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Ashcroft R, Menear M, Dahrouge S, Silveira J, Emode M, Booton J, Bahniwal R, Sheffield P, McKenzie K. Nurturing an organizational context that supports team-based primary mental health care: A grounded theory study. PLoS One 2024; 19:e0301796. [PMID: 38687719 PMCID: PMC11060570 DOI: 10.1371/journal.pone.0301796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND The expansion of the Patient-Centred Medical Home model presents a valuable opportunity to enhance the integration of team-based mental health services in primary care settings, thereby meeting the growing demand for such services. Understanding the organizational context of a Patient-Centred Medical Home is crucial for identifying the facilitators and barriers to integrating mental health care within primary care. The main objective of this paper is to present the findings related to the following research question: "What organizational features shape Family Health Teams' capacity to provide mental health services for depression and anxiety across Ontario, Canada?" METHODS Adopting a constructivist grounded theory approach, we conducted interviews with various mental health care providers, and administrators within Ontario's Family Health Teams, in addition to engaging provincial policy informants and community stakeholders. Data analysis involved a team-based approach, including code comparison and labelling, with a dedicated data analysis subcommittee convening monthly to explore coded concepts influencing contextual factors. RESULTS From the 96 interviews conducted, involving 82 participants, key insights emerged on the organizational contextual features considered vital in facilitating team-based mental health care in primary care settings. Five prominent themes were identified: i) mental health explicit in the organizational vision, ii) leadership driving mental health care, iii) developing a mature and stable team, iv) adequate physical space that facilitates team interaction, and v) electronic medical records to facilitate team communication. CONCLUSIONS This study underscores the often-neglected organizational elements that influence primary care teams' capacity to deliver quality mental health care services. It highlights the significance of strong leadership complemented by effective communication and collaboration within teams to enhance their ability to provide mental health care. Strengthening relationships within primary care teams lies at the core of effective healthcare delivery and should be leveraged to improve the integration of mental health care.
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Affiliation(s)
- Rachelle Ashcroft
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Menear
- Faculty of Medicine, Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
| | - Simone Dahrouge
- Faculty of Medicine, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jose Silveira
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Monica Emode
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jocelyn Booton
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter Sheffield
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Kwame McKenzie
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Wellesley Institute, Toronto, Ontario, Canada
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Peterson KA, Solberg LI, Carlin CS, Fu HN, Jacobsen R, Eder M. Successful Change Management Strategies for Improving Diabetes Care Delivery Among High-Performing Practices. Ann Fam Med 2023; 21:424-431. [PMID: 37748904 PMCID: PMC10519769 DOI: 10.1370/afm.3017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 05/07/2023] [Accepted: 05/31/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE To learn how the highest-performing primary care practices manage change when implementing improvements to diabetes care delivery. METHODS We ranked a total of 330 primary care practices submitting practice management assessments and diabetes reports to the Understanding Infrastructure Transformation Effects on Diabetes study in 2017 and 2019 by Optimal Diabetes Care performance. We ranked practices from the top quartile by greatest annual improvement to capture dynamic change. Starting with the top performers, we interviewed practice leaders to identify their most effective strategies for managing change. Interview transcripts were qualitatively analyzed to identify change management strategies. Saturation occurred when no new strategies were identified over 2 consecutive interviews. RESULTS Ten of the top 13 practices agreed to interviews. We identified 199 key comments representing 48 key care management concepts. We also categorized concepts into 6 care management themes and 37 strategic approaches. We categorized strategic approaches into 13 distinct change management strategies. The most common strategies identified were (1) standardizing the care process, (2) performance awareness, (3) enhancing care teams, (4) health care organization participation, (5) improving reporting systems, (6) engaging staff and clinicians, (7) accountability for tasks, (8) engaging leadership, and (9) tracking change. Care management themes identified by most practices included proactive care, improving patient relationships, and previsit planning. CONCLUSIONS Top-performing primary care practices identify a similar group of strategies as important for managing change during quality improvement activities. Practices involved in diabetes improvement activities, and perhaps other chronic conditions, should consider adopting these change management strategies.
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Affiliation(s)
- Kevin A Peterson
- Department of Family Medicine and Community Health, UMN Medical School, University of Minnesota, Minneapolis, Minnesota
| | | | - Caroline S Carlin
- Department of Family Medicine and Community Health, UMN Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Helen N Fu
- Public & Population Health Informatics, Regenstrief Institute, Center for Biomedical Informatics, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Rachel Jacobsen
- Department of Family Medicine and Community Health, UMN Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Milton Eder
- Department of Family Medicine and Community Health, UMN Medical School, University of Minnesota, Minneapolis, Minnesota
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STANGE KURTC, MILLER WILLIAML, ETZ REBECCAS. The Role of Primary Care in Improving Population Health. Milbank Q 2023; 101:795-840. [PMID: 37096603 PMCID: PMC10126984 DOI: 10.1111/1468-0009.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 04/26/2023] Open
Abstract
Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.
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Affiliation(s)
- KURT C. STANGE
- Center for Community Health IntegrationCase Western Reserve University
| | - WILLIAM L. MILLER
- Lehigh Valley Health System and University of South Florida Morsani College of Medicine
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Eder M, Jacobsen R, Peterson KA, Solberg LI. Quality and team care response to the pandemic stresses in high performing primary care practices: A qualitative study. PLoS One 2022; 17:e0278410. [PMID: 36454787 PMCID: PMC9714700 DOI: 10.1371/journal.pone.0278410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Milton Eder
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, United States of America
- * E-mail:
| | - Rachel Jacobsen
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Kevin A. Peterson
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Leif I. Solberg
- HealthPartners Institute, Bloomington, Minnesota, United States of America
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Cohen DJ, Wyte-Lake T, Bonsu P, Albert SL, Kwok L, Paul MM, Nguyen AM, Berry CA, Shelley DR. Organizational Factors Associated with Guideline Concordance of Chronic Disease Care and Management Practices. J Am Board Fam Med 2022:jabfm.2022.AP.210502. [PMID: 36113991 PMCID: PMC10515112 DOI: 10.3122/jabfm.2022.ap.210502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/08/2022] [Accepted: 06/27/2022] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND Guidelines for managing and preventing chronic disease tend to be well-known. Yet, translation of this evidence into practice is inconsistent. We identify a combination of factors that are connected to guideline concordant delivery of evidence-informed chronic disease care in primary care. METHODS Cross-sectional observational study; purposively selected 22 practices to vary on size, ownership and geographic location, using National Quality Forum metrics to ensure practices had a ≥ 70% quality level for at least 2 of the following: aspirin use in high-risk individuals, blood pressure control, cholesterol and diabetes management. Interviewed 2 professionals (eg, medical director, practice manager) per practice (n = 44) to understand staffing and clinical operations. Analyzed data using an iterative and inductive approach. RESULTS Community Health Centers (CHCs) employed interdisciplinary clinical teams that included a variety of professionals as compared with hospital-health systems (HHS) and clinician-owned practices. Despite this difference, practice members consistently reported a number of functions that may be connected to clinical chronic care quality, including: having engaged leadership; a culture of teamwork; engaging in team-based care; using data to inform quality improvement; empaneling patients; and managing the care of patient panels, with a focus on continuity and comprehensiveness, as well as having a commitment to the community. CONCLUSIONS There are mutable organizational attributes connected-guideline concordant chronic disease care in primary care. Research and policy reform are needed to promote and study how to achieve widespread adoption of these functions and organizational attributes that may be central to achieving equity and improving chronic disease prevention.
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Affiliation(s)
- Deborah J Cohen
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS).
| | - Tamar Wyte-Lake
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Pamela Bonsu
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Stephanie L Albert
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Lorraine Kwok
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Margaret M Paul
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Ann M Nguyen
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Carolyn A Berry
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
| | - Donna R Shelley
- From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS)
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Chrystal JG, Frayne S, Dyer KE, Moreau JL, Gammage CE, Saechao F, Berg E, Washington DL, Yano EM, Hamilton AB. Women Veterans' Attrition from the VA Health Care System. Womens Health Issues 2022; 32:182-193. [PMID: 34972600 DOI: 10.1016/j.whi.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care. METHODS A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use. RESULTS Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs. CONCLUSIONS Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.
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Affiliation(s)
- Joya G Chrystal
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California.
| | - Susan Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Karen E Dyer
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Jessica L Moreau
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Cynthia E Gammage
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California
| | - Fay Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Menlo Park, California
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles, California
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Health Services Research and Development (HSR&D), Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Semel Institute/NPI, Los Angeles, California
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Colasurdo J, Pizzimenti C, Singh S, Ramsey K, Ross R, Sachdeva B, Dorr DA. The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results. Med Care 2022; 60:149-155. [PMID: 35030564 DOI: 10.1097/mlr.0000000000001660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Primary Care Medical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements" (HVEs) for cost and utilization may improve effectiveness. OBJECTIVES The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals. RESEARCH DESIGN A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results. SUBJECTS Eight primary care clinics that were engaged in PCMH reform. MEASURES We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years. RESULTS In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03). DISCUSSION The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms.
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Affiliation(s)
- Joshua Colasurdo
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR
| | - Christie Pizzimenti
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR
| | - Sumeet Singh
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR
| | - Katrina Ramsey
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR
| | - Rachel Ross
- School of Public Health, University of California, Berkeley, CA
| | - Bhavaya Sachdeva
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR
| | - David A Dorr
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR
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Abstract
Aim: To determine whether environmental house calls that improved indoor air quality (IAQ) is effective in reducing symptoms of chemical intolerance (CI). Background: Prevalence of CI is increasing worldwide. Those affected typically report symptoms such as headaches, fatigue, ‘brain fog’, and gastrointestinal problems – common primary care complaints. Substantial evidence suggests that improving IAQ may be helpful in reducing symptoms associated with CI. Methods: Primary care clinic patients were invited to participate in a series of structured environmental house calls (EHCs). To qualify, participants were assessed for CI with the Quick Environmental Exposure and Sensitivity Inventory. Those with CI volunteered to allow the EHC team to visit their homes to collect air samples for volatile organic compounds (VOCs). Initial and post-intervention IAQ sampling was analyzed by an independent lab to determine VOC levels (ng/L). The team discussed indoor air exposures, their health effects, and provided guidance for reducing exposures. Findings: Homes where recommendations were followed showed the greatest improvements in IAQ. The improvements were based upon decreased airborne VOCs associated with reduced use of cleaning chemicals, personal care products, and fragrances, and reduction in the index patients’ symptoms. Symptom improvement generally was not reported among those whose homes showed no VOC improvement. Conclusion: Improvements in both IAQ and patients’ symptoms occur when families implement an action plan developed and shared with them by a trained EHC team. Indoor air problems simply are not part of most doctors’ differential diagnoses, despite relatively high prevalence rates of CI in primary care clinics. Our three-question screening questionnaire – the BREESI – can help physicians identify which patients should complete the QEESI. After identifying patients with CI, the practitioner can help by counseling them regarding their home exposures to VOCs. The future of clinical medicine could include environmental house calls as standard of practice for susceptible patients.
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Coleman KF, Krakauer C, Anderson M, Michaels L, Dorr DA, Fagnan LJ, Hsu C, Parchman ML. Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices. Ann Fam Med 2021; 19:499-506. [PMID: 34750124 PMCID: PMC8575517 DOI: 10.1370/afm.2733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 02/08/2021] [Accepted: 03/22/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease. METHODS A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance. RESULTS Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA. CONCLUSION Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.
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Affiliation(s)
- Katie F Coleman
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Melissa Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - LeAnn Michaels
- Oregon Rural Practice Research Network, Oregon Health & Science University, Portland, Oregon
| | - David A Dorr
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Lyle J Fagnan
- Oregon Rural Practice Research Network, Oregon Health & Science University, Portland, Oregon
| | - Clarissa Hsu
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Michael L Parchman
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Lim ZZB, Mohamed Kadir M, Ginting ML, Vrijhoef HJM, Yoong J, Wong CH. Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111160. [PMID: 34769680 PMCID: PMC8583400 DOI: 10.3390/ijerph182111160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022]
Abstract
Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. “Diffusion of innovations” emerged as an overarching theory to contextualize PCMH in its early implementation. Three core “innovations” differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to “adopt” and “assimilate” the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).
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Affiliation(s)
- Zoe Zon Be Lim
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
- Correspondence:
| | - Mumtaz Mohamed Kadir
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
| | - Mimaika Luluina Ginting
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
| | | | - Joanne Yoong
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
- Center for Economic and Social Research, University of Southern Carolina, Los Angeles, CA 90089, USA
- Research for Impact, Singapore 159964, Singapore
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, Singapore 768024, Singapore; (M.M.K.); (M.L.G.); (J.Y.); (C.H.W.)
- Tsao Foundation, Singapore 168730, Singapore
- Health Services & Systems Research, Duke-NUS, Singapore 169857, Singapore
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11
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Peikes D, Taylor EF, O'Malley AS, Rich EC. The Changing Landscape Of Primary Care: Effects Of The ACA And Other Efforts Over The Past Decade. Health Aff (Millwood) 2021; 39:421-428. [PMID: 32119624 DOI: 10.1377/hlthaff.2019.01430] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Providing high-quality primary care is key to improving health care in the United States. The Affordable Care Act sharpened the emerging focus on primary care as a critical lever to use in improving health care delivery, lowering costs, and improving the quality of care. We describe primary care delivery system reform models that were developed and tested over the past decade by the Center for Medicare and Medicaid Innovation-which was created by the Affordable Care Act-and reflect on key lessons and remaining challenges. Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality.
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Affiliation(s)
- Deborah Peikes
- Deborah Peikes ( dpeikes@mathematica-mpr. com ) is a senior fellow in the Health Policy Assessment division of Mathematica and is located in Princeton, New Jersey
| | - Erin Fries Taylor
- Erin Fries Taylor is a vice president and managing director of the Health Policy Assessment division of Mathematica and is located in Washington, D.C
| | - Ann S O'Malley
- Ann S. O'Malley is a senior fellow in the Health Policy Assessment division of Mathematica and is located in Washington, D.C
| | - Eugene C Rich
- Eugene C. Rich is a senior fellow in the Health Policy Assessment division of Mathematica and is located in Washington, D.C
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12
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Schuttner L, Coleman K, Ralston J, Parchman M. The role of organizational learning and resilience for change in building quality improvement capacity in primary care. Health Care Manage Rev 2021; 46:E1-E7. [PMID: 33630509 PMCID: PMC7541444 DOI: 10.1097/hmr.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown. PURPOSE The aim of the study was to examine the association of AR and development of QI capacity. METHODOLOGY One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined. RESULTS Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure. CONCLUSIONS Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity. PRACTICE IMPLICATIONS Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts.
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13
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Qureshi N, Quigley DD, Hays RD. Nationwide Qualitative Study of Practice Leader Perspectives on What It Takes to Transform into a Patient-Centered Medical Home. J Gen Intern Med 2020; 35:3501-3509. [PMID: 32748342 PMCID: PMC7728968 DOI: 10.1007/s11606-020-06052-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
| | | | - Ron D Hays
- Division of General Internal Medicine & Health Services Research, UCLA, Los Angeles, CA, USA
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14
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Lampman MA, Steffensmeier KRS, Reisinger HS, Sarrazin MV, Steffen MJA, Solimeo SL, Stewart GL, Mueller KJ. Patient Aligned Care Team (PACT) Performance in Urban and Rural VHA Primary Care Clinics: A Mixed Methods Study. J Rural Health 2020; 37:426-436. [PMID: 32632998 DOI: 10.1111/jrh.12490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA). METHODS An Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process-oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same-day access; continuity with primary care provider; and postdischarge follow-up. Qualitative data collected during on-site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics. FINDINGS After adjusting for patient- and practice-level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow-up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high-speed Internet were also reported as barriers. CONCLUSIONS This study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient-centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context.
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Affiliation(s)
- Michelle A Lampman
- Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa.,Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kenda R Stewart Steffensmeier
- Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Heather Schacht Reisinger
- Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa.,Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Mary Vaughan Sarrazin
- Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa.,Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Melissa J A Steffen
- Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Samantha L Solimeo
- Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa.,Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa.,Veterans Rural Health Resource Center, Iowa City, Iowa
| | - Greg L Stewart
- Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa.,Tippie College of Business, University of Iowa, Iowa City, Iowa
| | - Keith J Mueller
- Department of Health Management and Policy, University of Iowa, Iowa City, Iowa
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15
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Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
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Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
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16
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Swankoski KE, Peikes DN, Palakal M, Duda N, Day TJ. Primary Care Practice Transformation Introduces Different Staff Roles. Ann Fam Med 2020; 18:227-234. [PMID: 32393558 PMCID: PMC7213997 DOI: 10.1370/afm.2515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/19/2019] [Accepted: 11/04/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Practices in the 4-year Comprehensive Primary Care (CPC) initiative changed staffing patterns during 2012-2016 to improve care delivery. We sought to characterize these changes and to compare practice patterns with those in similar non-CPC practices in 2016. METHODS We conducted an online survey among selected US primary care practices. We statistically tested 2012-2016 changes in practice-reported staff composition among 461 CPC practices using 2-tailed t tests. Using logistic regression analysis, we compared differences in staff types between the CPC practices and 358 comparison practices that participated in the survey in 2016. RESULTS In 2012, most CPC practices reported having physicians (100%), administrative staff (99%), and medical assistants (90%). By 2016, 84% reported having care managers/care coordinators (up from 24% in 2012), and 29% reported having behavioral health professionals, clinical psychologists, or social workers (up from 19% in 2014). There were also smaller increases (of less than 10 percentage points) in the share of practices having pharmacists, nutritionists, registered nurses, quality improvement specialists, and health educators. Larger and system-affiliated practices were more likely to report having care managers/care coordinators and behavioral health professionals. In 2016, relative to comparison practices, CPC practices were more likely to report having various staff types-notably, care managers/care coordinators (84% of CPC vs 36% of comparison practices), behavioral health professionals (29% vs 12%), and pharmacists (18% vs 4%). CONCLUSIONS During the CPC initiative, CPC practices added different staff types to a fairly traditional staffing model of physicians with medical assistants. They most commonly added care managers/care coordinators and behavioral health staff to support the CPC model and, at the end of CPC, were more likely to have these staff members than comparison practices.
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Affiliation(s)
| | | | - Maya Palakal
- Mathematica Policy Research, Princeton, New Jersey
| | - Nancy Duda
- Mathematica Policy Research, Princeton, New Jersey
| | - Timothy J Day
- Centers for Medicare & Medicaid Services, Baltimore, Maryland
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17
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Crabtree BF, Miller WL, Howard J, Rubinstein EB, Tsui J, Hudson SV, O'Malley D, Ferrante JM, Stange KC. Cancer Survivorship Care Roles for Primary Care Physicians. Ann Fam Med 2020; 18:202-209. [PMID: 32393555 PMCID: PMC7213992 DOI: 10.1370/afm.2498] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/27/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODS We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge. CONCLUSIONS This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.
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Affiliation(s)
- Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey .,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | - Jenna Howard
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Denalee O'Malley
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Jeanne M Ferrante
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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18
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Sklar M, Seijo C, Goldman RE, Eaton CB. Beyond checkboxes: A qualitative assessment of physicians' experiences providing care in a patient-centred medical home. J Eval Clin Pract 2019; 25:1142-1151. [PMID: 30997740 DOI: 10.1111/jep.13136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/07/2019] [Accepted: 03/09/2019] [Indexed: 01/04/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The patient-centred medical home (PCMH) is an innovative approach to health care reform. Despite a well-established process for recognizing PCMH practices, fidelity to, and/or adaptation of, the PCMH model can limit health care and population health improvements. This study explored the connection between fidelity/adaptation to the PCMH model with implementation successes and challenges through the experiences of family and internal medicine PCMH physicians. METHODS Interviews were conducted at two academic PCMH clinics with faculty and resident physicians. Data were transcribed and coded on the basis of an a priori code list. Together, the authors reviewed text and furthered the analysis process to reach final interpretation of the data. RESULTS Ten faculty and nine resident physicians from the Family Care Centre (FCC; n = 11) and the Internal Medicine Clinic (IMC; n = 8) were interviewed. Both FCC and IMC physicians spoke positively about their clinic's adherence to the PCMH model of enhanced access to care, coordinated/integrated care, and improvements in quality and safety through data collection and documentation. However, physicians highlighted inadequate staffing and clinic hours. FCC physicians also discussed the challenge of providing high-quality care amidst differences in coverage between payers. CONCLUSION There remains significant variability in PCMH characteristics across the United States and Canada. This qualitative analysis uncovered factors contributing to fidelity/adaptation to the PCMH model in two academic PCMH clinics. For the PCMH to achieve the Triple Aim promise of improved patient health and experience at a reduced cost, policy must support fidelity to core elements of the PCMH.
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Affiliation(s)
- Marisa Sklar
- Department of Psychiatry, University of California San Diego, San Diego, California.,Child and Adolescent Services Research Center, University of California San Diego, San Diego, California
| | - Chariz Seijo
- Department of Psychiatry, University of California San Diego, San Diego, California.,Child and Adolescent Services Research Center, University of California San Diego, San Diego, California
| | - Roberta E Goldman
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island.,Center for Primary Care and Prevention, Brown University, Pawtucket, Rhode Island
| | - Charles B Eaton
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island.,Center for Primary Care and Prevention, Brown University, Pawtucket, Rhode Island
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19
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Abstract
Primary care transformation will usher in a new era of advanced team-based care with extensive roles beyond the physician to build authentic healing relationships with patients. Smart technology will support these relationships, empower and engage patients, and build confidence that their health care team will take excellent care of them. Investments need to shift from catastrophic hospital-based care to proactive prevention and wellness, pushing us to think of health beyond health care. Systems need to build a culture of continuous improvement, supported by data-driven improvement science, and keep a sharp focus on the patient experience of care.
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Affiliation(s)
- Gregory Sawin
- Tufts University Family Medicine Residency, Malden Family Medicine Center, Cambridge Health Alliance, Tufts University School of Medicine, Harvard University Faculty of Medicine, 195 Canal Street, Malden, MA 02148, USA.
| | - Nicole O'Connor
- Practice Improvement Team, Patient Advisory Council, Tufts University Family Medicine Residency, Malden Family Medicine Center, Cambridge Health Alliance, Tufts University School of Medicine, 195 Canal Street, Malden, MA 02148, USA
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20
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Stadnick NA, Sadler E, Sandall J, Turienzo CF, Bennett IM, Borkan J, Oladeji B, Gureje O, Aarons GA, Sklar M. Comparative case studies in integrated care implementation from across the globe: a quest for action. BMC Health Serv Res 2019; 19:899. [PMID: 31775740 PMCID: PMC6882190 DOI: 10.1186/s12913-019-4661-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/21/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Integrated care is the coordination of general and behavioral health and is a highly promising and practical approach to improving healthcare delivery and patient outcomes. While there is growing interest and investment in integrated care implementation internationally, there are no formal guidelines for integrated care implementation applicable to diverse healthcare systems. Furthermore, there is a complex interplay of factors at multiple levels of influence that are necessary for successful implementation of integrated care in health systems. METHODS Guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Aarons et al., 2011), a multiple case study design was used to address two research objectives: 1) To highlight current integrated care implementation efforts through seven international case studies that target a range of healthcare systems, patient populations and implementation strategies and outcomes, and 2) To synthesize the shared and unique challenges and successes across studies using the EPIS framework. RESULTS The seven reported case studies represent integrated care implementation efforts from five countries and continents (United States, United Kingdom, Vietnam, Israel, and Nigeria), target a range of clinical populations and care settings, and span all phases of the EPIS framework. Qualitative synthesis of these case studies illuminated common outer context, inner context, bridging and innovation factors that were key drivers of implementation. CONCLUSIONS We propose an agenda that outlines priority goals and related strategies to advance integrated care implementation research. These goals relate to: 1) the role of funding at multiple levels of implementation, 2) meaningful collaboration with stakeholders across phases of implementation and 3) clear communication to stakeholders about integrated care implementation. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Nicole A Stadnick
- Department of Psychiatry, University of California San Diego, La Jolla, USA.
- Child and Adolescent Services Research Center, San Diego, USA.
| | - Euan Sadler
- Health Service & Population Research Department, Centre for Implementation Science, King's College London, London, UK
- Department of Nursing, Midwifery and Health, School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Cristina Fernandez Turienzo
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Ian M Bennett
- Department of Family Medicine, University of Washington, Seattle, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - Jeffrey Borkan
- Department of Family Medicine, Brown University, Providence, USA
| | - Bibilola Oladeji
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Oye Gureje
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Gregory A Aarons
- Department of Psychiatry, University of California San Diego, La Jolla, USA
- Child and Adolescent Services Research Center, San Diego, USA
| | - Marisa Sklar
- Department of Psychiatry, University of California San Diego, La Jolla, USA
- Child and Adolescent Services Research Center, San Diego, USA
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21
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Van Tiem JM, Stewart Steffensmeier KR, Wakefield BJ, Stewart GL, Zemblidge NA, Steffen MJA, Moeckli J. Taking note: A qualitative study of implementing a scribing practice in team-based primary care clinics. BMC Health Serv Res 2019; 19:574. [PMID: 31412861 PMCID: PMC6694617 DOI: 10.1186/s12913-019-4355-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Though much is known about the benefits attributed to medical scribes documenting patient visits (e.g., reducing documentation time for the provider, increasing patient-care time, expanding the roles of licensed and non-licensed personnel), little attention has been paid to how care workers enact scribing as a part of their existing practice. The purpose of this study was to perform an ethnographic process evaluation of an innovative medical scribing practice with primary care teams in Veterans Health Administration (VHA) clinics across the United States. The aim of our study was to understand barriers and facilitators to implementing a scribing practice in primary care. METHODS At three to six months after medical scribing was introduced, we used semi-structured interviews and direct observations during site visits to five sites to describe the intervention, understand if the intervention was implemented as planned, and to record the experience of the teams who implemented the intervention. This manuscript only reports on semi-structured interview data collected from providers and scribes. Initial matrix analysis based on categories outlined in the evaluation plan informed subsequent deductive coding using the social-shaping theory Normalization Process Theory. RESULTS Through illustrating the slow accumulation of interactions and knowledge that fostered cautious momentum of teams working to normalize scribing practice in VHA primary care clinics, we show how the practice had 1) an organizing effect, as it centered a shared goal (the creation of the note) between the provider, scribe, and patient, and 2) a generative effect, as it facilitated care workers developing relationships that were both interpersonally and inter-professionally valuable. Based on our findings, we suggest that a scribing practice emphasizes the complementarity of existing professional roles, which thus leverage the interactional possibilities already present in the primary care team. Scribing, as a skill, forged moments of interprofessional fit. Scribing, in practice, created opportunities for interpersonal connection. CONCLUSIONS Our research suggests that individuals will notice different benefits to scribing based on their professional expectations and organizational roles related to documenting patient visits.
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Affiliation(s)
- Jennifer M. Van Tiem
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Kenda R. Stewart Steffensmeier
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Bonnie J. Wakefield
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- Sinclair School of Nursing, University of Missouri, S313 School of Nursing, University of Missouri, Columbia, MO 65211 USA
| | - Greg L. Stewart
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- Tippie College of Business, University of Iowa, 21 E Market St, Iowa City, Iowa, 52242 USA
| | - Nancy A. Zemblidge
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Melissa J. A. Steffen
- VISN 23 Patient Aligned Care Team Demonstration Lab, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
| | - Jane Moeckli
- CADRE, the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 West, Building 42, Iowa City, Iowa, 52246 USA
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22
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Sklar M, Hatch MR, Aarons GA. A climate for evidence-based practice implementation in the patient-centred medical home. J Eval Clin Pract 2019; 25:637-647. [PMID: 30350470 DOI: 10.1111/jep.13050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The patient-centred medical home (PCMH) is an important part of health care reform. While there is hope, the PCMH model can facilitate the provision of higher quality care, the extent to which organizational climate within the PCMH supports the implementation of evidence-based practices (EBPs) is unknown. Identifying and addressing factors that facilitate implementation and use of EBPs within the PCMH are crucial for improving the health and health care of the United States. METHODS This study used mixed methods to assess EBP implementation climate (ie, the extent to which organizational members perceive that the adoption and use of EBPs is expected, supported, and rewarded) and attitudes about EBPs in two PCMH clinics. RESULTS Staff and physicians from two Rhode Island PCMHs, the Family Care Centre (FCC; n = 39) and Internal Medicine Clinic (IMC; n = 21), participated in this study. Results identified differences between FCC and IMC with regard to attitudes toward EBPs and implementation climate. Compared with the IMC, FCC staff and physicians reported significantly more positive attitudes toward EBPs and greater willingness to adopt EBPs. FCC staff and physicians reported significantly greater educational support for EBPs than IMC staff and physicians. Analysis of in-depth interviews revealed themes regarding attitudes toward EBPs. Most physicians reported valuing EBPs, although a number of barriers to EBP use were identified including time pressure, disjointed coordination of services, complexity of patients' presenting health concerns, and patient choice. CONCLUSIONS Understanding factors that facilitate EBP implementation in the PCMH is important given widespread adoption of the PCMH model. Barriers to EBP implementation in the PCMH must be addressed for the sustainable implementation of EBP in the PCMH. Improving implementation climate may be an effective strategy to aid in creating an organizational context conducive to consideration and use of EBPs.
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Affiliation(s)
- Marisa Sklar
- Department of Psychiatry, University of California San Diego, San Diego, California.,Child and Adolescent Services Research Center, University of California San Diego, San Diego, California
| | - Melissa R Hatch
- Department of Psychiatry, University of California San Diego, San Diego, California.,Child and Adolescent Services Research Center, University of California San Diego, San Diego, California
| | - Gregory A Aarons
- Department of Psychiatry, University of California San Diego, San Diego, California.,Child and Adolescent Services Research Center, University of California San Diego, San Diego, California
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23
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Chakravorty S, Knapp CA. The Impact of the Patient-Centered Medical Home on Asthma-Related Visits to the Emergency Room: A Fixed Effects Regression Approach. Matern Child Health J 2019; 23:369-376. [PMID: 30552599 DOI: 10.1007/s10995-018-2661-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective To estimate the effect of a patient-centered medical home (PCMH) intervention on asthma-related emergency room (ER) visits of pediatric patients. Methods Patients receiving care at pediatric primary care practices participating in the Florida Pediatric Medical Home Demonstration Project as well as pediatric patients treated at non-participating clinics were identified from 4 years of claims and enrollment data. We estimate several fixed effects logistic regression models using one pre-treatment year and three post-treatment years to investigate whether asthma-related ER visits decreased because of the PCMH intervention. Results The estimation suggests that the intervention did have a negative effect on asthma-related ER visits in the earlier part of the intervention (OR 0.34; 95% CI 0.16-0.73). However, this effect was not detected in the later years. Because fixed effects models require repeated observations on the same individual, we believe our estimations of the PCMH model's impact is more accurate than previous studies. Conclusion for Practice Reducing asthma ER visits is a task that might be immediately actionable for PCMH practices, or those undergoing transformation. Our results adds to the others suggesting positive impacts of the PCMH.
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Affiliation(s)
- Shourjo Chakravorty
- Department of Economics, Istanbul Technical University, İşletme Fakültesi, Ekonomi Bölömü, Maçka, Istanbul, 34367, Turkey.
| | - Caprice A Knapp
- Department of Health Policy and Administration, Pennsylvania State University, 601A Donald H. Ford Building, University Park, PA, 16802, USA
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24
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Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial. EGEMS 2019; 7:20. [PMID: 31106226 PMCID: PMC6498873 DOI: 10.5334/egems.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization. Methods: We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input. Results: 2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures. Discussion: A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs. Conclusion: Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.
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25
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Schuttner L, Parchman M. Team-Based Primary Care for the Multimorbid Patient: Matching Complexity With Complexity. Am J Med 2019; 132:404-406. [PMID: 30300628 PMCID: PMC7521616 DOI: 10.1016/j.amjmed.2018.09.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/20/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Linnaea Schuttner
- VA Puget Sound Healthcare System,Health Services Research & Development, Seattle, Wash; Department of Internal Medicine, University of Washington, Seattle.
| | - Michael Parchman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute, Seattle
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26
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Zhu X, Wholey DR. Expertise Redundancy, Transactive Memory, and Team Performance in Interdisciplinary Care Teams. Health Serv Res 2018; 53:4921-4942. [PMID: 29896805 PMCID: PMC6232407 DOI: 10.1111/1475-6773.12996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine how expertise redundancy and transactive memory (TM) in interdisciplinary care teams (ICTs) are related to team performance. DATA SOURCES/STUDY SETTING Survey and administrative data were collected from 26 interdisciplinary mental health teams. STUDY DESIGN The study used a longitudinal, observational design. Independent variables were measured at baseline, 6, and 12 months: expertise redundancy (the extent to which team members possess highly overlapping knowledge), TM accuracy (the extent to which team members accurately recognize experts in relevant knowledge domains), and TM consensus (the extent to which team members agree on who is expert in which knowledge domain). Team performance was measured as risk-adjusted average number of client hospitalization for the 6 months following each survey. DATA COLLECTION METHODS Survey data were collected by the authors. Administrative data were collected by the state's administrative agency. PRINCIPAL FINDINGS Expertise redundancy had a negative effect on performance. TM accuracy had a positive effect on performance, and such effect was stronger when expertise redundancy was higher. No significant effect was found on TM consensus. CONCLUSIONS Transactive memory could serve as a cognitive coordination mechanism for mitigating the negative effect of complex knowledge structure in ICTs.
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Affiliation(s)
- Xi Zhu
- Department of Health Management and PolicyCollege of Public HealthUniversity of IowaIowa CityIA
| | - Douglas R. Wholey
- Division of Health Policy and ManagementSchool of Public HealthUniversity of MinnesotaMinneapolisMN
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27
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Fortney JC, Pyne JM, Ward-Jones S, Bennett IM, Diehl J, Farris K, Cerimele JM, Curran GM. Implementation of evidence-based practices for complex mood disorders in primary care safety net clinics. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2018; 36:267-280. [PMID: 29809039 PMCID: PMC6131024 DOI: 10.1037/fsh0000357] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Use quality improvement methods to implement evidence-based practices for bipolar depression and treatment-resistant depression in 6 Federally Qualified Health Centers. METHOD Following qualitative needs assessments, implementation teams comprised of front-line providers, patients, and content experts identified, adapted, and adopted evidence-based practices. With external facilitation, onsite clinical champions led the deployment of the evidence-based practices. Evaluation data were collected from 104 patients with probable bipolar disorder or treatment-resistant depression via chart review and an interactive voice response telephone system. RESULTS Five practices were implemented: (a) screening for bipolar disorder, (b) telepsychiatric consultation, (c) prescribing guidelines, (d) online cognitive-behavioral therapy, and (e) online peer support. Implementation outcomes were as follows: (a) 15% of eligible patients were screened for bipolar disorder (interclinic range = 3%-70%), (b) few engaged in online psychotherapy or peer support, (c) 38% received telepsychiatric consultation (interclinic range = 0%-83%), and (d) 64% of patients with a consult were prescribed the recommended medication. Clinical outcomes were as follows: Of those screening at high risk or very high risk, 67% and 69%, respectively, were diagnosed with bipolar disorder. A third (32%) of patients were prescribed a new mood stabilizer, and 28% were prescribed a new antidepressant. Clinical response (50% reduction in depression symptoms), was observed in 21% of patients at 3-month follow-up. DISCUSSION Quality improvement processes resulted in the implementation and evaluation of 5 detection and treatment processes. Though varying by site, screening improved detection and a substantial number of patients received consultations and medication adjustments; however, symptom improvement was modest. (PsycINFO Database Record
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Affiliation(s)
- John C Fortney
- Division of Population Health, Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Jeffrey M Pyne
- Division of Health Services Research, Department of Psychiatry, University of Arkansas for Medical Sciences
| | | | - Ian M Bennett
- Division of Population Health, Department of Psychiatry and Behavioral Sciences, University of Washington
| | | | | | - Joseph M Cerimele
- Division of Population Health, Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Geoffrey M Curran
- Center for Implementation Research, Department of Pharmacy Practice, University of Arkansas for Medical Sciences
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28
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Crabtree BF, Miller WL, Gunn JM, Hogg WE, Scott CM, Levesque JF, Harris MF, Chase SM, Advocat JR, Halma LM, Russell GM. Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach. Fam Pract 2018; 35:266-275. [PMID: 29069335 PMCID: PMC5965090 DOI: 10.1093/fampra/cmx091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - William L Miller
- Department of Family Medicine; Lehigh Valley Health Network, Allentown, USA
| | - Jane M Gunn
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
| | - William E Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Cathie M Scott
- Alberta Centre for Child, Family and Community Research, Edmonton, Canada
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia.,Bureau of Health Information, Chatswood, Australia
| | - Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia
| | - Sabrina M Chase
- Rutgers Biomedical and Health Sciences (RBHS), Rutgers School of Nursing, Rutgers University, New Brunswick, USA
| | - Jenny R Advocat
- Southern Academic Primary Care Research Unit, School of Primary and Allied Health Care, Monash University, Clayton, Australia
| | - Lisa M Halma
- Zone Analytics and Reporting Services, Alberta Health Services, Edmonton, Canada
| | - Grant M Russell
- Southern Academic Primary Care Research Unity, School of Primary and Allied Health Care, Monash University, Clayton, Australia
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Practice Facilitator Strategies for Addressing Electronic Health Record Data Challenges for Quality Improvement: EvidenceNOW. J Am Board Fam Med 2018; 31:398-409. [PMID: 29743223 PMCID: PMC5972525 DOI: 10.3122/jabfm.2018.03.170274] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/31/2017] [Accepted: 12/10/2017] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Practice facilitators ("facilitators") can play an important role in supporting primary care practices in performing quality improvement (QI), but they need complete and accurate clinical performance data from practices' electronic health records (EHR) to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform QI when complete or accurate performance data are not available. METHODS Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality's initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for QI. RESULTS We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust. CONCLUSION Facilitators can use a range of strategies to help practices perform data-driven QI when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven QI that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support.
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30
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McLellan RK. Work, Health, And Worker Well-Being: Roles And Opportunities For Employers. Health Aff (Millwood) 2018; 36:206-213. [PMID: 28167707 DOI: 10.1377/hlthaff.2016.1150] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Work holds the promise of supporting and promoting health. It also carries the risk of injury, illness, and death. In addition to harms posed by traditional occupational health hazards, such as physically dangerous workplaces, work contributes to health problems with multifactorial origins such as unhealthy lifestyles, psychological distress, and chronic disease. Not only does work affect health, but the obverse is true: Unhealthy workers are more frequently disabled, absent, and less productive, and they use more health care resources, compared to their healthy colleagues. The costs of poor workforce health are collectively borne by workers, employers, and society. For business as well as altruistic reasons, employers may strive to cost-effectively achieve the safest, healthiest, and most productive workforce possible. Narrowly focused health goals are giving way to a broader concept of employee well-being. This article explores the relationship between health and work, outlines opportunities for employers to make this relationship health promoting, and identifies areas needing further exploration.
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Affiliation(s)
- Robert K McLellan
- Robert K. McLellan is section chief of the Department of Occupational and Environmental Medicine at the Dartmouth-Hitchcock Medical Center, and a professor of medicine at the Geisel School of Medicine at Dartmouth, both in Lebanon, New Hampshire
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31
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Henderson KH, DeWalt DA, Halladay J, Weiner BJ, Kim JI, Fine J, Cykert S. Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study. Ann Fam Med 2018; 16:S29-S34. [PMID: 29632223 PMCID: PMC5891311 DOI: 10.1370/afm.2210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Our purpose was to assess whether a practice's adaptive reserve and high leadership capability in quality improvement are associated with population blood pressure control. METHODS We divided practices into quartiles of blood pressure control performance and considered the top quartile as the benchmark for comparison. Using abstracted clinical data from electronic health records, we performed a cross-sectional study to assess the association of top quartile hypertension control and (1) the baseline practice adaptive reserve (PAR) scores and (2) baseline practice leadership scores, using modified Poisson regression models adjusting for practice-level characteristics. RESULTS Among 181 practices, 46 were in the top quartile, which averaged 68% or better blood pressure control. Practices with higher PAR scores compared with lower PAR scores were not more likely to reside in the top quartile of performance (prevalence ratio [PR] = 1.92 for highest quartile; 95% CI, 0.9-4.1). Similarly, high quality improvement leadership capability compared with lower capability did not predict better blood pressure control performance (PR = 0.94; 95% CI, 0.57-1.56). Practices with higher proportions of commercially insured patients were more likely than practices with lower proportions of commercially insured patients to have top quartile performance (37% vs 26%, P =.002), whereas lower proportions of the uninsured (8% vs 14%, P =.055) were associated with better performance. CONCLUSIONS Our findings show that adaptive reserve and leadership capability in quality improvement implementation are not statistically associated with achieving top quartile practice-level hypertension control at baseline in the Heart Health NOW project. Our findings, however, may be limited by a lack of patient-related factors and small sample size to preclude strong conclusions.
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Affiliation(s)
- Kamal H Henderson
- Division of Cardiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina .,Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Jacquie Halladay
- Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Bryan J Weiner
- Departments of Global Health and Biostatistics, University of Washington, Seattle, Washington
| | - Jung I Kim
- UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Jason Fine
- UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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Marsteller JA, Hsu YJ, Gill C, Kiptanui Z, Fakeye OA, Engineer LD, Perlmutter D, Khanna N, Rattinger GB, Nichols D, Harris I. Maryland Multipayor Patient-centered Medical Home Program: A 4-Year Quasiexperimental Evaluation of Quality, Utilization, Patient Satisfaction, and Provider Perceptions. Med Care 2018; 56:308-320. [PMID: 29462077 PMCID: PMC5882272 DOI: 10.1097/mlr.0000000000000881] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate impact of the Maryland Multipayor Patient-centered Medical Home Program (MMPP) on: (1) quality, utilization, and costs of care; (2) beneficiaries' experiences and satisfaction with care; and (3) perceptions of providers. DESIGN 4-year quasiexperimental design with a difference-in-differences analytic approach to compare changes in outcomes between MMPP practices and propensity score-matched comparisons; pre-post design for patient-reported outcomes among MMPP beneficiaries. SUBJECTS Beneficiaries (Medicaid-insured and privately insured) and providers in 52 MMPP practices and 104 matched comparisons in Maryland. INTERVENTION Participating practices received unconditional financial support and coaching to facilitate functioning as medical homes, membership in a learning collaborative to promote education and dissemination of best practices, and performance-based payments. MEASURES Sixteen quality, 20 utilization, and 13 cost measures from administrative data; patient-reported outcomes on care delivery, trust in provider, access to care, and chronic illness management; and provider perceptions of team operation, team culture, satisfaction with care provided, and patient-centered medical home transformation. RESULTS The MMPP had mixed impact on site-level quality and utilization measures. Participation was significantly associated with lower inpatient and outpatient payments in the first year among privately insured beneficiaries, and for the entire duration among Medicaid beneficiaries. There was indication that MMPP practices shifted responsibility for certain administrative tasks from clinicians to medical assistants or care managers. The program had limited effect on measures of patient satisfaction (although response rates were low) and on provider perceptions. CONCLUSIONS The MMPP demonstrated mixed results of its impact and indicated differential program effects for privately insured and Medicaid beneficiaries.
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Affiliation(s)
- Jill A. Marsteller
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | | | | | - Oludolapo A. Fakeye
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Lilly D. Engineer
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | | | - Niharika Khanna
- Department of Family and Community Medicine (NK), University of Maryland School of Medicine, Baltimore, MD
| | - Gail B. Rattinger
- Department of Health Outcomes and Administrative Sciences (GBR), Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY
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Barsanti S, Bonciani M. General practitioners: Between integration and co-location. The case of primary care centers in Tuscany, Italy. Health Serv Manage Res 2018; 32:2-15. [DOI: 10.1177/0951484818757154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Healthcare systems have followed several strategies aimed at integrating primary care services and professionals. Medical homes in the USA and Canada, and primary care centres across Europe have collocated general practitioners and other health and social professionals in the same building in order to boost coordination among services and the continuity of care for patients. However, in the literature, the impact of co-location on primary care has led to controversial results. This article analyses the possible benefits of the co-location of services in primary care focusing on the Italian model of primary care centres (Case della Salute) in terms of general practitioners’ perception. We used the results of a web survey of general practitioners in Tuscany to compare the experiences and satisfaction of those general practitioners involved and not involved in a primary care centre, performed a MONAVA and ANOVA analysis. Our case study highlights the positive impact of co-location on the integration of professionals, especially with nurses and social workers, and on organizational integration, in terms of frequency of meeting to discuss about quality of care. Conversely, no significant differences were found in terms of either clinical or system integration. Furthermore, the collaboration with specialists is still weak. Considering the general practitioners’ perspective in terms of experience and satisfaction towards primary care, co-location strategies is a necessary step in order to facilitate the collaboration among professionals and to prevent unintended consequences in terms of an even possible isolation of primary care as an involuntary ‘disintegration of the integration’.
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Affiliation(s)
- Sara Barsanti
- Laboratorio Management e Sanità, Institute of Management of Scuola Superiore Sant’Anna of Pisa, Pisa, Italy
| | - Manila Bonciani
- Laboratorio Management e Sanità, Institute of Management of Scuola Superiore Sant’Anna of Pisa, Pisa, Italy
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Locatelli SM, Turcios S, LaVela SL. Optimizing the patient-centered environment: results of guided tours with health care providers and employees. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2018; 8:18-30. [PMID: 25816378 DOI: 10.1177/1937586714565610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine providers' perspectives on the care environment and patient-centered care (PCC) through the eyes of the veteran patient, using guided tours qualitative methodology. BACKGROUND Environmental factors, such as attractiveness and function, have the potential to improve patients' experiences. Participatory qualitative methods allow researchers to explore the environment and facilitate discussion. METHODS Guided tours were conducted with 25 health care providers/employees at two Veterans Affairs (VA) health care facilities. In guided tours, participants lead the researcher through an environment, commenting on their surroundings, thoughts, and feelings. The researcher walks along with the participant, asking open-ended questions as needed to foster discussion and gain an understanding of the participant's view. Participants were asked to walk through the facility as though they were a veteran. Tours were audio recorded, with participant permission, and transcribed verbatim by research assistants. Three qualitative researchers were responsible for codebook development and coding transcripts and used data-driven coding approaches. RESULTS Participants discussed physical appearance of the environment and how that influences perceptions about care. Overall, participants highlighted the need to shed the "institutional" appearance. Differences between VA and non-VA health care facilities were discussed, including availability of private rooms and staff to assist with navigating the facility. They reviewed resources in the facility, such as the information desk to assist patients and families. Finally, they offered suggestions for future improvements, including improvements to waiting areas and quiet areas for patients to relax and "get away" from their rooms. CONCLUSIONS Participants highlighted many small changes to the care environment that could enhance the patient experience. Additionally, they examined the environment from the patient's perspective, to identify elements that enhance, or detract from, the patient's care experience.
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Affiliation(s)
- Sara M Locatelli
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA Center for Evaluation of Practices and Experiences of Patient-Centered Care, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
| | - Stephanie Turcios
- Center for Evaluation of Practices and Experiences of Patient-Centered Care, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
| | - Sherri L LaVela
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA Center for Evaluation of Practices and Experiences of Patient-Centered Care, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project. Med Care 2017. [PMID: 28650922 DOI: 10.1097/mlr.0000000000000759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. STUDY SETTING In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. STUDY DESIGN Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools. DATA COLLECTION METHODS Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites. PRINCIPAL FINDINGS Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES. CONCLUSIONS A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.
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Abstract
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.
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Paul MM, Albert SL, Mijanovich T, Shih SC, Berry CA. Patient-Centered Care in Small Primary Care Practices in New York City: Recognition Versus Reality. J Prim Care Community Health 2017; 8:228-232. [PMID: 28553751 PMCID: PMC5932730 DOI: 10.1177/2150131917709404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The Primary Care Information Project (PCIP) is a program administered by the New York City Department of Health and Mental Hygiene to help primary care providers adopt a fully functional electronic health record (EHR) and focus on population health. PCIP also offers practices assistance with the National Committee for Quality Assurance (NCQA) patient-centered medical home (PCMH) recognition application. The objectives of this study were to assess the presence of key dimensions of PCMH among PCIP practices with 5 or fewer providers and to determine whether and to what extent NCQA recognition was related to the presence of these dimensions. METHODS Analyses relied on data collected from a comprehensive practice assessment survey of PCIP practices administered in summer 2012. The survey was developed to assess discrete dimensions of the PCMH model and other practice characteristics. The study population includes practices for which survey results were available among PCIP practices with 5 or fewer providers (63% response rate; n = 83). RESULTS At the time of survey, 57% of practices had received some level of NCQA recognition (n = 47). Practices with recognition scored significantly higher on several dimensions, including whole person orientation, team-based care, care coordination and integration, and quality and safety. CONCLUSIONS Results indicate that very small urban practices in New York City are implementing many key features of PCMH. In general, practices with NCQA recognition scored higher on PCMH constructs and domains relative to practices without recognition; however, there is room for improvement on construct and domain scores in both groups.
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Affiliation(s)
| | | | | | - Sarah C Shih
- 3 New York City Department of Health and Mental Hygiene, New York, NY, USA
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Lieberthal RD, Karagiannis T, Bilheimer E, Verma M, Payton C, Sarfaty M, Valko G. Exploring Variation in Transformation of Primary Care Practices to Patient-Centered Medical Homes: A Mixed Methods Approach. Popul Health Manag 2017; 20:411-418. [PMID: 28099065 DOI: 10.1089/pop.2016.0132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The objective was to quantify the activities required for patient-centered medical home (PCMH) transformation in a sample of small to medium-sized National Committee for Quality Assurance (NCQA) recognized practices, and explore barriers and facilitators to transformation. Eleven small to medium-sized PCMH practices in Southeastern Pennsylvania completed a survey, which was adapted from the 2011 NCQA standards. Semistructured follow-up interviews were conducted, descriptive statistics were computed for the quantitative analysis, and a process of thematic coding was deployed for the qualitative analysis. Practices had considerable quantitative variation in their workforce composition and the PCMH-related activities they implemented. Most practices improved access and continuity through staff training and team-based care as well as expanded data collection for population management. The barriers to PCMH recognition were least burdensome for the largest practices. The heterogeneity of the small PCMH practices within the study sample underscore the need to understand the key transformation issues as efforts to disseminate the PCMH model continue.
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Affiliation(s)
- Robert D Lieberthal
- 1 Department of Public Health, University of Tennessee , Knoxville, Knoxville, Tennessee.,2 College of Population Health, Thomas Jefferson University , Philadelphia, Pennsylvania
| | - Tom Karagiannis
- 2 College of Population Health, Thomas Jefferson University , Philadelphia, Pennsylvania
| | - Evan Bilheimer
- 2 College of Population Health, Thomas Jefferson University , Philadelphia, Pennsylvania.,3 Sidney Kimmel Medical College, Thomas Jefferson University , Philadelphia, Pennsylvania
| | - Manisha Verma
- 4 Einstein Healthcare Network , Philadelphia, Pennsylvania
| | - Colleen Payton
- 3 Sidney Kimmel Medical College, Thomas Jefferson University , Philadelphia, Pennsylvania
| | - Mona Sarfaty
- 3 Sidney Kimmel Medical College, Thomas Jefferson University , Philadelphia, Pennsylvania
| | - George Valko
- 3 Sidney Kimmel Medical College, Thomas Jefferson University , Philadelphia, Pennsylvania
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El-Mallakh P, McPeak D, Khara M, Okoli CT. Smoking Behaviors and Medical Co-Morbidities in Patients With Mental Illnesses. Arch Psychiatr Nurs 2016; 30:740-746. [PMID: 27888969 DOI: 10.1016/j.apnu.2016.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 06/28/2016] [Accepted: 07/09/2016] [Indexed: 11/27/2022]
Abstract
Correlations among smoking behaviors and co-morbid medical illnesses were examined among 982 smokers with mental illnesses enrolled in a smoking cessation program within Mental Health and Addictions Services in Vancouver, Canada. Significant correlates among individuals with psychotic disorders included associations between a history of emphysema/chronic obstructive pulmonary (COPD) disease and cigarettes smoked per day (r's=.35, p≤.01), Confidence in quitting (r's=-.33, p≤.01), and nicotine dependence (r's=.32, p≤.01). Study findings may have implications for the development of integrated medical-psychiatric treatment delivery models that include comprehensive tobacco cessation programs tailored toward people with mental illnesses.
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Affiliation(s)
| | - Danielle McPeak
- Phyllis D. Corbitt Community Health Center, University of Kentucky College of Nursing, Wilmore, KY
| | - Milan Khara
- University of British Columbia School of Medicine, Vancouver, British Columbia, Canada
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Investigating a Multistakeholder Alliance Approach to Reducing Hospital Readmissions. J Healthc Qual 2016; 38:396-407. [DOI: 10.1097/jhq.0000000000000019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Deri Armstrong C, Taljaard M, Hogg W, Mark AE, Liddy C. Practice facilitation for improving cardiovascular care: secondary evaluation of a stepped wedge cluster randomized controlled trial using population-based administrative data. Trials 2016; 17:434. [PMID: 27596224 PMCID: PMC5011906 DOI: 10.1186/s13063-016-1547-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Practice facilitation (PF), a multifaceted approach in which facilitators (external health care professionals) help family physicians to improve their adoption of best practices, has been highly successful. Improved Delivery of Cardiovascular Care (IDOCC) was an innovative PF trial designed to improve evidence-based care for people who have, or are at risk of, cardiovascular disease (CVD). The intervention was found to be ineffective as assessed by a patient-level composite score based on chart reviews from a subsample of patients (N = 5292). Here, we used population-based administrative data to examine IDOCC's effect on CVD-related hospitalizations. METHODS IDOCC used a pragmatic, stepped wedge cluster randomized controlled design involving primary care providers recruited across Eastern Ontario, Canada. IDOCC's effect on CVD-related hospitalizations was assessed in the 2 years of active intervention and post-intervention years. Marginal and mixed-effects regression analyses were used to account for the study design and to control for patient, physician, and practice characteristics. Secondary and subgroup analyses investigated robustness. RESULTS Our sample included 262,996 patient/year observations representing 54,085 unique patients who had, or were at risk of, CVD, from 70 practices. There was a strong decreasing secular trend in CVD-related hospitalizations but no statistically significant effect of IDOCC. Relative to patients in the control condition, patients in the intervention condition were estimated to have 4 % lower odds of CVD-related hospitalizations (adjOR = 0.96, 99 % CI 0.83 to 1.11). The nonsignificant result persisted across robustness analyses. CONCLUSIONS Clinical outcomes from administrative databases were examined to form a more complete picture of the (in)effectiveness of a large-scale quality improvement intervention. IDOCC did not have a significant effect on CVD hospitalizations, suggesting that the results from the primary composite adherence score analysis were neither due to choice of outcome nor relatively short follow-up period. TRIAL REGISTRATION ClinicalTrials.gov NCT00574808 , registered on 14 December 2007.
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Affiliation(s)
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - William Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada
| | - Amy E Mark
- Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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Eiff MP, Green LA, Holmboe E, McDonald FS, Klink K, Smith DG, Carraccio C, Harding R, Dexter E, Marino M, Jones S, Caverzagie K, Mustapha M, Carney PA. A Model for Catalyzing Educational and Clinical Transformation in Primary Care: Outcomes From a Partnership Among Family Medicine, Internal Medicine, and Pediatrics. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:1293-1304. [PMID: 27028034 DOI: 10.1097/acm.0000000000001167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE To report findings from a national effort initiated by three primary care certifying boards to catalyze change in primary care training. METHOD In this mixed-method pilot study (2012-2014), 36 faculty in 12 primary care residencies (family medicine, internal medicine, pediatrics) from four institutions participated in a professional development program designed to prepare faculty to accelerate change in primary care residency training by uniting them in a common mission to create effective ambulatory clinical learning environments. Surveys administered at baseline and 12 months after initial training measured changes in faculty members' confidence and skills, continuity clinics, and residency training programs. Feasibility evaluation involved assessing participation. The authors compared quantitative data using Wilcoxon signed-rank and Bhapkar tests. Observational field notes underwent narrative analysis. RESULTS Most participants attended two in-person training sessions (92% and 72%, respectively). Between baseline and 12 months, faculty members' confidence in leadership improved significantly for 15/19 (79%) variables assessed; their self-assessed skills improved significantly for 21/22 (95%) competencies. Two medical home domains ("Continuity of Care," "Support/Care Coordination") improved significantly (P < .05) between the two time periods. Analyses of qualitative data revealed that interdisciplinary learning communities formed during the program and served to catalyze transformational change. CONCLUSIONS Results suggest that improvements in faculty perceptions of confidence and skills occurred and that the creation of interdisciplinary learning communities catalyzed transformation. Lengthening the intervention period, engaging other professions involved in training the primary care workforce, and a more discriminating evaluation design are needed to scale this model nationally.
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Affiliation(s)
- M Patrice Eiff
- M.P. Eiff is professor and vice chair, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. L.A. Green is professor of family medicine, Epperson-Zorn Chair for Innovation in Family Medicine and Primary Care, University of Colorado, Denver, Colorado. E. Holmboe is senior vice president, Milestone Development and Evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois. F.S. McDonald is senior vice president, Academic and Medical Affairs, American Board of Internal Medicine, Philadelphia, Pennsylvania. K. Klink is director, Medical & Dental Education, Department of Veterans Affairs Office of Academic Affiliations, Washington, DC. D.G. Smith is director, Graduate Medical Education, Abington Memorial Hospital, Abington, Pennsylvania, and clinical associate professor of medicine, Temple University School of Medicine, Philadelphia, Pennsylvania. C. Carraccio is vice president, Competency-Based Assessment Program, American Board of Pediatrics, Chapel Hill, North Carolina. R. Harding is research assistant, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. E. Dexter is biostatistician, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. M. Marino is assistant professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. S. Jones is program director, Virginia Commonwealth University-Fairfax Residency Program, Fairfax, Virginia. K. Caverzagie is associate dean for educational strategy, University of Nebraska School of Medicine, Omaha, Nebraska. M. Mustapha is assistant professor, Department of Internal Medicine and Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota. P.A. Carney is professor of family medicine, School of Medicine, and professor of public health, School of Public Health, Oregon Health & Science University, Portland, Oregon
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Practice-Based Research Networks: Integrating Clinical Data for Improved Pharmacoepidemiology. Pain Ther 2016; 5:143-148. [PMID: 27550176 PMCID: PMC5130904 DOI: 10.1007/s40122-016-0054-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Indexed: 11/24/2022] Open
Abstract
Pharmacovigilance is concerned with the detection, assessment, understanding, and prevention of adverse reactions to medicines. It is helpful to prevent undesired harm sustained by the patient due to inappropriate or unsafe use of medicinal agents. As the use of drugs and polypharmacy increase in prevalence, pharmacovigilance gains relevance and momentum. Practice-based research networks have the potential to enhance health research by promoting earlier detection of adverse events at a decreased level of cost. This article explores the recent evidence of an improved benefit of administering non-steroidal antiinflammatory drugs (NSAIDs) in the fasting state, and authors propose that an improved pharmacovigilance system is both needed and feasible provided records are adapted to a nationwide integration of pharmacoepidemiology data.
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Dorr DA, Anastas T, Ramsey K, Wagner J, Sachdeva B, Michaels L, Fagnan LJ. Effect of a Pragmatic, Cluster-randomized Controlled Trial on Patient Experience With Care: The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Study. Med Care 2016; 54:745-51. [PMID: 27116107 PMCID: PMC4945405 DOI: 10.1097/mlr.0000000000000552] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Health reform programs like the patient-centered medical home are intended to improve the triple aim. Previous studies on patient-centered medical homes have shown mixed effects, but high value elements (HVEs) are expected to improve the triple aim. OBJECTIVE The aim of this study is to understand whether focusing on HVEs would improve patient experience with care. METHODS Eight clinics were cluster-randomized in a year-long trial. Both arms received practice facilitation, IT-based reporting, and financial incentives. Intervention practices were encouraged to choose HVEs for quality improvement goals. To assess patient experience, 1597 Consumer Assessment of Healthcare Providers and Systems surveys were sent pretrial and posttrial to a stratified random sample of patients. Difference-in-difference multivariate analysis was used to compare patient responses from intervention and control practices, adjusting for confounders. RESULTS The response rate was 43% (n=686). Nonrespondent analysis showed no difference between arms, although differences were seen by risk status and age. The overall difference in difference was 2.8%, favoring the intervention. The intervention performed better in 9 of 11 composites. The intervention performed significantly better in follow-up on test results (P=0.091) and patients' rating of the provider (P=0.091), whereas the control performed better in access to care (P=0.093). Both arms also had decreases, including 4 of 11 composites for the intervention, and 8 of 11 for the control. DISCUSSION Practices that targeted HVEs showed significantly more improvement in patient experience of care. However, contemporaneous trends may have affected results, leading to declines in patient experience in both arms.
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Affiliation(s)
- David A Dorr
- Oregon Health and Science University, Portland, OR
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Lanham HJ, Palmer RF, Leykum LK, McDaniel RR, Nutting PA, Stange KC, Crabtree BF, Miller WL, Jaén CR. Trust and Reflection in Primary Care Practice Redesign. Health Serv Res 2016; 51:1489-514. [PMID: 26611650 PMCID: PMC4946034 DOI: 10.1111/1475-6773.12415] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). DATA SOURCES/STUDY SETTING Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. STUDY DESIGN We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. DATA COLLECTION/EXTRACTION METHODS We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. PRINCIPAL FINDINGS Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection. CONCLUSIONS Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.
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Affiliation(s)
- Holly Jordan Lanham
- Department of Medicine/Hospital Medicine & Department of Family and Community MedicineThe University of Texas Health Science CenterSan AntonioTX
- South Texas Veterans Health Care SystemSan AntonioTX
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
| | - Raymond F. Palmer
- Department of Family and Community MedicineThe University of Texas Health Science CenterSan AntonioTX
| | - Luci K. Leykum
- South Texas Veterans Health Care SystemSan AntonioTX
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
- Department of Medicine/Hospital MedicineThe University of Texas Health Science CenterSan AntonioTX
| | - Reuben R. McDaniel
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
| | | | - Kurt C. Stange
- Departments of Family Medicine, Epidemiology and Biostatistics, and SociologyCase Comprehensive Cancer CenterCase Western Reserve UniversityClevelandOH
| | - Benjamin F. Crabtree
- Department of Family Medicine & Community HealthRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - William L. Miller
- Department of Family MedicineLehigh Valley Health NetworkAllentownPA
| | - Carlos Roberto Jaén
- Departments of Family & Community Medicine, and Epidemiology and BiostatisticsResearch to Advance Community Health CenterThe University of Texas Health Sciences CenterSan AntonioTX
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DiCicco-Bloom B, DiCicco-Bloom B. The benefits of respectful interactions: fluid alliancing and inter-occupational information sharing in primary care. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:965-979. [PMID: 27363598 DOI: 10.1111/1467-9566.12418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Though inter-occupational interactions in health care have been the focus of increasing attention, we still know little about how such interactions shape information sharing in clinical settings. This is particularly true in primary care where research on teams and collaboration has been based on individual perceptions of work (using surveys and interviews) rather than observing the interactions that directly mediate the inter-occupational flow of information. To explore how interactions shape information sharing, we conducted a secondary analysis of ethnographic data from 27 primary care practices. Ease of information sharing among nurses and doctors is linked to the degree to which practices feature respectful interactions, with practices in the sample falling into one of three categories (those with low, uneven, and high degrees of respectful interactions). Those practices with the highest degree of respectful interactions demonstrate what we describe as fluid-alliancing: flexible interactions between individuals from different occupational groups in which bidirectional information sharing occurs for the benefit of patients and the efficacy of the practice community. We conclude by arguing that this process unlocks the strengths of all practice members, and that leadership should encourage respectful interactions to augment organisational efficacy and the ability of individual practice members to provide quality patient care.
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Affiliation(s)
- Barbara DiCicco-Bloom
- Department of Nursing, College of Staten Island & CUNY Graduate Center, City University of New York, USA
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Shi L, Lee DC, Chung M, Liang H, Lock D, Sripipatana A. Patient-Centered Medical Home Recognition and Clinical Performance in U.S. Community Health Centers. Health Serv Res 2016; 52:984-1004. [PMID: 27324440 DOI: 10.1111/1475-6773.12523] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION America's community health centers (HCs) are uniquely poised to implement the patient-centered medical home (PCMH) model, as they are effective in providing comprehensive, accessible, and continuous primary care. This study aims to evaluate the relationship between PCMH recognition in HCs and clinical performance. METHODS Data for this study came from the 2012 Uniform Data System (UDS) as well as a survey of HCs' PCMH recognition achievement. The dependent variables included all 16 measures of clinical performance collected through UDS. Control measures included HC patient, provider, and practice characteristics. Bivariate analyses and multiple logistic regressions were conducted to compare clinical performance between HCs with and without PCMH recognition. FINDINGS Health centers that receive PCMH recognition generally performed better on clinical measures than HCs without PCMH recognition. After controlling for HC patient, provider, and practice characteristics, HCs with PCMH recognition reported significantly better performance on asthma-related pharmacologic therapy, diabetes control, pap testing, prenatal care, and tobacco cessation intervention. CONCLUSION This study establishes a positive association between PCMH recognition and clinical performance in HCs. If borne out in future longitudinal studies, policy makers and practices should advance the PCMH model as a strategy to further enhance the quality of primary care.
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Affiliation(s)
- Leiyu Shi
- Johns Hopkins Primary Care Policy Center, Baltimore, MD.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - De-Chih Lee
- Johns Hopkins Primary Care Policy Center, Baltimore, MD.,Department of Information Management, Da-Yeh University, Changhua, Taiwan
| | - Michelle Chung
- Bureau of Primary Health Care, U.S. Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD
| | - Hailun Liang
- Johns Hopkins Primary Care Policy Center, Baltimore, MD.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Diana Lock
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Alek Sripipatana
- Bureau of Primary Health Care, U.S. Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD
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O'Malley D, Hudson SV, Nekhlyudov L, Howard J, Rubinstein E, Lee HS, Overholser LS, Shaw A, Givens S, Burton JS, Grunfeld E, Parry C, Crabtree BF. Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care. J Cancer Surviv 2016; 11:13-23. [PMID: 27277895 DOI: 10.1007/s11764-016-0555-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 05/30/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE This study describes the experiences of early implementers of primary care-focused cancer survivorship delivery models. METHODS Snowball sampling was used to identify innovators. Twelve participants (five cancer survivorship primary care innovators and seven content experts) attended a working conference focused on cancer survivorship population strategies and primary care transformation. Data included meeting discussion transcripts/field notes, transcribed in-depth innovator interviews, and innovators' summaries of care models. We used a multistep immersion/crystallization analytic approach, guided by a primary care organizational change model. RESULTS Innovative practice models included: (1) a consultative model in a primary care setting; (2) a primary care physician (PCP)-led, blended consultative/panel-based model in an oncology setting; (3) an oncology nurse navigator in a primary care practice; and (4) two subspecialty models where PCPs in a general medical practice dedicated part of their patient panel to cancer survivors. Implementation challenges included (1) lack of key stakeholder buy-in; (2) practice resources allocated to competing (non-survivorship) change efforts; and (3) competition with higher priority initiatives incentivized by payers. CONCLUSIONS Cancer survivorship delivery models are potentially feasible in primary care; however, significant barriers to widespread implementation exist. Implementation efforts would benefit from increasing the awareness and potential value-add of primary care-focused strategies to address survivors' needs. IMPLICATIONS FOR CANCER SURVIVORS Current models of primary care-based cancer survivorship care may not be sustainable. Innovative strategies to provide quality care to this growing population of survivors need to be developed and integrated into primary care settings.
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Affiliation(s)
- Denalee O'Malley
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA.
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ, USA.
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, New Brunswick, NJ, 08873, USA.
- Rutgers, School of Social Work, New Brunswick, NJ, USA.
| | - Shawna V Hudson
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ, USA
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, New Brunswick, NJ, 08873, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Larissa Nekhlyudov
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA
| | - Jenna Howard
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ, USA
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, New Brunswick, NJ, 08873, USA
| | - Ellen Rubinstein
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ, USA
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, New Brunswick, NJ, 08873, USA
| | - Heather S Lee
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ, USA
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, New Brunswick, NJ, 08873, USA
| | - Linda S Overholser
- Department of General Internal Medicine, University of Colorado, Denver, CO, USA
| | - Amy Shaw
- Annadel Medical Group, Santa Rosa, CA, USA
| | | | - Jay S Burton
- Springfield Medical Associates, Enfield, CT, USA
| | - Eva Grunfeld
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Carly Parry
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC, USA
| | - Benjamin F Crabtree
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ, USA
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, New Brunswick, NJ, 08873, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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Mundt MP, Agneessens F, Tuan WJ, Zakletskaia LI, Kamnetz SA, Gilchrist VJ. Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study. Int J Nurs Stud 2016; 58:1-11. [PMID: 27087293 PMCID: PMC4835690 DOI: 10.1016/j.ijnurstu.2016.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 01/28/2016] [Accepted: 01/30/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care. OBJECTIVE To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes. METHODS A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling. PARTICIPANTS 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013. RESULTS Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (rate ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes. CONCLUSIONS Primary care teams which relied on frequent daily face-to-face communication among more team members, and had a single RN communicating patient care information to the PCP, had greater shared team vision, better patient outcomes, and lower medical costs for their diabetes patient panels.
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Affiliation(s)
- Marlon P Mundt
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, WI 53715, USA; Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI 53715, USA.
| | | | - Wen-Jan Tuan
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, WI 53715, USA
| | - Larissa I Zakletskaia
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, WI 53715, USA
| | - Sandra A Kamnetz
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, WI 53715, USA
| | - Valerie J Gilchrist
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, Madison, WI 53715, USA
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