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McGowan D, Morley C, Hansen E, Shaw K, Winzenberg T. Experiences of participants in the co-design of a community-based health service for people with high healthcare service use. BMC Health Serv Res 2024; 24:339. [PMID: 38486164 PMCID: PMC10938828 DOI: 10.1186/s12913-024-10788-5] [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: 09/26/2023] [Accepted: 02/26/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Incorporating perspectives of health consumers, healthcare workers, policy makers and stakeholders through co-design is essential to design services that are fit for purpose. However, the experiences of co-design participants are poorly understood. The aim of this study is to explore the experiences and perceptions of people involved in the co-design of a new service for people with high healthcare service utilisation. METHODS A methodology informed by the principles of grounded theory was used in this qualitative study to evaluate the experiences and perceptions of co-design participants. Participants were healthcare professionals, health managers and leaders and health consumers involved in the co-design of the new service in Tasmania, Australia. Semi-structured interviews were conducted, and data were iteratively and concurrently collected and analysed using constant comparative analysis. Audio/audio-visual recordings of interviews were transcribed verbatim. Transcripts, memos, and an audit trail were coded for experiences and perspectives of participants. RESULTS There were thirteen participants (5 health professionals, 6 health managers and leaders, and 2 health consumers). Codes were collapsed into six sub-themes and six themes. Themes were bureaucracy hinders co-design, importance of consumers and diversity, importance of a common purpose, relationships are integral, participants expectations inform their co-design experience and learning from co-design. CONCLUSION Most participants reported positive aspects such as having a common purpose, valuing relationships, and having a personal motivation for participating in co-design. However, there were factors which hindered the adaptation of co-design principles and the co-design process. Our research highlights that bureaucracy can hinder co-design, that including people with lived experience is essential and the need to consider various types of diversity when assembling co-design teams. Future co-design projects could use these findings to improve the co-design experience for participants, and ultimately the outcome for communities.
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Affiliation(s)
- Deirdre McGowan
- Menzies Institute for Medical Research University of Tasmania, Hobart, Australia.
| | - Claire Morley
- Menzies Institute for Medical Research University of Tasmania, Hobart, Australia
| | | | - Kelly Shaw
- Menzies Institute for Medical Research University of Tasmania, Hobart, Australia
- KP Health, Hobart, Australia
| | - Tania Winzenberg
- Menzies Institute for Medical Research University of Tasmania, Hobart, Australia
- Primary Health Tasmania, Hobart, Australia
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2
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Chan B, Edwards ST, Srikanth P, Mitchell M, Devoe M, Nicolaidis C, Kansagara D, Korthuis PT, Solotaroff R, Saha S. Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness: The SUMMIT Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2342012. [PMID: 37948081 PMCID: PMC10638646 DOI: 10.1001/jamanetworkopen.2023.42012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023] Open
Abstract
Importance Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited. Objective To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes. Design, Setting, and Participants The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021. Intervention The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months. Main Outcomes and Measures The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes. Results This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed. Conclusions and Relevance The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization. Trial Registration ClinicalTrials.gov Identifier: NCT03224858.
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Affiliation(s)
- Brian Chan
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Central City Concern, Portland, Oregon
| | - Samuel T. Edwards
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Priya Srikanth
- Biostatistics Design Program, Oregon Health & Science University, Portland
| | | | - Meg Devoe
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Central City Concern, Portland, Oregon
| | - Christina Nicolaidis
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- School of Social Work, Portland State University, Portland, Oregon
| | - Devan Kansagara
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - P. Todd Korthuis
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University–Portland State University, Portland
| | | | - Somnath Saha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
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3
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Bergman AA, Stockdale SE, Zulman DM, Katz ML, Asch SM, Chang ET. Types of Engagement Strategies to Engage High-Risk Patients in VA. J Gen Intern Med 2023; 38:3288-3294. [PMID: 37620722 PMCID: PMC10681963 DOI: 10.1007/s11606-023-08336-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 07/11/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging. OBJECTIVE To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program. METHODS We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. RESULTS The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change. CONCLUSION We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.
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Affiliation(s)
- Alicia A Bergman
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Susan E Stockdale
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Donna M Zulman
- VA HSR&D Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Marian L Katz
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Steven M Asch
- VA HSR&D Center for Innovation to Implementation, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Evelyn T Chang
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Berkman ND, Chang E, Seibert J, Ali R. Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis. Ann Intern Med 2022; 175:1728-1741. [PMID: 36343343 DOI: 10.7326/m21-4562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers. PURPOSE To identify characteristics and criteria to distinguish HNHC patients. DATA SOURCES Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022. STUDY SELECTION English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost. DATA EXTRACTION Independent, dual-review extraction and quality assessment. DATA SYNTHESIS The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC. LIMITATION Little evidence distinguished potentially preventable or modifiable health care use from overall use. CONCLUSION A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).
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Affiliation(s)
- Nancy D Berkman
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina (N.D.B., R.A.)
| | - Eva Chang
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina, and Advocate Aurora Health, Advocate Aurora Research Institute, Downers Grove, Illinois (E.C.)
| | - Julie Seibert
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, and North Carolina Department of Health and Human Services, Division of Mental Health, Developmental Disability and Substance Abuse Services, Raleigh, North Carolina (J.S.)
| | - Rania Ali
- RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina (N.D.B., R.A.)
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Chang E, Ali R, Berkman ND. Unpacking complex interventions that manage care for high-need, high-cost patients: a realist review. BMJ Open 2022; 12:e058539. [PMID: 35680272 PMCID: PMC9185578 DOI: 10.1136/bmjopen-2021-058539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Payers, providers and policymakers in the USA are interested in developing interventions that reduce preventable or modifiable healthcare use among high-need, high-cost (HNHC) patients. This study seeks to describe how and why complex interventions for HNHC patients lead to more appropriate use of healthcare services. DESIGN A realist review which develops programme theories from causal explanations generated and articulated through the creation of context-mechanism-outcome configurations. METHODS Electronic databases (including PubMed and Embase) and gray literature from January 2000 to March 2021 were searched. All study designs were included if the article provided data to develop our programme theories. Included studies were conducted in the USA and focused on interventions for adult, HNHC patients. RESULTS Data were synthesised from 48 studies. Identifying HNHC patients for inclusion in interventions requires capturing a combination of characteristics including their prior use of healthcare services, complexity of chronic disease(s) profile, clinician judgment and willingness to participate. Once enrolled, engaging HNHC patients in interventions requires intervention care providers and patients to build a trusting relationship. Tailored, individualised assistance for medical and non-medical needs, emotional support and self-management education empowers patients to increase their participation in managing their own care. Engagement of care providers in interventions to expand support of HNHC patients is facilitated by targeted outreach, adequate staffing support with shared values and regular and open communication. CONCLUSIONS Building relationships with HNHC patients and gaining their trust is a key component for interventions to successfully change HNHC patients' behaviors. Identifying HNHC patients for an intervention can be best achieved through a multipronged strategy that accounts for their clinical and psychosocial complexity and prior experiences with the healthcare system. Successful interventions recognise that relationships with HNHC patients require the sustained engagement of care providers. To succeed, providers need ongoing emotional, financial, logistical and practical resources. PROSPERO REGISTRATION NUMBER CRD42020161179.
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Affiliation(s)
- Eva Chang
- RTI-University of North Carolina Evidence-Based Practice Center, RTI International, Research Triangle Park, North Carolina, USA
- Advocate Aurora Research Institute, Advocate Aurora Health Inc, Downers Grove, Illinois, USA
| | - Rania Ali
- RTI-University of North Carolina Evidence-Based Practice Center, RTI International, Research Triangle Park, North Carolina, USA
| | - Nancy D Berkman
- RTI-University of North Carolina Evidence-Based Practice Center, RTI International, Research Triangle Park, North Carolina, USA
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6
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Knox M, Esteban EE, Hernandez EA, Fleming MD, Safaeinilli N, Brewster AL. Defining case management success: a qualitative study of case manager perspectives from a large-scale health and social needs support program. BMJ Open Qual 2022; 11:bmjoq-2021-001807. [PMID: 35667706 PMCID: PMC9171266 DOI: 10.1136/bmjoq-2021-001807] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Health systems are expanding efforts to address health and social risks, although the heterogeneity of early evidence indicates need for more nuanced exploration of how such programs work and how to holistically assess program success. This qualitative study aims to identify characteristics of success in a large-scale, health and social needs case management program from the perspective of interdisciplinary case managers. Setting Case management program for high-risk, complex patients run by an integrated, county-based public health system. Participants 30 out of 70 case managers, purposively sampled to represent their interdisciplinary health and social work backgrounds. Interviews took place in March–November 2019. Primary and secondary outcome measures The analysis intended to identify characteristics of success working with patients. Results Case managers described three characteristics of success working with patients: (1) establishing trust; (2) observing change in patients’ mindset or initiative and (3) promoting stability and independence. Cross-cutting these characteristics, case managers emphasised the importance of patients defining their own success, often demonstrated through individualised, incremental progress. Thus, moments of success commonly contrasted with external perceptions and operational or productivity metrics. Conclusions Themes emphasise the importance of compassion for complexity in patients’ lives, and success as a step-by-step process that is built over longitudinal relationships.
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Affiliation(s)
- Margae Knox
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | | | | | - Mark D Fleming
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Nadia Safaeinilli
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Amanda L Brewster
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
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Zellmer L, Johnson B, Idris A, Mehus CJ, Borowsky IW. Post-Identification Approaches to Addressing Health-Related Social Needs in Primary Care: A Qualitative Study. J Gen Intern Med 2022; 37:802-808. [PMID: 34331212 PMCID: PMC8904656 DOI: 10.1007/s11606-021-07033-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Social determinants of health play a fundamental role in a patient's health status. In recent years, health systems across the nation have implemented numerous strategies aimed at identifying and addressing the health-related social needs of the patients they serve. Despite the influx of peer-reviewed research highlighting outcomes of specific health-related social needs interventions, the spectrum of practices utilized by primary care clinics has not been established. OBJECTIVE To determine the range of ways primary care clinics address health-related social needs after identification and initial contact with a frontline staff person is completed. DESIGN We conducted 12 semi-structured, in-person interviews with staff from purposively sampled clinics. If the interview included more than one staff person, all participants were interviewed together. PARTICIPANTS Twenty-one administrative staff and frontline clinic personnel with experience in 24 separate primary care clinics in the Minneapolis-St. Paul, Minnesota metropolitan area. APPROACH Interviews focused on the range of health-related social needs processes utilized by clinics, including staff titles, referral procedures, and barriers to addressing needs. Interview recordings were transcribed and coded using thematic analysis. KEY RESULTS Thematic analysis identified variation in four key areas involving how clinics address patients' health-related social needs after identification and initial contact by frontline staff: clinic personnel involved in addressing needs, clinic referral processes, "resource" and "success" definitions, and barriers to accessing community-based supports. CONCLUSIONS This study describes the large variation in primary care clinic practices to address health-related social needs after they are identified. The results suggest challenges to standardization and real-world application of previously published studies. Our findings also highlight the opportunity for improved relationships between health systems and community-based agencies.
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Affiliation(s)
- Lucas Zellmer
- University of Minnesota Medical School, University of Minnesota, Minneapolis, MN, USA.
| | - Bryan Johnson
- University of Minnesota Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Ahmed Idris
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Christopher J Mehus
- Institute for Translational Research in Children's Mental Health, University of Minnesota, Minneapolis, MN, USA
| | - Iris W Borowsky
- Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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Gelberg L, Edwards ST, Hooker ER, Niederhausen M, Shaner A, Cowan BJ, Warde CM. Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization. J Gen Intern Med 2021; 36:3659-3664. [PMID: 34595681 PMCID: PMC8642561 DOI: 10.1007/s11606-021-06856-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/26/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization. METHODS Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018. RESULTS Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups' post-intervention slopes for numbers of primary care visits (difference in slopes =-0.16 visits/100 patients/month; 95% CI -0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI -0.16, 0.32; p=0.50), mental health visits (difference in slopes = -1.37 visits/month; 95% CI -2.95, 0.20; p= 0.09), and psychiatric hospitalizations (-0.005 admissions/100 patients/month; 95% CI -0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations. CONCLUSIONS Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals' capabilities to care for vulnerable populations.
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Affiliation(s)
- Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
- Office of Healthcare Transformation and Innovation, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Samuel T Edwards
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University (OHSU), Portland, OR, USA
| | - Elizabeth R Hooker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University (OHSU), Portland, OR, USA
- Portland State University School of Public Health, Portland, OR, USA
| | - Andrew Shaner
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Brianna J Cowan
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Carole M Warde
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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9
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Wong MS, Luger TM, Katz ML, Stockdale SE, Ewigman NL, Jackson JL, Zulman DM, Asch SM, Ong MK, Chang ET. Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot. J Gen Intern Med 2021; 36:3366-3372. [PMID: 33987789 PMCID: PMC8606366 DOI: 10.1007/s11606-021-06869-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value. OBJECTIVE To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients. DESIGN A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation. PARTICIPANTS High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites. APPROACH We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects. KEY RESULTS Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization. CONCLUSIONS Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).
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Affiliation(s)
- Michelle S Wong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.
| | - Tana M Luger
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Covenant Health Network, Phoenix, AZ, USA
| | - Marian L Katz
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Jeffrey L Jackson
- Department of Medicine, Zablocki VA Medical Center, Milwaukee, WI, USA.,Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Michael K Ong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles HSR&D, Los Angeles, CA, USA.,Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Patient Activation, Depressive Symptoms, and Self-Rated Health: Care Management Intervention Effects among High-Need, Medically Complex Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115690. [PMID: 34073277 PMCID: PMC8198245 DOI: 10.3390/ijerph18115690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/20/2021] [Accepted: 05/23/2021] [Indexed: 11/17/2022]
Abstract
The purpose of this randomized controlled trial (n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.
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11
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Hulen E, Laliberte A, Ono S, Saha S, Edwards ST. "Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care. J Gen Intern Med 2021; 36:894-900. [PMID: 33432431 PMCID: PMC8042101 DOI: 10.1007/s11606-020-06356-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 11/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors. OBJECTIVE Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery. DESIGN, SETTING, AND PARTICIPANTS Between 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits. APPROACH We employed an exploratory, content-driven approach to qualitative data analysis. RESULTS Four thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having "eyes in the home" yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides. CONCLUSION AND RELEVANCE HBPC providers emphasized the importance of having "eyes in the home" to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.
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Affiliation(s)
- Elizabeth Hulen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA. .,Department of Sociology, Portland State University, Portland, OR, USA.
| | - Avery Laliberte
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Sarah Ono
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,Veterans Rural Health Resource Center-Portland, Veterans Health Administration Office of Rural Health, Portland, OR, USA
| | - Somnath Saha
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Samuel T Edwards
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
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12
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Affiliation(s)
| | | | - Joseph Doyle
- Massachusetts Institute of Technology, Cambridge, MA
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