importance of tailoring facilitation approaches based on ownership-related characteristics in future QI initiatives.

Multiple health behaviour change primary care intervention for smoking cessation, physical activity and healthy diet in adults 45 to 75 years old (EIRA study): a hybrid effectiveness-implementation cluster randomised trial

BACKGROUND

This study aimed to evaluate the effectiveness of a) a Multiple Health Behaviour Change (MHBC) intervention on reducing smoking, increasing physical activity and adherence to a Mediterranean dietary pattern in people aged 45-75 years compared to usual care; and b) an implementation strategy.

METHODS

A cluster randomised effectiveness-implementation hybrid trial-type 2 with two parallel groups was conducted in 25 Spanish Primary Health Care (PHC) centres (3062 participants): 12 centres (1481 participants) were randomised to the intervention and 13 (1581 participants) to the control group (usual care). The intervention was based on the Transtheoretical Model and focused on all target behaviours using individual, group and community approaches. PHC professionals made it during routine care. The implementation strategy was based on the Consolidated Framework for Implementation Research (CFIR). Data were analysed using generalised linear mixed models, accounting for clustering. A mixed-methods data analysis was used to evaluate implementation outcomes (adoption, acceptability, appropriateness, feasibility and fidelity) and determinants of implementation success.

RESULTS

14.5% of participants in the intervention group and 8.9% in the usual care group showed a positive change in two or all the target behaviours. Intervention was more effective in promoting dietary behaviour change (31.9% vs 21.4%). The overall adoption rate by professionals was 48.7%. Early and final appropriateness were perceived by professionals as moderate. Early acceptability was high, whereas final acceptability was only moderate. Initial and final acceptability as perceived by the participants was high, and appropriateness moderate. Consent and recruitment rates were 82.0% and 65.5%, respectively, intervention uptake was 89.5% and completion rate 74.7%. The global value of the percentage of approaches with fidelity ≥50% was 16.7%. Eight CFIR constructs distinguished between high and low implementation, five corresponding to the Inner Setting domain.

CONCLUSIONS

Compared to usual care, the EIRA intervention was more effective in promoting MHBC and dietary behaviour change. Implementation outcomes were satisfactory except for the fidelity to the planned intervention, which was low. The organisational and structural contexts of the centres proved to be significant determinants of implementation effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03136211 . Registered 2 May 2017, "retrospectively registered".

Cultural And Structural Features Of Zero-Burnout Primary Care Practices

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.

Implementation of a patient centred medical home (PCMH) initiative in general practices in New South Wales, Australia

BACKGROUND

With an ageing population and an increase in chronic disease burden in Australia, Patient Centred Medical Home (PCMH) models of care have been identified as potential options for primary care reform and improving health care outcomes. Adoption of PCMH models are not well described outside of North America. We examined the experiences of seven general practices in an Australian setting that implemented projects aligned with PCMH values and goals supported by their local Primary Health Network (PHN).

METHOD

Qualitative and quantitative data were collected over a twelve month period, including semi-structured interviews, participant observation, and practice data to present a detailed examination of a subject of study; the implementation of PCMH projects in seven general practices. We conducted 49 interviews (24 pre and 25 post) with general practitioners, practice managers, practice nurses and PHN staff. Framework analysis deploying the domains of a logic model was used to synthesis and analyse the data.

RESULTS

Facilitators in implementing successful, sustainable change included the capacity and willingness of practices to undertake change; whole of practice engagement with a shared vision towards PCMH change; engaged leadership; training and support; and structures and processes required to provide team-based, data driven care. Barriers to implementation included change fatigue, challenges of continued engaged leadership and insufficient time to implement PCMH change.

CONCLUSIONS

Our study examined the experiences of implementing PCMH initiatives in an Australian general practice setting, describing facilitators and barriers to PCMH change. Our findings provide guidance for PHNs and practices within Australia, as well as general practice settings internationally, that are interested in undertaking similar quality improvement projects.

Eliciting and Understanding Primary Care and Specialist Mental Models of Cirrhosis Care: A Cognitive Task Analysis Study

BACKGROUND

Gaps in coordination and transitions of care for liver cirrhosis contribute to high rates of hospital readmissions and inadequate quality of care. Understanding the differences in the mental models held by specialty and primary care physicians may help to identify the root causes of problems in the coordination of cirrhosis care.

AIM

To compare and identify differences in the mental models of cirrhosis care held by primary and specialty care physicians and nurse practitioners that may be addressed to improve coordination and transitions.

METHODS

Cross-sectional formal elicitation of mental models using Cognitive Task Analysis. Purposive and chain-referral sampling to select family physicians (n = 8), specialists (n = 9), and cirrhosis-dedicated nurse practitioners (n = 2) across Alberta.

RESULTS

Family physicians do not maintain rich mental models of cirrhosis care. They see cirrhosis patients relatively infrequently, rebuilding their mental models when required (knowledge on demand). They have reactive and patient-need-focused, rather than proactive and system-of-care, mental models. Specialists' mental models are rich but vary widely between patient-centered and task-centered and in the degree to which they incorporate responsibility for addressing system gaps. Nurse practitioners hold patient-centered mental models like specialists but take responsibility for addressing gaps in the system.

CONCLUSIONS

Improving the coordination of cirrhosis care will require infrastructure to design care pathways and work processes that will support family physicians' knowledge-on-demand needs, facilitate primary care-specialist relationships, and deliberately work toward building a shared mental model of responsibilities for addressing medical care and social determinants of health.

Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home

BACKGROUND

Despite widespread adoption of patient-centered medical home (PCMH), little is known about why practices pursue PCMH and what is needed to undergo transformation.

OBJECTIVE

Examine reasons practices obtained and maintained PCMH recognition and what resources were needed.

DESIGN

Qualitative study of practice leader perspectives on PCMH transformation, based on a random sample of primary care practices engaged in PCMH transformation, stratified by US region, practice size, PCMH recognition history, and practice use of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) PCMH survey.

PARTICIPANTS

105 practice leaders from 294 sampled practices (36% response rate).

APPROACH

Content analysis of interviews with practice leaders to identify themes.

RESULTS

Most practice leaders had local control of PCMH transformation decisions, even if practices adopted quality initiatives under the direction of an organization or network. Financial incentives, being in a statewide effort, and the intrinsic desire to improve care or experiences were the most common reasons practice leaders decided to obtain PCMH recognition and pursue associated care delivery changes. Leadership support and direction were highlighted as essential throughout PCMH transformation. Practice leaders reported needing specialized staff knowledge and significant resources to meet PCMH requirements, including staff knowledgeable about how to implement PCMH changes, track and monitor improvements, and navigate implementation of simultaneous changes, and staff with specific quality improvement (QI) expertise related to evaluating changes and scaling-up programs.

CONCLUSION

PCMH efforts necessitated support and assistance to frontline, on-site practice leaders leading care delivery changes. Such change efforts should include financial incentives (e.g., direct payment or additional reimbursement), leadership direction and support, and internal or external staff with experience with the PCMH application process, implementation changes, and QI expertise in monitoring process and outcome data. Policies that recognize and meet the needs of on-site practice leaders will better promote primary care practice transformation and move practices further toward their PCMH transformation goals.

Practice level factors associated with enhanced engagement with practice facilitators; findings from the heart health now study

BACKGROUND

Practice facilitation is a promising strategy to enhance care processes and outcomes in primary care settings. It requires that practices and their facilitators engage as teams to drive improvement. In this analysis, we explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month practice facilitation intervention focused on implementing cardiovascular prevention activities in practice. Understanding factors associated with greater engagement with facilitators in practice-based quality improvement can assist practice facilitation programs with planning and resource allocation.

METHODS

One hundred thirty-six ambulatory care small to medium sized primary care practices that participated in the EvidenceNow initiative's NC Cooperative, named Heart Health Now (HHN), fit the eligibility criteria for this analysis. We explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month intervention using a retrospective cohort design that included baseline survey data, monthly practice activity implementation data and information about facilitator's experience. Generalized linear mixed-effects models (GLMMs) identified variables associated with greater odds of team engagement using an ordinal scale for level of team engagement.

RESULTS

Among our practice cohort, over half were clinician-owned and 27% were Federally Qualified Health Centers. The mean number of clinicians was 4.9 (SD 4.2) and approximately 40% of practices were in Medically Underserved Areas (MUA). GLMMs identified a best fit model. The Model presented as odd ratios and 95% confidence intervals suggests greater odds ratios of higher team engagement with greater practice QI leadership 17.31 (5.24-57.19), [0.00], and practice location in a MUA 7.25 (1.8-29.20), [0.005]. No facilitator characteristics were independently associated with greater engagement.

CONCLUSIONS

Our analysis provides information for practice facilitation stakeholders to consider when considering which practices may be more amendable to embracing facilitation services.

Perceived enabling factors and barriers for the implementation of improvements in health care in order to achieve patient-centred care: A case report from Sweden

RATIONALE, AIM, AND OBJECTIVES

More knowledge is needed regarding the complex factors and perceptions that enable the implementation of change in health care. The study aimed to examine the enabling factors and barriers encountered in the implementation of improvements in health care in order to achieve patient-centred care (PCC) and to study if there was a correlation in the extent the improvements were perceived to be implemented and the preconditions that were considered to affect them.

METHODS

Using a mixed method design, data were gathered via a questionnaire and individual interviews with health care personnel, clinic managers, and first-line managers. The data collection and analyses were based on the framework for Promoting Action on Research Implementation in Health Services (PARiHS). Correlations between PCC improvements and preconditions for improvements were performed.

RESULTS

A high level of involvement, knowledge, and adequate resources were considered important to achieve an implementation of PCC with joint responsibility. Leadership and management need to be explicit and promote continuous follow-up and feedback. Preconditions for improvement had a linear correlation with the perceived level of implementation. Knowledge-related preconditions had greatest impact on implementation.

CONCLUSIONS

The PARiHS framework was appropriate to use since the three components of evidence, context, and facilitation present different important preconditions in the implementation process. Evidence was the highest rated contributor since evidence-based practices in health care are necessary. It is vital that the important role of the context and facilitators is acknowledged in the implementation process to enable a successful implementation of change. There is a need to incorporate a clear strategy involving all levels in the organization. Furthermore, leaders play an important role in the implementation by facilitating communication and support and by having trust in facilitators and health care personnel. The results are applicable to other interventions implementing change in health care.

Patients' expectations for and experiences with primary healthcare services received from a patient centered medical home

OBJECTIVE

Expectations for and experiences with healthcare services are summarized for 1143 patients receiving care in a statewide demonstration of Patient Centered Medical Homes (PCMH).

METHODS

Patients were recruited from 91 primary care clinics for semi-structured interviews to determine what patients expect, what they plan to do and how they intend to execute their plans in partnership with their healthcare team.

RESULTS

The majority (78%) of patients defined the patient-team partnership as a collaborative and problem-solving effort. Overall, 68% defined responsibility for own health as a personal responsibility; 55% defined listening to patient's concerns and answering questions as a responsibility of their healthcare team. Diet and exercise came up most frequently whether as a personal responsibility, issues for receiving additional help from their clinic, or plans for personal change.

CONCLUSION

Patients' preferred a collaborative, problem-solving healthcare team partnership but also had boundaries for what additional services they wanted from this team.

PRACTICE IMPLICATIONS

Patients' expectations for a collaborative partnership, acceptance of personal responsibility and interest in diet and exercise expands opportunities for patient education and teamwork. Clinics' engagement with broader resources would be needed to address patients' many and varied challenges to taking care of their health.

Leading Innovative Practice: Leadership Attributes in LEAP Practices

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.

CONTEXT

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.

METHODS

A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.

FINDINGS

We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.

CONCLUSIONS

Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration

Background

Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants’ fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity.

Methods

Nine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010–2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis.

Results

Seven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity.

Conclusions

This study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.

The roles of healthcare professionals in diabetes care: a qualitative study in Norwegian general practice

Objective: To explore the experiences of general practitioners (GPs), nurses and medical secretaries in providing multi-professional diabetes care and their perceptions of professional roles.Design, setting and subjects: Semi-structured interviews were conducted with six GPs, three nurses and two medical secretaries from five purposively sampled diabetes teams. Interviews were analysed thematically.Main outcome measures: Healthcare professionals' (HCPs') experiences of multi-professional diabetes care in general practice.Results: The involvement of nurses and medical secretaries (collaborating health care professionals) was mainly motivated by GPs' time pressure and their perception of diabetes care as easy to standardize. GPs reported that diabetes care had become more structured and continuous after the involvement of collaborating health care professionals (cHCPs). cHCPs defined their role differently from GPs, emphasizing that their approach included acknowledging patients' need for diabetes education, listening to their stories and meeting their need for emotional support. GPs appeared less involved in patients' emotional concerns and more focused on the biomedical aspects of illness. There was little emphasis on teamwork among GPs and cHCPs, and none of the practices used care plans to involve patients in decisions or unify treatment among professionals. Participants stated that institutional structures including a discriminatory remuneration system, lack of role descriptions and missing procedures for collaborative approaches were an obstacle to MPC.Conclusions: cHCPs worked independently under delegated leadership of the GPs. Although cHCPs had a complementary role, HCPs in general practice may not take full advantage of the potential of sharing patient responsibility and learning with, from and about each other. Contextual barriers for team-based care approaches should be addressed in future research.KEY POINTSIt has been suggested that multi-professional approaches improve quality of care in people with long-term conditions.In this study, nurses and medical secretaries perceived to have a complementary role to general practitioners (GPs) in diabetes care, focusing on patient education, building trusting relationships and providing patients with emotional support.As multi-professional collaboration was minimal, GPs, nurses and medical secretaries in the included practices may not take full advantage of the potential of sharing care responsibility and learning with, from and about each other.

The 3 Cs of Content, Context, and Concepts: A Practical Approach to Recording Unstructured Field Observations

Most primary care researchers lack a practical approach for including field observations in their studies, even though observations can offer important qualitative insights and provide a mechanism for documenting behaviors, events, and unexpected occurrences. We present an overview of unstructured field observations as a qualitative research method for analyzing material surroundings and social interactions. We then detail a practical approach to collecting and recording observational data through a "3 Cs" template of content, context, and concepts. To demonstrate how this method works in practice, we provide an example of a completed template and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar.

An observational study of a clinical guideline implementation project in primary care

Explorations of workflow development within primary care allow us to understand initial steps in the pace of knowledge and practice acclimatization within clinics. This study describes use of practice facilitation as an implementation strategy to communicate shared project goals and monitor and support refinement of practice behavior. This study engaged eight health care organizations, including 55 primary care practices, ≈380 clinicians, and ≈620 nursing and support staff in a guideline implementation project regarding United States Preventive Services Task Force use of aspirin recommendations for primary prevention of cardiovascular events.

Differences in Team Mental Models Associated With Medical Home Transformation Success

PURPOSE

Primary care transformation is widely seen as essential to improving patient outcomes and health care costs. The medical home model can achieve these ends, but dissemination and scale-up of practice transformation is challenging. We sought to understand how to move past successful pilot efforts by early adopters to widespread adoption by applying cognitive task analysis using the diffusion of innovations framework.

METHODS

We undertook a qualitative cross-sectional comparison of 3 early adopter practices and 15 early majority practices in Alberta, Canada. Practices completed a total of 42 cognitive task analysis interviews. We conducted a framework-guided qualitative analysis, with allowance for emergent themes, using the macrocognition framework on which cognitive task analysis is based. Independent codings of interview transcripts for key macrocognitive functions were reviewed in group analysis meetings to describe macrocognitive functions and team mental models, and identify emergent themes. Two external focus groups provided support for these findings.

RESULTS

Three prominent findings emerged. The first was a spectrum of mental models from "doctor with helpers," through degrees of delegation, to fully team based care. The second was differences in how teams distributed macrocognitive functions among members, with early adopters distributing these functions more widely across the team than early majority practices. Finally, we saw emergence of several themes also common in the diffusion of innovations literature, such as the importance of trying new practices in small, reversible steps.

CONCLUSIONS

Our findings provide guidance to practice teams, health systems, and policymakers seeking to move beyond early adopters, to improve team functioning and advance the medical home transformation at scale.

Communication Among Team Members Within the Patient-centered Medical Home and Patient Satisfaction With Providers: The Mediating Role of Patient-Provider Communication

BACKGROUND

The Patient-centered Medical Home (PCMH) uses team-based care to improve patient outcomes, including satisfaction. The quality of patients' communication with their primary care providers (PCPs) is a key determinant of patient satisfaction. A shift to team-based care could disrupt the therapeutic relationship between patients and their PCPs and reduce patient satisfaction if communication and coordination among primary care team members is poor. Little is known about the relationship between intrateam communication within a PCMH and patient satisfaction with PCPs, and whether patient-provider communication might mediate this relationship.

OBJECTIVES

To examine the relationship between intrateam communication in a PCMH and patients' satisfaction with assigned PCPs, and whether patient-provider communication mediates this relationship.

RESEARCH DESIGN

Cross-sectional surveys of Veterans Health Administration PCPs (2011-2012, n=149) matched with their assigned patients' surveys (n=3329). Mediation analyses using a nested data structure, controlling for patient and provider characteristics.

MEASURES

Patient satisfaction with PCPs, patient-reported patient-provider communication, and PCP-reported intrateam communication within the PCMH.

RESULTS

Intrateam communication and patient-provider communication were independently associated with patients' satisfaction with their PCPs. Patient-provider communication mediated 56% of the association between intrateam communication and patient satisfaction. Better intrateam communication combined with better patient-provider communication predicted high satisfaction (81%), compared with poor intrateam communication and poor patient-provider communication (22%).

CONCLUSIONS

PCMH environments with better communication among team members are likely to experience better patient-provider communication and high patient satisfaction. PCMH practices with low ratings of patient satisfaction may need to look beyond individual PCPs to communication within and across teams.

The Effects of a Primary Care Transformation Initiative on Primary Care Physician Burnout and Workplace Experience

BACKGROUND

Physician burnout is associated with deleterious effects for physicians and their patients and might be exacerbated by practice transformation.

OBJECTIVE

Assess the effect of the Comprehensive Primary Care (CPC) initiative on primary care physician experience.

DESIGN

Prospective cohort study conducted with about 500 CPC and 900 matched comparison practices. Mail surveys of primary care physicians, selected using cross-sectional stratified random selection 11 months into CPC, and a longitudinal design with sample replacement 44 months into CPC.

PARTICIPANTS

Primary care physicians in study practices.

INTERVENTION

A multipayer primary care transformation initiative (October 2012-December 2016) that required care delivery changes and provided enhanced payment, data feedback, and learning support.

MAIN MEASURES

Burnout, control over work, job satisfaction, likelihood of leaving current practice within 2 years.

KEY RESULTS

More than 1000 physicians responded (over 630 of these in CPC practices) in each round (response rates 70-81%, depending on round and research group). Physician experience outcomes were similar for physicians in CPC and comparison practices. About one third of physician respondents in CPC and comparison practices reported high levels of burnout in each round (32 and 29% in 2013 [P = 0.59], and 34 and 36% in 2016 [P = 0.63]). Physicians in CPC and comparison practices reported some to moderate control over work, with an average score from 0.50 to 0.55 out of 1 in 2013 and 2016 (CPC-comparison differences of - 0.04 in 2013 [95% CI - 0.08-0.00, P = 0.07], and - 0.03 in 2016 [95% CI - 0.03-0.02, P = 0.19]). In 2016, roughly three quarters of CPC and comparison physicians were satisfied with their current job (77 and 74%, P = 0.77) and about 15% planned to leave their practice within 2 years (14 and 15%, P = 0.17).

CONCLUSIONS

Despite requiring substantial practice transformation, CPC did not affect physician experience. Research should track effects of other transformation initiatives on physicians and test new ways to address burnout.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT02320591.

Development and Implementation of an HIV Health Care Practice Transformation Model for Latinos

A Latino Community Health Center in Washington, D.C. implemented and evaluated a practice transformative model to optimize human resources and improve quality health outcomes in HIV service delivery for Latino patients. We conducted a qualitative formative assessment through interviews and focus groups with clinic staff and patients living with HIV/AIDS in order to inform implementation. The formative assessment identified specific training and practice facilitation needs and provided valuable insight for choosing evaluation metrics. Incorporating staff input fostered staff engagement in laying the foundation of the transformation and helped build a sense of ownership of the transformative process. Through the formative assessment process we gained insight into the organization's HIV practice and improved our ability to align practice transformation goals with evaluation metrics to better measure changes resulting from the model implementation. The formative assessment process also highlighted challenges in conducting health systems research with Latino communities in the U.S.

Correlates of Patient-Centered Medical Home Recognition in School-Based Health Centers

BACKGROUND

The patient-centered medical home (PCMH) is promoted as a way to improve access to care, health care outcomes, and control costs. The organizational, environmental, and patient characteristics associated with school-based health centers (SBHCs) obtaining PCMH recognition is currently unknown. A multitheoretical approach was used to explore the correlates of formal PCMH recognition in SBHCs.

METHODS

The 2013-2014 National Census of School-Based Health Centers was used as the primary data source for this analysis. Multivariable logistic regression was used to assess the odds of an SBHC obtaining any type of PCMH recognition, and obtaining national PCMH recognition.

RESULTS

Only 29% of SBHCs had received any type of recognition as a PCMH and 17% reported receiving national-level recognition. School-based health centers that were managed care preferred providers, received Health Resources and Services Administration SBHC Capital Funding, and based in schools without adolescents had greater odds of both types of PCMH recognition outcomes. High levels of revenue from patient billing and more staff were also associated with national PCMH recognition.

CONCLUSIONS

Financial and personnel resources are needed for national-level PCMH recognition, and managed care is supportive of PCMH implementation. Efforts should be made to increase medical home activity in SBHCs that serve adolescents.

Implementing Community-Created Self-Management Support Tools in Primary Care Practices: Multimethod Analysis From the INSTTEPP Study

PURPOSE

With one-half of Americans projected to be living with at least one chronic condition before 2020, enhancing patient self-management support (SMS) may improve health-related behaviors and clinical outcomes. Routine SMS implementation in primary care settings is difficult. Little is known about the practice conditions required for successful implementation of SMS tools.

METHODS

Four primary care practice-based research networks (PBRNs) recruited 16 practices to participate in a boot camp translation process to adapt patient-centered SMS tools. Boot camp translation sessions were held over a 2-month period with 2 patients, a clinician, and a care manager from each practice. Qualitative case comparison and qualitative comparative analysis were used to examine practice conditions needed to implement SMS tools. The Consolidated Framework for Implementation Research guided data collection and analysis.

RESULTS

Four different practice conditions affected the implementation of new SMS tools: functional practice organization; system that enables innovation and change; presence of a visible, activated champion; and synergy and alignment of SMS changes with other work. Qualitative comparative analysis suggested that it was necessary to have an enabling system, a visible champion, and synergy for a practice to at least minimally implement the SMS tools. Sufficiency testing, however, failed to show robust consistency to satisfactorily explain conditions required to implement new SMS tools.

CONCLUSIONS

To implement tailored self-management support tools relatively rapidly, the minimum necessary conditions include a system that enables innovation and change, presence of a visible champion, and alignment of SMS changes with other work; yet, these alone are insufficient to ensure successful implementation.

The Politics of Primary Care Expansion: Lessons From Cancer Survivorship and Substance Abuse

EXECUTIVE SUMMARY

The purpose of this study is to understand the perspectives of primary care innovators treating patient populations not traditionally considered to be within the purview of primary care. Data were obtained from the 2015 Working Conference for PCMH (Patient-Centered Medical Home) Innovation funded by the Agency for Healthcare Research and Quality. The conference convened representatives from 10 innovative primary care practices and content experts to discuss experiences with integrating care for two nontraditional populations: patients with substance abuse issues and cancer survivors. Transcripts of the conference, one-on-one interviews, and written summaries of practice innovations were coded in NVivo (QSR International) and analyzed by means of an immersion/crystallization approach to identifying thematic patterns. Our study findings suggest that the politics surrounding entrenched professional identities contributed to barriers faced by conference participants in their efforts to provide innovative care for these nontraditional populations. Specifically, obstacles surfaced in relation to sharing patients across disciplinary boundaries, which resulted in issues of possessiveness, a questioning of provider qualifications, and a lack of interprofessional trust. Though support is increasing for primary care expansion and care integration, policy change may precede the identity transformations necessary for medical practitioners to embrace new primary care-centered models. For this reason, it is important that the formation and entrenchment of professional identities be critically considered as part of future efforts to transform primary care practice.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries

BACKGROUND

Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm.

OBJECTIVE

To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.

METHODS

An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.

RESULTS

Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.

CONCLUSION

The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach

BACKGROUND

Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies.

OBJECTIVE

To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials.

METHODS

We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights.

RESULTS

CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions.

CONCLUSIONS

The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Outcomes For High-Needs Patients: Practices With A Higher Proportion Of These Patients Have An Edge

High-value primary care for high-needs patients-those with multiple physical, mental, or behavioral health conditions-is critical to improving health system performance. However, little is known about what types of physician practices perform best for high-needs patients. We examined two scale-related characteristics that could predict how well physician practices delivered care to this population: the proportion of patients in the practice that were high-needs and practice size (number of physicians). Using four years of data on commercially insured, high-needs patients in Michigan primary care practices, we found lower spending and utilization among practices with a higher proportion of high-needs patients (more than 10 percent of the practice's panel) compared to practices with smaller proportions. Small practices (those with one or two physicians) had lower overall spending, but not less utilization, compared to large practices. However, practices with a substantial proportion of high-needs patients, as well as small practices, performed slightly worse on a composite measure of process quality than their associated reference group. Practices that treat a high proportion of high-needs patients might have structural advantages or have developed specialized approaches to serve this population. If so, this raises questions about how best to make use of this knowledge to foster high-value care for high-needs patients.

EvidenceNOW: Balancing Primary Care Implementation and Implementation Research

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to generate knowledge about how America's health care delivery system can provide high-quality care, and to ensure that health care professionals and systems understand and use this evidence. In 2015 AHRQ invested in the largest primary care research project in its history. EvidenceNOW is a $112 million effort to disseminate and implement patient-centered outcomes research evidence in more than 1,500 primary care practices and to study how quality-improvement support can build the capacity of primary care practices to understand and apply evidence.EvidenceNOW comprises 7 implementation research grants, each funded to provide external quality-improvement support to primary care practices to implement evidence-based cardiovascular care and to conduct rigorous internal evaluations of their work. An independent, external evaluator was funded to conduct an overarching evaluation using harmonized outcome measures and pooled data. The design of EvidenceNOW required resolving tensions between implementation and implementation research goals.EvidenceNOW is poised to develop a blueprint for how stakeholders can invest in strengthening the primary care delivery system and to offer a variety of resources and tools to improve the capacity of primary care to deliver evidence-based care. Federal agencies must maximize the value of research investments to show improvements in the lives and health of Americans and the timeliness of research results. Understanding the process and decisions of a federal agency in designing a large clinical practice transformation initiative may provide researchers, policy makers, and clinicians with insights into future implementation research, as well as improve responsiveness to funding announcements and the implementation of evidence in routine clinical care.

Effect of Practice Ownership on Work Environment, Learning Culture, Psychological Safety, and Burnout

PURPOSE

Physicians have joined larger groups and hospital systems in the face of multiple environmental challenges. We examine whether there are differences across practice ownership in self-reported work environment, a practice culture of learning, psychological safety, and burnout.

METHODS

Using cross-sectional data from staff surveys of small and medium-size practices that participated in EvidenceNOW in Virginia, we tested for differences in work environment, culture of learning, psychological safety, and burnout by practice type. We conducted weighted multivariate linear regression of outcomes on ownership, controlling for practice size, specialty mix, payer mix, and whether the practice was located in a medically underserved area. We further analyzed clinician and staff responses separately.

RESULTS

Participating were 104 hospital-owned and 61 independent practices and 24 federally qualified health centers (FQHCs). We analyzed 2,005 responses from practice clinicians and staff, a response rate of 49%. Working in a hospital-owned practice was associated with favorable ratings of work environment, psychological safety, and burnout compared with independent practices. When we examined separately the responses of clinicians vs staff, however, the association appears to be largely driven by staff.

CONCLUSIONS

Hospital ownership was associated with positive perceptions of practice work environment and lower burnout for staff relative to independent ownership, whereas clinicians in FQHCs perceive a more negative, less joyful work environment and burnout. Our findings are suggestive that clinician and nonclinician staff perceive practice adaptive reserve differently, which may have implications for creating the energy for ongoing quality improvement work.

Developing measures to assess constructs from the Inner Setting domain of the Consolidated Framework for Implementation Research

Background

Scientists and practitioners alike need reliable, valid measures of contextual factors that influence implementation. Yet, few existing measures demonstrate reliability or validity. To meet this need, we developed and assessed the psychometric properties of measures of several constructs within the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR).

Methods

We searched the literature for existing measures for the 7 Inner Setting domain constructs (Culture Overall, Culture Stress, Culture Effort, Implementation Climate, Learning Climate, Leadership Engagement, and Available Resources). We adapted items for the healthcare context, pilot-tested the adapted measures in 4 Federally Qualified Health Centers (FQHCs), and implemented the revised measures in 78 FQHCs in the 7 states (N = 327 respondents) with a focus on colorectal cancer (CRC) screening practices. To psychometrically assess our measures, we conducted confirmatory factor analysis models (CFA; structural validity), assessed inter-item consistency (reliability), computed scale correlations (discriminant validity), and calculated inter-rater reliability and agreement (organization-level construct reliability and validity).

Results

CFAs for most constructs exhibited good model fit (CFI > 0.90, TLI > 0.90, SRMR < 0.08, RMSEA < 0.08), with almost all factor loadings exceeding 0.40. Scale reliabilities ranged from good (0.7 ≤ α < 0.9) to excellent (α ≥ 0.9). Scale correlations fell below 0.90, indicating discriminant validity. Inter-rater reliability and agreement were sufficiently high to justify measuring constructs at the clinic-level.

Conclusions

Our findings provide psychometric evidence in support of the CFIR Inner Setting measures. Our findings also suggest the Inner Setting measures from individuals can be aggregated to represent the clinic-level. Measurement of the Inner Setting constructs can be useful in better understanding and predicting implementation in FQHCs and can be used to identify targets of strategies to accelerate and enhance implementation efforts in FQHCs.

Change implementation: the association of adaptive reserve and burnout among inpatient medicine physicians and nurses

Adaptive Reserve (AR) is positively associated with implementing change in ambulatory settings. Deficits in AR may lead to change fatigue or burnout. We studied the association of self-reported AR and burnout among providers to hospitalized medicine patients in an academic medical center. An electronic survey containing a 23-item Adaptive Reserve scale, burnout inventory, and demographic questions was sent to a convenience sample of nurses, house staff team members, and hospitalists. A total of 119 self-administered, online surveys collected from June 2014 to March 2015 were analyzed. Ordinal regression analyses were used to examine the association between AR and burnout. Eighty percent of participants reported either level 1 or 2 burnout. Additionally, 10.9% of participants responded level 0% and 7.6% of participants reported level 3. Participants reporting higher burnout were about three times more likely to report lower AR levels. AR is strongly associated with self-reported burnout by physicians and nurses providing inpatient care at this academic medical center. Growing evidence supports the positive association of AR to successful change implementation in ambulatory settings. Similar studies are needed to determine whether certain levels of AR can predict successful change in hospital settings.

How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation

BACKGROUND

Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs.

METHODS

We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains.

RESULTS

Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges.

CONCLUSIONS

Transforming healthcare systems to focus on patient-centered care and better serve the "whole" patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.

Implementing the patient-centered medical home in complex adaptive systems: Becoming a relationship-centered patient-centered medical home

BACKGROUND

This study explores the implementation experience of nine primary care practices becoming patient-centered medical homes (PCMH) as part of the New Hampshire Citizens Health Initiative Multi-Stakeholder Medical Home Pilot.

PURPOSE

The purpose of this study is to apply complex adaptive systems theory and relationship-centered organizations theory to explore how nine diverse primary care practices in New Hampshire implemented the PCMH model and to offer insights for how primary care practices can move from a structural PCMH to a relationship-centered PCMH.

METHODOLOGY/APPROACH

Eighty-three interviews were conducted with administrative and clinical staff at the nine pilot practices, payers, and conveners of the pilot between November and December 2011. The interviews were transcribed, coded, and analyzed using both a priori and emergent themes.

FINDINGS

Although there is value in the structural components of the PCMH (e.g., disease registries), these structures are not enough. Becoming a relationship-centered PCMH requires attention to reflection, sensemaking, learning, and collaboration. This can be facilitated by settings aside time for communication and relationship building through structured meetings about PCMH components as well as the implementation process itself. Moreover, team-based care offers a robust opportunity to move beyond the structures to focus on relationships and collaboration.

PRACTICE IMPLICATIONS

(a) Recognize that PCMH implementation is not a linear process. (b) Implementing the PCMH from a structural perspective is not enough. Although the National Committee for Quality Assurance or other guidelines can offer guidance on the structural components of PCMH implementation, this should serve only as a starting point. (c) During implementation, set aside structured time for reflection and sensemaking. (d) Use team-based care as a cornerstone of transformation. Reflect on team structures and also interactions of the team members. Taking the time to reflect will facilitate greater sensemaking and learning and will ultimately help foster a relationship-centered PCMH.

A Quasi-experimental Evaluation of Performance Improvement Teams in the Safety-Net: A Labor-Management Partnership Model for Engaging Frontline Staff

BACKGROUND

Unit-based teams (UBTs), initially developed by Kaiser Permanente and affiliated unions, are natural work groups of clinicians, managers, and frontline staff who work collaboratively to identify areas for improvement and implement solutions.

OBJECTIVE

We evaluated the UBT model implemented by the Los Angeles County Department of Health Services in partnership with its union to engage frontline staff in improving patient care.

DESIGN

We conducted a quasi-experimental study, comparing surveys at baseline and 6 months, among personnel in 10 clinics who received UBT training to personnel in 5 control clinics. We also interviewed staff from 5 clinics that received UBT training and 3 control clinics.

PARTICIPANTS

We conducted 330 surveys and 38 individual, semi-structured interviews with staff at an outpatient facility in South Los Angeles.

INTERVENTIONS

Each UBT leader received an 8-hour training in basic performance improvement methods, and each UBT was assigned a team "coach."

MAIN MEASURES

Our outcome measure was 6-month change in the "adaptive reserve" score, the units' self-reported ability to make and sustain change. We analyzed transcripts of the interviews to find common themes regarding the UBT intervention.

KEY RESULTS

The survey response rate was 63% (158/252) at baseline and 75% (172/231) at 6 months. There was a significant difference-in-change in adaptive reserve between UBTs and non-UBTs at 6 months (+0.11 vs -0.13; P = .02). Nine of the 10 UBTs reported increases in adaptive reserve and 8 UBTs reported decreased no-show rates or patient length of stay in clinic. Staff overwhelmingly felt the UBTs were a positive intervention because it allowed all levels of staff to have a voice in improvement.

CONCLUSIONS

Our results indicate that partnership between management and unions to engage frontline staff in teams may be a useful tool to improve delivery of health care in a safety-net setting.

Patient-Centered Medical Home Implementation and Burnout Among VA Primary Care Employees

Burnout is widespread throughout primary care and is associated with negative consequences for providers and patients. The relationship between the patient-centered medical home model and burnout remains unclear. Using survey data from 8135 and 7510 VA primary care employees in 2012 and 2013, respectively, we assessed whether clinic-level medical home implementation was independently associated with burnout prevalence and estimated whether burnout changed among this workforce from 2012 to 2013. Adjusting for differences in respondent and clinic characteristics, we found that burnout was common among primary care employees, increased by 3.9% from 2012 to 2013, and was not associated with the extent of medical home implementation.

Cancer Survivorship Care in Advanced Primary Care Practices: A Qualitative Study of Challenges and Opportunities

IMPORTANCE

Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors.

OBJECTIVE

To explain why primary care has not begun to integrate comprehensive cancer survivorship services.

DESIGN, SETTING, AND PARTICIPANTS

Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes.

MAIN OUTCOMES AND MEASURES

Description of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care.

RESULTS

The 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care.

CONCLUSIONS AND RELEVANCE

To increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a functional information system infrastructure.

Tools to Gauge Progress During Patient-Centered Medical Home Transformation

OBJECTIVES

To review tools designed to evaluate and improve the extent of patient-centered medical home (PCMH) implementation.

STUDY DESIGN

Literature search and review of tools to evaluate PCMH "medical homeness" and track progress toward practice transformation.

METHODS

We conducted a literature search to identify tools designed for evaluation and quality improvement during the PCMH change process. We identified and reviewed the content of 5 publicly available PCMH survey tools used by an administrator or clinical lead to collect data at the practice level for evaluation and/or quality improvement during PCMH implementation. We assessed each tool's coverage of PCMH content, standards, and requirements.

RESULTS

We found that 3 tools (Patient-Centered Medical Home Assessment [PCMH-A], Primary Care Assessment Tool-Facility Edition, and Medical Home Care Coordination Survey-Healthcare Team [MHCCS-H]) are actionable for quality improvement. PCMH-A assesses the broadest array of practice capabilities and includes items pertaining to all National Committee for Quality Assurance PCMH standards. MHCCS-H was the only tool to contain items on comprehensiveness of care. There was variation in emphasis on main domains, with some content areas covered by only 1 tool.

CONCLUSIONS

There is currently little evidence on which PCMH tools are associated with improved quality outcomes, as relatively few longitudinal studies have been conducted. Of the 5 tools we reviewed, only PCMH-A and MHCCS-H impose a light administrative burden (less than 10 minutes to complete) and can identify specific actions to improve a given practice capability. Each tool is lacking in a particular content area: PCMH-A, for example, lacks items on comprehensiveness of care, whereas MHCCS-H lacks items addressing access to care.

A Randomized Trial of High-Value Change Using Practice Facilitation

PURPOSE

To understand how focused versus general practice facilitation can impact goal setting, action planning, and team performance in primary care transformation.

BACKGROUND

Practice transformation in primary care is a crucial part of health reform, but can fatigue teams, leading to variable results. Practice facilitation may reduce primary care fatigue to help teams reach challenging transformation goals, but may require a more focused approach than previous studies suggest.

METHODS

We performed a 12-month cluster randomized trial, during which 8 primary care clinics received practice facilitation. Four practices in the intervention arm received targeted facilitation to focus quality improvement (QI) goals on high-value elements (HVEs) intended to reduce cost and utilization, whereas 4 control practices received generalized QI facilitation. We investigated the impact of the targeted versus generalized approach on goal selection, action item selection and achievement, HVE attainment, and collaborative practice, using quantitative and qualitative methods.

RESULTS

Intervention clinics selected an average of 7 goals and 29 action items, compared with 8 goals and 40 action items among controls. Eighty-three percent of intervention goals were related to HVEs, compared with 27% of goals among controls. Intervention clinics selected 101 HVE goals and met 68%, while controls selected 41 and met 61%. Analysis of pre-post practice surveys indicated greater improvement among intervention across 4 of 8 domains of collaborative practice.

CONCLUSION

Targeted facilitation may be more effective than a generalized approach to support practices in reaching high-value change goals, as well as fostering improvement of team focus on goals, roles and responsibilities.

Role enactment of facilitation in primary care - a qualitative study

Background

Facilitation is a widely used implementation method in quality improvement. Reviews reveal a variety of understandings of facilitation and facilitator roles. Research suggests that facilitation interventions should be flexible and tailored to the needs and circumstances of the receiving organisations. The complexity of the facilitation field and diversity of potential facilitator roles fosters a need to investigate in detail how facilitation is enacted. Hence, the purpose of this study was to explore the enactment of external peer facilitation in general practice in order to create a stronger basis for discussing and refining facilitation as an implementation method.

Methods

The facilitation intervention under study was conducted in general practice in the Capital Region of Denmark in order to support an overall strategy for implementing chronic disease management programmes. We observed 30 facilitation visits in 13 practice settings and had interviews and focus groups with facilitators. We applied an explorative approach in data collection and analysis, and conducted an inductive thematic analysis.

Results

The facilitators mainly enacted four facilitator roles: teacher, super user, peer and process manager. Thus, apart from trying to keep the process structured and focused the facilitators were engaged in didactic presentations and hands-on learning as they tried to pass on factual information and experienced based knowledge as well as their own enthusiasm towards implementing practice changes. While occasional challenges were observed with enacting these roles, more importantly we found that a coaching based role which was also envisioned in the intervention design was only sparsely enacted meaning that the facilitators did not enable substantial internal group discussions during their facilitation visits.

Conclusion

Facilitation is a complex phenomenon both conceptually and in practice. This study complements existing research by showing how facilitation can be enacted in various ways and by suggesting that some facilitator roles are more likely to be enacted than others, depending on the context and intervention design and the professional background of the facilitators. This complexity requires caution when comparing and evaluating facilitation studies and highlights a need for precision and clarity about goals, roles, and competences when designing, conducting, and reporting facilitation interventions.

Challenges of Multimorbidities in the Era of an Aging Population

The health care system introduced a reimbursement system based on the existing care when the prevalence rate of acute diseases was still. However, the types of diseases in developed countries are mostly noncommunicable diseases such as cancer or vascular disease, and thus, it impossible to fully recover from these chronic diseases. The increase in noncommunicable diseases is related to unhealthy lifestyle habits such as smoking, heavy drinking, and lack of exercise. Thus, the health care system is changing by improving the prevention of diseases and promoting healthy lifestyles. However, multimorbidities have emerged as an important concept in this process. In countries where the population is rapidly aging, those who have multimorbidities have become a burden to the health care system's revenue, manpower, and service quality. Therefore, health care reform to cope with those who are aging and have multimorbidities is necessary to establish. Reform measures can consist of the following suggestions. First, proper medical guidelines for multiple diseases need to be developed. Second, professional manpower should be trained. Third, the reimbursement system should be improved to relieve those with multimorbidities. Fourth, disease prevention services should be improved. Finally, instruments to measure health care service quality for chronic disease need to be developed.

Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

Background

Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps.

Methods and findings

An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals.

Conclusion

A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work.

Systematic review registration

International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.

"In Principle We Have Agreement, But in Practice It Is a Bit More Difficult": Obtaining Organizational Buy-In to Patient-Centered Medical Home Transformation

The patient-centered medical home (PCMH) is a model of care that emphasizes the coordination of patient treatment among health care providers. Practice transformation to this model, however, presents a number of challenges. One of these challenges is getting the buy-in of all personnel to commit to making organizational changes in the journey to becoming a nationally recognized medical home. This study investigated internal messages of buy-in as communicated by practices transitioning to this type of care. Grounding itself in stakeholder theory, this study analyzed interviews with staff, administration, and practitioners from 20 medical practices in a mid-Atlantic state. The analysis revealed three overarching themes: (a) communication among staff that is open, consistent; (b) implementation of reinforcement techniques; and (c) access to a change implementer who encourages successful evolution. Discussion of these themes provides recommendations for communication approaches to organizational buy-in for medical practices hoping to become a PCMH.

Impact of the Cancer Prevention and Control Research Network: Accelerating the Translation of Research Into Practice

The Cancer Prevention and Control Research Network (CPCRN) is a thematic network dedicated to accelerating the adoption of evidence-based cancer prevention and control practices in communities by advancing dissemination and implementation science. Funded by the Centers for Disease Control and Prevention and National Cancer Institute, CPCRN has operated at two levels: Each participating network center conducts research projects with primarily local partners as well as multicenter collaborative research projects with state and national partners. Through multicenter collaboration, thematic networks leverage the expertise, resources, and partnerships of participating centers to conduct research projects collectively that might not be feasible individually. Although multicenter collaboration is often advocated, it is challenging to promote and assess. Using bibliometric network analysis and other graphical methods, this paper describes CPCRN's multicenter publication progression from 2004 to 2014. Searching PubMed, Scopus, and Web of Science in 2014 identified 249 peer-reviewed CPCRN publications involving two or more centers out of 6,534 total. The research and public health impact of these multicenter collaborative projects initiated by CPCRN during that 10-year period were then examined. CPCRN established numerous workgroups around topics such as: 2-1-1, training and technical assistance, colorectal cancer control, federally qualified health centers, cancer survivorship, and human papillomavirus. This paper discusses the challenges that arise in promoting multicenter collaboration and the strategies that CPCRN uses to address those challenges. The lessons learned should broadly interest those seeking to promote multisite collaboration to address public health problems, such as cancer prevention and control.

Clinic Workload, the Quality of Staff Relationships and Diabetes Management in Community Health Centers Catering to Latino and Chinese Patients

We examine whether workplace climate-quality of staff relationships (QSR) and manageable clinic workload (MCW) are related to better patient care experiences and diabetes care in community health centers (CHCs) catering to Latino and Chinese patients. Patient experience surveys of adult patients with type 2 diabetes and workplace climate surveys of clinicians and staff from CHCs were included in an analytic sample. Comparisons of means analyses examine patient and provider characteristics. The associations of QSR, MCW and the diabetes care management were examined using regression analyses. Diabetes care process were more consistently provided in CHCs with high quality staff relations and more manageable clinic workload, but HbA1c, LDL cholesterol, and blood pressure outcomes were no different between clinics with high vs. low QSR and MCW. Focusing efforts on improvements in practice climate may lead to more consistent provision of important processes of diabetes care for these patients.