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Goh LH, Szücs A, Siah CJR, Lazarus MA, Tai ES, Valderas JM, Young DYL. Patient perspectives of diabetes care in primary care networks in Singapore: a mixed-methods study. BMC Health Serv Res 2023; 23:1445. [PMID: 38124081 PMCID: PMC10734143 DOI: 10.1186/s12913-023-10310-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Type 2 diabetes (T2D) remains an important chronic condition worldwide requiring integrated patient-centred care as advocated by the Chronic Care Model (CCM). The Primary Care Networks (PCNs) in Singapore organise general practitioners (GPs) with nurses and care coordinators to deliver team-based care for patients with chronic conditions. This study examined the quality of care in the PCNs as defined by the CCM from the patients' perspective. METHODS This study followed a cross-sectional convergent mixed-method design with T2D patients across three PCN types (GP-led, Group, and Cluster). The Patient Assessment of Chronic Illness Care (PACIC, range 1-5) was completed by a convenience sample of 343 patients. Multivariate linear regression was performed to estimate the associations between patient and service characteristics and PACIC summary score. Twenty-four participants were purposively recruited for interviews on the experienced care until thematic saturation was reached. Quantitative and qualitative data were collected concurrently and independently. Integration occurred during study design and data analysis using the CCM as guidance. Quantitative and qualitative results were compared side-by-side in a joint comparison table to develop key concepts supported by themes, subthemes, and patients' quotes. RESULTS The PACIC mean summary score of 3.21 for 343 patients evidenced that some have received CCM consistent care in the PCNs. Being younger and spending more time with the GP were associated with higher PACIC summary scores. PACIC summary scores did not differ across PCN types. The 24 patients interviewed in the qualitative study reported receiving team-based care, nurse services, good continuity of care, as well as patient-centred care, convenient access, and affordable care. Key concepts showed that integrated care consistent with the CCM was sometimes received by patients in the PCNs. Patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling were sometimes received by patients, while follow-up/coordination was generally not received. CONCLUSIONS Patients with T2D from the Singapore Primary Care Networks received integrated care consistent with the Chronic Care Model, particularly in patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling. Follow-up/coordination needed improvement to ensure higher quality of diabetes care.
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Affiliation(s)
- Lay Hoon Goh
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Anna Szücs
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Chiew Jiat Rosalind Siah
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, Block MD11, level 2, 10 Medical Drive, Singapore, 117597, Singapore
| | - Monica A Lazarus
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - E Shyong Tai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jose M Valderas
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Doris Yee Ling Young
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
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Developing a nurse practitioner to work in residential aged care: A qualitative evaluative study. Collegian 2023. [DOI: 10.1016/j.colegn.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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Snyder K, Mollard E, Bargstadt-Wilson K, Peterson J. “We don’t talk about it enough”: Perceptions of pelvic health among postpartum women in rural communities. WOMEN'S HEALTH 2022; 18:17455057221122584. [PMID: 36148940 PMCID: PMC9510969 DOI: 10.1177/17455057221122584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: A descriptive qualitative study was conducted to explore perceptions and
experiences related to pelvic health in the postpartum period among a cohort
of women residing in communities with less than 50,000 residents. Methods: A semi-structured interview approach guided by the Theory of Planned Behavior
was used. Postpartum individuals (<6 months since childbirth) were
interviewed in the fall/winter of 2021–2022. Results: Specific to individuals’ attitudes toward pelvic health, women viewed Kegels
as an important component to improving pelvic health but had a negative
attitude toward their own pelvic health, often identifying their pelvic
floor as “weak.” The subjective norms influencing a woman’s perception were
typically, a positive influence by family/friends and the Internet, although
the Internet was viewed as an insufficient resource. Healthcare providers
were noted as an infrequent and ineffective resource for education and
support in the postpartum period. Finally, women’s perceived behavioral
control to manage their pelvic health was influenced by limited knowledge of
pelvic health and time, and a desire for more education from their primary
care provider and geographical barriers. Conclusion: Innovative strategies are needed to support postpartum women’s pelvic health
within rural communities. Primary care providers may benefit from the
development of “quick tips” by specialists, such as women’s health physical
therapists, to optimize pelvic health discussions with their postpartum
patients. Education interventions targeted toward postpartum women in rural
communities should focus on strategies that address the geographic barriers
identified while still providing individualized care. Options, such as
webinars, telehealth, and text message interventions, could be
considered.
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Affiliation(s)
- Kailey Snyder
- Physical Therapy Department, Creighton University, Omaha, NE, USA
| | - Elizabeth Mollard
- College of Nursing-Lincoln Divison, University Nebraska Medical Center, Lincoln, NE, USA
| | | | - Julie Peterson
- Physical Therapy Department, Creighton University, Omaha, NE, USA
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Casillas A, Valdovinos C, Wang E, Abhat A, Mendez C, Gutierrez G, Portz J, Brown A, Lyles CR. Perspectives from leadership and frontline staff on telehealth transitions in the Los Angeles safety net during the COVID-19 pandemic and beyond. Front Digit Health 2022; 4:944860. [PMID: 36016601 PMCID: PMC9398195 DOI: 10.3389/fdgth.2022.944860] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives The start of the COVID-19 pandemic led the Los Angeles safety net health system to dramatically reduce in-person visits and transition abruptly to telehealth/telemedicine services to deliver clinical care (remote telephone and video visits). However, safety net patients and the settings that serve them face a "digital divide" that could impact effective implementation of such digital care. The study objective was to examine attitudes and perspectives of leadership and frontline staff regarding telehealth integration in the Los Angeles safety net, with a focus on telemedicine video visits. Methods This qualitative study took place in the Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net health system in the US. This system disproportionately serves the uninsured, Medicaid, racial/ethnic minority, low-income, and Limited English Proficient (LEP) patient populations of Los Angeles County. Staff and leadership personnel from each of the five major LAC DHS hospital center clinics, and community-based clinics from the LAC DHS Ambulatory Care Network (ACN) were individually interviewed (video or phone calls), and discussions were recorded. Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), and included questions about the video visit technology platform and its usability, staff resources, clinic needs, and facilitators and barriers to general telehealth implementation and use. Interviews were analyzed for summary of major themes. Results Twenty semi-structured interviews were conducted in August to October 2020. Participants included LAC DHS physicians, nurses, medical assistants, and physical therapists with clinical and/or administrative roles. Narrative themes surrounding telehealth implementation, with video visits as the case study, were identified and then categorized at the patient, clinic (including provider), and health system levels. Conclusions Patient, clinic, and health system level factors must be considered when disseminating telehealth services across the safety net. Participant discussions illustrated how multilevel facilitators and barriers influenced the feasibility of video visits and other telehealth encounters. Future research should explore proposed solutions from frontline stakeholders as testable interventions towards advancing equity in telehealth implementation: from patient training and support, to standardized workflows that leverage the expertise of multidisciplinary teams.
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Affiliation(s)
- Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, United States
- Correspondence: Alejandra Casillas
| | - Cristina Valdovinos
- UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Elizabeth Wang
- UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Anshu Abhat
- Harbor-UCLA Medical Center, Los Angeles County Department of Health Services, Los Angeles, California, United States
| | - Carmen Mendez
- Harbor-UCLA Medical Center, Los Angeles County Department of Health Services, Los Angeles, California, United States
| | - Griselda Gutierrez
- Harbor-UCLA Medical Center, Los Angeles County Department of Health Services, Los Angeles, California, United States
| | - Jennifer Portz
- University of Colorado School of Medicine, Denver, Colorado, United States
| | - Arleen Brown
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, United States
| | - Courtney R. Lyles
- UCSF Departments of Medicine and Epidemiology and Statistics, San Francisco, California, United States
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California, United States
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De Santiago A, Bingham JM, Vaffis S, Scovis N, McGlamery E, Boesen K, Warholak T, Dhatt H. Evaluating the role and value of a clinical pharmacist in a concierge primary care clinic. J Am Pharm Assoc (2003) 2021; 61:240-247.e1. [PMID: 33478927 DOI: 10.1016/j.japh.2020.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To understand the perceived role and value of the clinical pharmacist in a southern Arizona concierge primary care practice (CPCP) by employees. METHODS Semistructured face-to-face interviews were conducted with health care team members employed by the CPCP site in December 2019 and January 2020 for this study. The interviews were audio recorded, transcribed, and thematically analyzed using an inductive approach with ATLAS.ti (version 7). A qualitative assessment was performed by 2 independent reviewers to identify the themes, which included clinical, economic, and humanistic outcomes. RESULTS Eleven CPCP employees were interviewed: physicians (n = 2), a nurse practitioner (n = 1), medical assistants (n = 4), and administrative staff (n = 4). The perceived role and value of the clinical pharmacist in this CPCP varied by employee position; yet, all expressed the pharmacist's positive impact on patient care. Five themes were identified. The most common pharmacist roles identified included providing medication knowledge to providers, preventing abuse of controlled substances, monitoring clinical response to medications and adverse drug events, aiding in prior authorizations, educating patients, and providing patient-centered care. CONCLUSION These results demonstrate that the integration of a clinical pharmacist into a CPCP can be valuable. This study highlights that the pharmacist was positively received by the physicians and staff. This further supports the value of the pharmacist as a key interprofessional health care team member. Further study is warranted to assess the longitudinal impact of pharmacists' services in a CPCP.
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Goldstein P, Losin EAR, Anderson SR, Schelkun VR, Wager TD. Clinician-Patient Movement Synchrony Mediates Social Group Effects on Interpersonal Trust and Perceived Pain. THE JOURNAL OF PAIN 2020; 21:1160-1174. [PMID: 32544602 PMCID: PMC7722052 DOI: 10.1016/j.jpain.2020.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/24/2020] [Accepted: 03/22/2020] [Indexed: 12/19/2022]
Abstract
Pain is an unfortunate consequence of many medical procedures, which in some patients becomes chronic and debilitating. Among the factors affecting medical pain, clinician-patient (C-P) similarity and nonverbal communication are particularly important for pain diagnosis and treatment. Participants (N = 66) were randomly assigned to clinician and patient roles and were grouped into C-P dyads. Clinicians administered painful stimuli to patients as an analogue of a painful medical procedure. We manipulated the perceived C-P similarity of each dyad using groups ostensibly based on shared beliefs and values, and each patient was tested twice: Once with a same group clinician (concordant, CC) and once with a clinician from the other group (discordant, DC). Movement synchrony was calculated as a marker of nonverbal communication. We tested whether movement synchrony mediated the effects of group concordance on patients' pain and trust in the clinician. Movement synchrony was higher in CC than DC dyads. Higher movement synchrony predicted reduced pain and increased trust in the clinician. Movement synchrony also formally mediated the group concordance effects on pain and trust. These findings increase our understanding of the role of nonverbal C-P communication on pain and related outcomes. Interpersonal synchrony may be associated with better pain outcomes, independent of the specific treatment provided. PERSPECTIVE: This article demonstrates that movement synchrony in C-P interactions is an unobtrusive measure related to their relationship quality, trust toward the clinician, and pain. These findings suggest that interpersonal synchrony may be associated with better patient outcomes, independent of the specific treatment provided.
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Affiliation(s)
- Pavel Goldstein
- Institute of Cognitive Science, University of Colorado, Boulder, Colorado; The School of Public Health, University of Haifa, Israel
| | | | | | - Victoria R Schelkun
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire
| | - Tor D Wager
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire; Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado.
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Fortmann AL, Philis-Tsimikas A, Euyoque JA, Clark TL, Vital DG, Sandoval H, Bravin JI, Savin KL, Jones JA, Roesch S, Gilmer T, Bodenheimer T, Schultz J, Gallo LC. Medical assistant health coaching ("MAC") for type 2 diabetes in diverse primary care settings: A pragmatic, cluster-randomized controlled trial protocol. Contemp Clin Trials 2020; 100:106164. [PMID: 33053431 DOI: 10.1016/j.cct.2020.106164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/28/2020] [Accepted: 08/06/2020] [Indexed: 01/30/2023]
Abstract
In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-min primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. "Team-based" chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or "health coaching." While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings - A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N = 600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n = 300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability.
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Affiliation(s)
- Addie L Fortmann
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Athena Philis-Tsimikas
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Johanna A Euyoque
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Taylor L Clark
- San Diego State University/ University of California, San Diego Joint Doctoral Program in Clinical Psychology, 5500 Campanile Dr, San Diego, CA 92182 / 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Daniela G Vital
- San Diego State University Research Foundation, 5500 Campanile Dr, San Diego, CA 92182, USA.
| | - Haley Sandoval
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Julia I Bravin
- San Diego State University/ University of California, San Diego Joint Doctoral Program in Clinical Psychology, 5500 Campanile Dr, San Diego, CA 92182 / 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Kimberly L Savin
- San Diego State University/ University of California, San Diego Joint Doctoral Program in Clinical Psychology, 5500 Campanile Dr, San Diego, CA 92182 / 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Jennifer A Jones
- Scripps Whittier Diabetes Institute, Scripps Health, 10140 Campus Point Drive, Suite 200, San Diego, CA 92121, USA.
| | - Scott Roesch
- Department of Psychology, San Diego State University, 5500 Campanile Dr, San Diego, CA 92182, USA.
| | - Todd Gilmer
- Department of Family Medicine and Public Health, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Thomas Bodenheimer
- Department of Family and Community Medicine, University of California at San Francisco School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - James Schultz
- Neighborhood Healthcare, 460 N Elm St, Escondido, CA 92025, USA.
| | - Linda C Gallo
- Department of Psychology, San Diego State University, 5500 Campanile Dr, San Diego, CA 92182, USA.
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Experiences of Patient-Centered Medical Home Staff Team Members Working in Interprofessional Training Environments. J Gen Intern Med 2020; 35:2976-2982. [PMID: 32728958 PMCID: PMC7573084 DOI: 10.1007/s11606-020-06055-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Evidence is growing that interprofessional team-based models benefit providers, trainees, and patients, but less is understood about the experiences of staff who work beside trainees learning these models. OBJECTIVE To understand the experiences of staff in five VA training clinics participating in an interprofessional team-based learning initiative. DESIGN Individual semi-structured interviews with staff were conducted during site visits, qualitatively coded, and analyzed for themes across sites and participant groups. PARTICIPANTS Patient-centered medical home (PCMH) staff members (n = 32; RNs, Clinical and Clerical Associates) in non-primary care provider (PCP) roles working on teams with trainees from medicine, nursing, pharmacy, and psychology. APPROACH Benefits and challenges of working in an interprofessional, academic clinic were coded by the primary author using a hybrid inductive/directed thematic analytic approach, with review and iterative theme development by the interprofessional author team. KEY RESULTS Efforts to improve interprofessional collaboration among trainees and providers, such as increased shared leadership, have positive spillover effects for PCMH staff members. These staff members perceive themselves playing an educational role for trainees that is not always acknowledged. Playing this role, learning from the "fresh" knowledge imparted by trainees, and contributing to the future of health care all bring satisfaction to staff members. Some constraints exist for full participation in the educational efforts of the clinic. CONCLUSIONS Increased recognition of and expanded support for PCMH staff members to participate in educational endeavors is essential as interprofessional training clinics grow.
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Lucas PRMB, Nunes EMGT. Nursing practice environment in Primary Health Care: a scoping review. Rev Bras Enferm 2020; 73:e20190479. [PMID: 32813805 DOI: 10.1590/0034-7167-2019-0479] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/17/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To examine the scientific evidence about the nursing practice environment in Primary Health Care. METHODS Three-step scoping review. 1) An initial research on CINAHL and MEDLINE. 2) A broader search using the same keywords and search terms in the remaining EBSCOHost platform databases. 3) Search the bibliographical references of the selected articles. The studies selected were from 2007 to 2018. RESULTS 19 articles were included, most reported findings of the nursing practice environment and results for clients, nurses, nurse managers and the efficiency of organizations, in Primary Health Care. CONCLUSION Improving the environment of nursing practice has consequences on the quality of nursing care, with increased results for clients, nursing and Primary Health Care.
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Borgès Da Silva R, Brault I, Pineault R, Chouinard MC, Prud'homme A, D'Amour D. Nursing Practice in Primary Care and Patients' Experience of Care. J Prim Care Community Health 2019; 9:2150131917747186. [PMID: 29357748 PMCID: PMC5937150 DOI: 10.1177/2150131917747186] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: Nurses are identified as a key provider in the management of
patients in primary care. The objective of this study was to evaluate patients’ experience
of care in primary care as it pertained to the nursing role. The aim was to test the
hypothesis that, in primary health care organizations (PHCOs) where patients are
systematically followed by a nurse, and where nursing competencies are therefore optimally
used, patients’ experience of care is better. Method: Based on a
cross-sectional analysis combining organizational and experience of care surveys, we built
2 groups of PHCOs. The first group of PHCOs reported having a nurse who systematically
followed patients. The second group had a nurse who performed a variety of activities but
did not systematically follow patients. Five indicators of care were constructed based on
patient questionnaires. Bivariate and multivariate linear mixed models with random
intercepts and with patients nested within were used to analyze the experience of care
indicators in both groups. Results: Bivariate analyses revealed a better
patient experience of care in PHCOs where a nurse systematically followed patients than in
those where a nurse performed other activities. In multivariate analyses that included
adjustment variables related to PHCOs and patients, the accessibility indicator was found
to be higher. Conclusion: Results indicated that systematic follow-up of
patients by nurses improved patients’ experience of care in terms of accessibility. Using
nurses’ scope of practice to its full potential is a promising avenue for enhancing both
patients’ experience of care and health services efficiency.
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Affiliation(s)
- Roxane Borgès Da Silva
- 1 University of Montreal Public Health Research Insitute, Montreal, Quebec, Canada.,2 Faculty of Nursing of University of Montreal, Montreal, Quebec, Canada.,3 Center for Interuniversity Research and Analysis of Organisations, Montreal, Quebec, Canada
| | - Isabelle Brault
- 1 University of Montreal Public Health Research Insitute, Montreal, Quebec, Canada.,2 Faculty of Nursing of University of Montreal, Montreal, Quebec, Canada
| | - Raynald Pineault
- 1 University of Montreal Public Health Research Insitute, Montreal, Quebec, Canada.,2 Faculty of Nursing of University of Montreal, Montreal, Quebec, Canada
| | | | - Alexandre Prud'homme
- 1 University of Montreal Public Health Research Insitute, Montreal, Quebec, Canada.,3 Center for Interuniversity Research and Analysis of Organisations, Montreal, Quebec, Canada
| | - Danielle D'Amour
- 1 University of Montreal Public Health Research Insitute, Montreal, Quebec, Canada.,2 Faculty of Nursing of University of Montreal, Montreal, Quebec, Canada
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, Piña IL. Type 2 Diabetes Mellitus and Heart Failure: A Scientific Statement From the American Heart Association and the Heart Failure Society of America: This statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update. Circulation 2019; 140:e294-e324. [PMID: 31167558 DOI: 10.1161/cir.0000000000000691] [Citation(s) in RCA: 314] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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12
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, PiÑa IL. Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America. J Card Fail 2019; 25:584-619. [PMID: 31174952 DOI: 10.1016/j.cardfail.2019.05.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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Ono SS, Crabtree BF, Hemler JR, Balasubramanian BA, Edwards ST, Green LA, Kaufman A, Solberg LI, Miller WL, Woodson TT, Sweeney SM, Cohen DJ. Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension. Health Aff (Millwood) 2019; 37:222-230. [PMID: 29401016 DOI: 10.1377/hlthaff.2017.1100] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.
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Affiliation(s)
- Sarah S Ono
- Sarah S. Ono ( ) is an assistant professor in the Department of Family Medicine at Oregon Health & Science University and an investigator in the Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, both in Portland
| | - Benjamin F Crabtree
- Benjamin F. Crabtree is a professor in the Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, in New Brunswick, New Jersey
| | - Jennifer R Hemler
- Jennifer R. Hemler is a research associate in the Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School
| | - Bijal A Balasubramanian
- Bijal A. Balasubramanian is an associate professor in the Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, in Texas
| | - Samuel T Edwards
- Samuel T. Edwards is an assistant research professor in the Department of Family Medicine and an assistant professor of medicine at Oregon Health & Science University and a staff physician in the Section of General Internal Medicine, VA Portland Health Care System
| | - Larry A Green
- Larry A. Green is a professor of family medicine and the Epperson-Zorn Chair for Innovation in Family Medicine at the University of Colorado Denver, in Aurora
| | - Arthur Kaufman
- Arthur Kaufman is distinguished professor in the Department of Family and Community Medicine and vice chancellor for community health at the University of New Mexico, in Albuquerque
| | - Leif I Solberg
- Leif I. Solberg is a senior adviser and director for care improvement research at HealthPartners Institute, in Minneapolis, Minnesota
| | - William L Miller
- William L. Miller is chair emeritus in the Department of Family Medicine, Lehigh Valley Health Network, in Allentown, Pennsylvania
| | - Tanisha Tate Woodson
- Tanisha Tate Woodson is a senior research associate in the Department of Family Medicine, Oregon Health & Science University
| | - Shannon M Sweeney
- Shannon M. Sweeney is a research associate in the Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School
| | - Deborah J Cohen
- Deborah J. Cohen is a professor and vice chair of research in the Department of Family Medicine at Oregon Health & Science University
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14
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Bush H, Golabi P, Otgonsuren M, Rafiq N, Venkatesan C, Younossi ZM. Nonalcoholic Fatty Liver is Contributing to the Increase in Cases of Liver Disease in US Emergency Departments. J Clin Gastroenterol 2019; 53:58-64. [PMID: 29608451 DOI: 10.1097/mcg.0000000000001026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GOALS/BACKGROUND We aimed to assess temporal changes in the different types of liver disease (LD) cases and outcomes from emergency departments (EDs) across the United States. STUDY We used data from the National Inpatient Survey database from 2005 to 2011. The International Classification of Diseases, Ninth Revision (ICD-9) clinical modification codes identified hepatitis C virus (HCV), hepatitis B virus (HBV), alcoholic liver disease (ALD), nonalcoholic fatty liver disease (NAFLD), and other LDs including autoimmune hepatitis. We excluded cases without LD, nonhepatocellular carcinoma-related cancers, human immunodeficiency virus infection, or those with missing information. Logistic regression was used to estimate odds ratios with 95% confidence intervals. Controls were matched to cases without LD. RESULTS During the study period, 20,641,839 cases were seen in EDs. Of these, 1,080,008 cases were related to LD and were matched to controls without LD (N=19,557,585). The number of cases with LD increased from 123,873 (2005) to 188,501 (2011) (P<0.0001). Among cases with LD, diagnosis of HCV, HBV, and ALD remained stable during the study years (41.60% vs. 38.20%, 3.70% vs. 2.80%, and 41.4% vs. 38.5%, respectively), whereas NAFLD doubled [6.00% of all LD (2005) to 11.90% of all LD (2011) (P<0.0001)]. Diagnosis of LD in the ED independently predicted increased patient mortality [odds ratio, 1.20 (1.17 to 1.22)]. CONCLUSIONS The number of LD cases presenting to EDs is increasing, and a diagnosis of LD is associated with a higher patient mortality for those admitted through the ED. There is a dramatic increase of NAFLD diagnoses in the ED.
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Affiliation(s)
- Haley Bush
- Betty and Guy Beatty Center for Integrated Research, Inova Health System
| | - Pegah Golabi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System
| | | | - Nila Rafiq
- Betty and Guy Beatty Center for Integrated Research, Inova Health System.,Department of Medicine, Center For Liver Disease, Inova Fairfax Hospital, Falls Church, VA
| | - Chapy Venkatesan
- Department of Medicine, Center For Liver Disease, Inova Fairfax Hospital, Falls Church, VA
| | - Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System.,Department of Medicine, Center For Liver Disease, Inova Fairfax Hospital, Falls Church, VA
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15
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Harry ML, Saman DM, Allen CI, Ohnsorg KA, Sperl-Hillen JM, O’Connor PJ, Ziegenfuss JY, Dehmer SP, Bianco JA, Desai JR. Understanding Primary Care Provider Attitudes and Behaviors Regarding Cardiovascular Disease Risk and Diabetes Prevention in the Northern Midwest. Clin Diabetes 2018; 36:283-294. [PMID: 30363898 PMCID: PMC6187954 DOI: 10.2337/cd17-0116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
IN BRIEF We sought to fill critical gaps in understanding primary care providers' (PCPs') beliefs regarding diabetes prevention and cardiovascular disease risk in the prediabetes population, including through comparison of attitudes between rural and non-rural PCPs. We used data from a 2016 cross-sectional survey sent to 299 PCPs practicing in 36 primary clinics that are part of a randomized control trial in a predominately rural northern Midwestern integrated health care system. Results showed a few significant, but clinically marginal, differences between rural and non-rural PCPs. Generally, PCPs agreed with the importance of screening for prediabetes and thoroughly and clearly discussing CV risk with high-risk patients.
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Affiliation(s)
| | - Daniel M. Saman
- Essentia Health, Essentia Institute of Rural Health, Duluth, MN
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Guraya SY, Almaramhy HH. Mapping the factors that influence the career specialty preferences by the undergraduate medical students. Saudi J Biol Sci 2018; 25:1096-1101. [PMID: 30174508 PMCID: PMC6117166 DOI: 10.1016/j.sjbs.2017.03.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/18/2017] [Accepted: 03/28/2017] [Indexed: 01/13/2023] Open
Abstract
It is often perceived that undergraduate medical students do not select their career specialty until they are graduated. This study aimed to probe the preferences of undergraduate medical students about their career specialty and the factors influencing their choices. A self-administered questionnaire was distributed to 3rd through 5th year undergraduate medical students to record their choices of specialties and to identify the factors that influence their career selection. Out of 220 respondents, 29 (13.2%) students selected General Surgery, 24 (10.9%) Pediatrics, and 18 (8.2%) Internal Medicine as their career specialties; whereas 24 (10.9%) students were not able to select a major specialty. The least popular specialties were Gynecology and Obstetrics, Oncology, Histopathology, Orthopedics, Genetics, Psychology, each selected by one student. One hundred and seventeen (53.1%) thought their selected specialty 'matched their capabilities' and 82 (37.2%) perceived their selection as "innovative field in medicine". Career advice by friends and families and the desire to serve academic institutions could not influence career selection. Career preferences by medical students result from the interplay of a range of factors. General Surgery, Pediatrics and Internal Medicine were the most preferred specialties. The professional grooming programs to target specialties matching the trainees' capabilities and the specialties with state-of-the-art innovative technologies attract medical undergraduate students. The attained knowledge is vitally important for the policy makers in modifying the existing framework that can cater the popular and favored specialties.
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Affiliation(s)
| | - Hamdi H. Almaramhy
- Department of Surgery, The College of Medicine, Taibah University, Almadinah Almunawwarah, Saudi Arabia
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17
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Hartzler AL, Tuzzio L, Hsu C, Wagner EH. Roles and Functions of Community Health Workers in Primary Care. Ann Fam Med 2018; 16:240-245. [PMID: 29760028 PMCID: PMC5951253 DOI: 10.1370/afm.2208] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/13/2017] [Accepted: 01/11/2017] [Indexed: 11/09/2022] Open
Abstract
Community health workers have potential to enhance primary care access and quality, but remain underutilized. To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis. Analysis of 30 studies identified 12 functions (ie, care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, health education, and literacy support) and 3 prominent roles representing clusters of functions: clinical services, community resource connections, and health education and coaching. We discuss implications for community health worker training and clinical support in primary care.
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Affiliation(s)
- Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Edward H Wagner
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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18
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Hung DY, Harrison MI, Truong Q, Du X. Experiences of primary care physicians and staff following lean workflow redesign. BMC Health Serv Res 2018; 18:274. [PMID: 29636052 PMCID: PMC5894127 DOI: 10.1186/s12913-018-3062-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members. METHODS The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses. RESULTS We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign. CONCLUSIONS Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce.
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Affiliation(s)
- Dorothy Y Hung
- Palo Alto Medical Foundation Research Institute, 2350 W. El Camino Real #447, Mountain View, CA, 94040, USA.
| | - Michael I Harrison
- Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, 5600 Fishers Lane, Mail Stop 7W25B, Rockville, MD, 20857, USA
| | - Quan Truong
- Palo Alto Medical Foundation Research Institute, 2350 W. El Camino Real #4012, Mountain View, CA, 94040, USA
| | - Xue Du
- Palo Alto Medical Foundation Research Institute, 2350 W. El Camino Real #4014, Mountain View, CA, 94040, USA
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19
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Ng G, Tan SW, Tan NC. Health outcomes of patients with chronic disease managed with a healthcare kiosk in primary care: protocol for a pilot randomised controlled trial. BMJ Open 2018; 8:e020265. [PMID: 29574445 PMCID: PMC5875634 DOI: 10.1136/bmjopen-2017-020265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/05/2018] [Accepted: 02/15/2018] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The rising prevalence of chronic disease is leading to an increase in the demand for primary care services and a shortage of primary care physicians globally. Addressing these challenges calls for innovations in the healthcare delivery model with greater use of healthcare technology tools. We previously examined the feasibility of using an automated healthcare kiosk for the management of patients with stable chronic disease in the primary care setting. The aim of this follow-up study is to evaluate the health outcomes of patients with chronic disease who are on kiosk management compared with patients who are on routine management by nurse clinicians. METHODS AND ANALYSIS The pilot study will be a two-armed randomised controlled trial of 120 patients with well-controlled chronic disease on 4-monthly follow-up visits over a 12-month period. Patients with prior diagnoses of hypertension, hyperlipidaemia and/or diabetes will be included in the study and will be randomly assigned to intervention or control groups to receive kiosk or nurse management, respectively. The main primary outcome measure is the overall chronic disease control of the patients. Other primary outcome measures are the blood pressure and low-density lipoprotein cholesterol levels for patients without diabetes, and blood pressure, low-density lipoprotein cholesterol and haemoglobin A1c levels for patients with diabetes. Secondary outcome measures are visit duration, patient satisfaction with the management process, health-related quality of life and the occurrence of any adverse event. Data will be captured longitudinally at baseline, 4 months, 8 months and 12 months, and will be analysed using multiple regression models. ETHICS AND DISSEMINATION The study has been approved by the Singapore Health Services (SingHealth) Centralised Institutional Review Board (2017/2715). Findings of the study will be submitted for publication in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT03274089; Pre-results.
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Affiliation(s)
- Grace Ng
- Singapore Health Services (SingHealth) Polyclinics, Singapore
- Biomedical Research Council, Agency for Science, Technology and Research (A*STAR), Singapore
| | - Sze Wee Tan
- Science and Engineering Research Council, Agency for Science, Technology and Research (A*STAR), Singapore
| | - Ngiap Chuan Tan
- Singapore Health Services (SingHealth) Polyclinics, Singapore
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20
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Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: A mixed methods study. Health Care Manage Rev 2018; 42:28-41. [PMID: 26545206 DOI: 10.1097/hmr.0000000000000091] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. PURPOSE The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. METHODOLOGY First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. FINDINGS Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. PRACTICE IMPLICATIONS Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to improve aspects of team dynamics may also help resolve critical challenges in workforce planning in primary care.
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21
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Crocker RL, Grizzle AJ, Hurwitz JT, Rehfeld RA, Abraham I, Horwitz R, Weil A, Maizes V. Integrative medicine primary care: assessing the practice model through patients' experiences. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 17:490. [PMID: 29141643 PMCID: PMC5688715 DOI: 10.1186/s12906-017-1996-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/07/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The University of Arizona Integrative Health Center (UAIHC) was an innovative integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC used a hybrid payment model to deliver comprehensive healthcare that includes conventional and complementary medical treatments. METHODS Fidelity measures were collected to evaluate how well the IM care delivery process matched ideals for IM. Patient experiences are presented here. Patients visiting UAIHC on 1 of 10 randomly selected days between September 2013 and February 2015 were surveyed. Patients were asked about their experience with: holistic care; promotion of health, self-care, and well-being; relationship and communication with practitioners; and overall satisfaction. RESULTS Eighty-three patients completed surveys. Based on patient-reported experiences, UAIHC delivered IM care as defined by the practice model. CONCLUSIONS Patients received holistic care, established positive caring relationships with providers who promoted their self-care and well-being, and reported high overall satisfaction with UAIHC.
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Affiliation(s)
- Robert L Crocker
- University of Arizona Center for Integrative Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Amy J Grizzle
- Center for Health Outcomes & PharmacoEconomic Research (HOPE), College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Jason T Hurwitz
- Center for Health Outcomes & PharmacoEconomic Research (HOPE), College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Rick A Rehfeld
- Center for Health Outcomes & PharmacoEconomic Research (HOPE), College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Ivo Abraham
- Center for Health Outcomes & PharmacoEconomic Research (HOPE), College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Randy Horwitz
- University of Arizona Center for Integrative Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Andrew Weil
- University of Arizona Center for Integrative Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Victoria Maizes
- University of Arizona Center for Integrative Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
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22
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Bashshur RL, Howell JD, Krupinski EA, Harms KM, Bashshur N, Doarn CR. The Empirical Foundations of Telemedicine Interventions in Primary Care. Telemed J E Health 2017; 22:342-75. [PMID: 27128779 DOI: 10.1089/tmj.2016.0045] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world. MATERIALS AND METHODS The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost. RESULTS The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective. CONCLUSIONS Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral component of primary care around the world.
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Affiliation(s)
- Rashid L Bashshur
- 1 University of Michigan Health System, University of Michigan , Ann Arbor, Michigan
| | - Joel D Howell
- 2 Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan.,3 Department of History and Health Management and Policy, University of Michigan , Ann Arbor, Michigan
| | | | - Kathryn M Harms
- 5 Family Medicine, University of Michigan , Ann Arbor, Michigan
| | - Noura Bashshur
- 1 University of Michigan Health System, University of Michigan , Ann Arbor, Michigan
| | - Charles R Doarn
- 6 Department of Family and Community Medicine, University of Cincinnati , Cincinnati, Ohio
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Chung S, Panattoni L, Chi J, Palaniappan L. Can Secure Patient-Provider Messaging Improve Diabetes Care? Diabetes Care 2017; 40:1342-1348. [PMID: 28807977 DOI: 10.2337/dc17-0140] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/09/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Internet-based secure messaging between patients and providers through a patient portal is now common in the practice of modern medicine. There is limited evidence on how messaging is associated with use and clinical quality measures among patients with type 2 diabetes. We examine whether messaging with physicians for medical advice is associated with fewer face-to-face visits and better diabetes management. RESEARCH DESIGN AND METHODS Patients with diabetes who were enrolled in an online portal of an outpatient health care organization in 2011-2014 were studied (N = 37,762 patient-years). Messages from/to primary care physicians or diabetes-related specialists for medical advice were considered. We estimated the association of messaging with diabetes quality measures, adjusting for patient and provider characteristics and patient-level clustering. RESULTS Most patients (72%) used messaging, and those who made frequent visits were also more likely to message. Given visit frequency, no (vs. any) messaging was negatively associated with the likelihood of meeting an HbA1c target of <8% (64 mmol/mol) (odds ratio [OR] 0.83 [95% CI 0.77, 0.90]). Among message users, additional messages (vs. 1) were associated with better outcome (two more messages: OR 1.17 [95% CI 1.06, 1.28]; three more messages: 1.38 [1.25, 1.53]; four more messages: 1.55 [1.43, 1.69]). The relationship was stronger for noninsulin users. Message frequency was also positively associated, but to a smaller extent, with process measures (e.g., eye examination). Physician-initiated messages had effects similar to those for patient-initiated messages. CONCLUSIONS Patients with diabetes frequently used secure messaging for medical advice in addition to routine visits to care providers. Messaging was positively associated with better diabetes management in a large community outpatient practice.
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Affiliation(s)
- Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Laura Panattoni
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeffrey Chi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Latha Palaniappan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Freihoefer K, Kaiser L, Vonasek D, Bayramzadeh S. Setting the Stage: A Comparative Analysis of an Onstage/Offstage and a Linear Clinic Modules. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2017; 11:89-103. [DOI: 10.1177/1937586717729348] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The purpose of this study was to understand how two different ambulatory design modules—traditional and onstage/offstage—impact operational efficiency, patient throughput, staff collaboration, and patient privacy. Background: Delivery of healthcare is greatly shifting to ambulatory settings because of rapid advancement of medicine and technology, resulting in more day procedures and follow-up care occurring outside of hospitals. It is anticipated that outpatient services will grow roughly 15–23% within the next 10 years (Sg2, 2014). Nonetheless, there is limited research that evaluates how the built environment impacts care delivery and patient outcomes. Method: This is a cross-sectional, comparative study consisted of a mixed-method approach that included shadowing clinic staff and observing and surveying patients. The linear module had shared corridors and publicly exposed workstations, whereas the onstage/offstage module separates patient/visitors from staff with dedicated patient corridors leading to exam rooms (onstage) and enclosed staff work cores (offstage). Roughly 35 hr of clinic staff shadowing and 55 hr of patient observations occurred. A total of 269 questionnaires were completed by patients/visitors. Results: The results demonstrate that the onstage/offstage module significantly improved staff workflow, reduced travel distances, increased communication in private areas, and significantly reduced patient throughput and wait times. However, patients’ perception of privacy did not change among the two modules. Conclusion: Compared to the linear module, this study provides evidence that the onstage/offstage module could have helped to optimize operational efficiencies, staff workflow, and patient throughput.
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Affiliation(s)
| | - Len Kaiser
- HealthEast Care System, Saint Paul, MN, USA
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Bleijenberg N, Drubbel I, Neslo RE, Schuurmans MJ, Ten Dam VH, Numans ME, de Wit GA, de Wit NJ. Cost-Effectiveness of a Proactive Primary Care Program for Frail Older People: A Cluster-Randomized Controlled Trial. J Am Med Dir Assoc 2017; 18:1029-1036.e3. [PMID: 28801235 DOI: 10.1016/j.jamda.2017.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 06/22/2017] [Accepted: 06/23/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND A proactive integrated approach has shown to preserve daily functioning among older people in the community. The aim is to determine the cost-effectiveness of a proactive integrated primary care program. METHODS Economic evaluation embedded in a single-blind, 3-armed, cluster-randomized controlled trial with 12 months' follow-up in 39 general practices in the Netherlands. General practices were randomized to one of 3 trial arms: (1) an electronic frailty screening instrument using routine medical record data followed by standard general practitioner (GP) care; (2) this screening instrument followed by a nurse-led care program; or (3) usual care. Health resource utilization data were collected using electronic medical records and questionnaires. Associated costs were calculated. A cost-effectiveness analysis from a societal perspective was undertaken. The incremental cost per quality-adjusted life-year was calculated comparing proactive screening arm with usual care, and screening plus nurse-led care arm with usual care, as well as the screening arm with screening plus nurse-led care arm. RESULTS Out of 7638 potential participants, 3092 (40.5%) older adults participated. Whereas effect differences were minor, the total costs per patient were lower in both intervention groups compared with usual care. The probability of cost-effectiveness at €20,000 per QALY threshold was 87% and 91% for screening plus GP care versus usual care and for screening plus nurse-led care compared to usual care, respectively. For screening plus nurse-led care vs screening plus standard GP care, the probability was 55%. CONCLUSION A proactive screening intervention has a high probability of being cost-effective compared to usual care. The combined intervention showed less value for money.
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Affiliation(s)
- Nienke Bleijenberg
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Irene Drubbel
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rabin Ej Neslo
- Department Health Technology Assessment, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke J Schuurmans
- Department of Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Valerie H Ten Dam
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mattijs E Numans
- Department of General Practice, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - G Ardine de Wit
- Department Health Technology Assessment, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; Department of General Practice, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Niek J de Wit
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Cassel C, Wilkes M. Location, Location, Location: Where We Teach Primary Care Makes All the Difference. J Gen Intern Med 2017; 32:411-415. [PMID: 28243875 PMCID: PMC5377892 DOI: 10.1007/s11606-016-3966-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/02/2016] [Accepted: 12/13/2016] [Indexed: 11/29/2022]
Abstract
Creating a new model to train a high-quality primary care workforce is of great interest to American health care stakeholders. There is consensus that effective educational approaches need to be combined with a rewarding work environment, emphasize a good work/life balance, and a focus on achieving meaningful outcomes that center on patients and the public. Still, significant barriers limit the numbers of clinicians interested in pursuing careers in primary care, including low earning potential, heavy medical school debt, lack of respect from physician colleagues, and enormous burdens of record keeping. To enlarge and energize the pool of primary care trainees, we look especially at changes that focus on institutions and the practice environment. Students and residents need training environments where primary care clinicians and interdisciplinary teams play a crucially important role in patient care. For a variety of reasons, many academic medical centers cannot easily meet these standards. The authors propose that a major part of primary care education and training be re-located to settings in high-performing health systems built on comprehensive integrated care models where primary care clinicians play a principle role in leadership and care delivery.
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Affiliation(s)
- Christine Cassel
- Kaiser Permanente School of Medicine, 1 Kaiser Plaza, 18th Floor, Oakland, CA, 94612, USA.
| | - Michael Wilkes
- University of California, Davis School of Medicine, Sacramento, CA, USA
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Price-Haywood EG, Amering S, Luo Q, Lefante JJ. Clinical Pharmacist Team-Based Care in a Safety Net Medical Home: Facilitators and Barriers to Chronic Care Management. Popul Health Manag 2017; 20:123-131. [PMID: 27124294 PMCID: PMC5397232 DOI: 10.1089/pop.2015.0177] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Collaborative care models incorporating pharmacists have been shown to improve quality of care for patients with hypertension and/or diabetes. Little is known about how to integrate such services outside of clinical trials. The authors implemented a 22-month observational study to evaluate pharmacy collaborative care for hypertension and diabetes in a safety net medical home that incorporated population risk stratification, clinical decision support, and medication dose adjustment protocols. Patients in the pharmacy group saw their primary care provider (PCP) more often and had higher baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) and A1c levels compared to patients who only received care from their PCPs. There were no significant differences in the proportion of patients achieving treatment goals (SBP <140, DBP <90; A1c < 8) or the magnitude of change in BP or A1c among patients who underwent collaborative care versus those who did not. Age, race, and number of PCP encounters were associated with BP and A1c trends. The median time to achieve disease control was longer in the pharmacy group. Although 70% of all patients with poorly controlled hypertension achieved treatment goals within 7 months, less than 50% of patients with poorly controlled diabetes achieved A1c < 8 within 15 months, suggesting that diabetes was harder to manage overall. Contextual factors that facilitated or hindered practice redesign included organizational culture, health information technology and related workflows, and pharmacy caseload optimization. Future studies should further examine implementation strategies that work best in specific settings to optimize the benefits of team-based care with clinical pharmacists.
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Affiliation(s)
- Eboni G. Price-Haywood
- Ochsner Clinic Foundation, Center for Applied Health Services Research, New Orleans, Louisiana
- Ochsner Clinical School, University of Queensland, Brisbane, Australia
| | - Sarah Amering
- Xavier University of Louisiana, College of Pharmacy, New Orleans, Louisiana
| | - Qingyang Luo
- Ochsner Clinic Foundation, Center for Applied Health Services Research, New Orleans, Louisiana
| | - John J. Lefante
- Tulane University School of Public Health and Tropical Medicine, Department of Biostatistics and Bioinformatics, New Orleans, Louisiana
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Abstract
Aims To identify education priorities for practice nursing across eight London Clinical Commissioning Groups (CCGs); to identify the education, training, development and support needs of practice nurses in undertaking current and future roles. BACKGROUND The education needs of practice nurses have long been recognised but their employment status means that accessing education requires the support of their GP employer. This study scopes the educational requirements of the practice nurse workforce and working with educational providers and commissioners describes a coherent educational pathway for practice nurses. METHOD A survey of practice nurses to scope their educational attainment needs was undertaken. Focus groups were carried out which identified the education, training, development and support needs of practice nurses to fulfil current and future roles. Findings A total of 272 respondents completed the survey. Practice nurses took part in three focus groups (n=34) and one workshop (n=39). Findings from this research indicate a practice nurse workforce which lacked career progression, role autonomy or a coherent educational framework. Practice nurses recognised the strength of their role in building relationship-centred care with patients over an extended period of time. They valued this aspect of their role and would welcome opportunities to develop this to benefit patients. CONCLUSION This paper demonstrates an appetite for more advanced education among practice nurses, a leadership role by the CCGs in working across the whole system to address the education needs of practice nurses, and a willingness on the part of National Health Service education commissioners to commission education which meets the education needs of the practice nurse workforce. Evidence is still required, however, to inform the scope of the practice nurse role within an integrated system of care and to identify the impact of practice nursing on improving health outcomes and care of local populations.
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Ashcroft R, Menear M, Silveira J, Dahrouge S, McKenzie K. Incentives and disincentives for treating of depression and anxiety in Ontario Family Health Teams: protocol for a grounded theory study. BMJ Open 2016; 6:e014623. [PMID: 28186951 PMCID: PMC5128770 DOI: 10.1136/bmjopen-2016-014623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION There is strong consensus that prevention and management of common mental disorders (CMDs) should occur in primary care and evidence suggests that treatment of CMDs in these settings can be effective. New interprofessional team-based models of primary care have emerged that are intended to address problems of quality and access to mental health services, yet many people continue to struggle to access care for CMDs in these settings. Insufficient attention directed towards the incentives and disincentives that influence care for CMDs in primary care, and especially in interprofessional team-based settings, may have resulted in missed opportunities to improve care quality and control healthcare costs. Our research is driven by the hypothesis that a stronger understanding of the full range of incentives and disincentives at play and their relationships with performance and other contextual factors will help stakeholders identify the critical levers of change needed to enhance prevention and management of CMDs in interprofessional primary care contexts. Participant recruitment began in May 2016. METHODS AND ANALYSIS An explanatory qualitative design, based on a constructivist grounded theory methodology, will be used. Our study will be conducted in the Canadian province of Ontario, a province that features a widely implemented interprofessional team-based model of primary care. Semistructured interviews will be conducted with a diverse range of healthcare professionals and stakeholders that can help us understand how various incentives and disincentives influence the provision of evidence-based collaborative care for CMDs. A final sample size of 100 is anticipated. The protocol was peer reviewed by experts who were nominated by the funding organisation. ETHICS AND DISSEMINATION The model we generate will shed light on the incentives and disincentives that are and should be in place to support high-quality CMD care and help stimulate more targeted, coordinated stakeholder responses to improving primary mental healthcare quality.
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Affiliation(s)
- Rachelle Ashcroft
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Menear
- CHU de Quebec Research Centre, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada
| | - Jose Silveira
- Mental Health and Addiction Program, St. Joseph's Health Centre, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Simone Dahrouge
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Kwame McKenzie
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Wellesley Institute, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Challenges to Meeting Access and Continuity Performance Measures in a Large Hospital-Based Primary Care Clinic Implementing the Patient-Centered Medical Home: A Qualitative Study. Jt Comm J Qual Patient Saf 2016. [DOI: 10.1016/s1553-7250(16)42083-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Development of an Automated Healthcare Kiosk for the Management of Chronic Disease Patients in the Primary Care Setting. J Med Syst 2016; 40:169. [DOI: 10.1007/s10916-016-0529-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 05/23/2016] [Indexed: 11/25/2022]
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Gray CP, Harrison MI, Hung D. Medical Assistants as Flow Managers in Primary Care: Challenges and Recommendations. J Healthc Manag 2016. [DOI: 10.1097/00115514-201605000-00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The persistence of child poverty in the United States and the pervasive health consequences it engenders present unique challenges to the health care system. Human capital theory and empirical observation suggest that the increased disease burden experienced by poor children originates from social conditions that provide suboptimal educational, nutritional, environmental, and parental inputs to good health. Faced with the resultant excess rates of pediatric morbidity, the US health care system has developed a variety of compensatory strategies. In the first instance, Medicaid, the federal-state governmental finance system designed to assure health insurance coverage for poor children, has increased its eligibility thresholds and expanded its benefits to allow greater access to health services for this vulnerable population. A second arm of response involves a gradual reengineering of health care delivery at the practice level, including the dissemination of patient-centered medical homes, the use of team-based approaches to care, and the expansion of care management beyond the practice to reach deep into the community. Third is a series of recent experiments involving the federal government and state Medicaid programs that includes payment reforms of various kinds, enhanced reporting, concentration on high-risk populations, and intensive case management. Fourth, pediatric practices have begun to make use of specific tools that permit the identification and referral of children facing social stresses arising from poverty. Finally, constituencies within the health care system participate in enhanced advocacy efforts to raise awareness of poverty as a distinct threat to child health and to press for public policy responses such as minimum wage increases, expansion of tax credits, paid family leave, universal preschool education, and other priorities focused on child poverty.
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Affiliation(s)
- Andrew D Racine
- Albert Einstein College of Medicine and the Montefiore Health System, Bronx, NY.
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Harrod M, Weston LE, Robinson C, Tremblay A, Greenstone CL, Forman J. "It goes beyond good camaraderie": A qualitative study of the process of becoming an interprofessional healthcare "teamlet". J Interprof Care 2016; 30:295-300. [PMID: 27028059 DOI: 10.3109/13561820.2015.1130028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Within the US, the patient-centred medical home has become a predominant model in the delivery of primary care. This model requires a shift from the physician-centric model to an interprofessional team-based approach. Thus, healthcare staff are being reorganized into teams, resulting in having to work and relate to one another in new ways. In 2010, the Veterans Health Administration implemented the patient aligned care team (PACT) model, its version of the patient-centred medical home. The transition to the PACT model involved restructuring primary care staff into "teamlets", consisting of a registered nurse, licensed practical nurse, and administrative clerk for each full-time-equivalent primary care provider. This qualitative study used observation and semi-structured interviews to understand the factors that affect teamlet functioning as they implement this new model of care and how teams are interacting to address those factors. Findings suggest that role understanding includes understanding how each teamlet member's tasks are performed in the daily operations of the clinic. In addition, willingness to perform tasks that benefit the teamlet and acceptance of delegation from all teamlet members were found to be important for teamlet functioning and cohesion. In order for healthcare teams to provide patient-centred care, it is important to provide guidance and support about what these new relationships and roles will entail. The building of team relationships is not a static process; ways of working together build over time and, therefore, should be seen as a continuous cycle of quality improvement.
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Affiliation(s)
- Molly Harrod
- a VA Ann Arbor Healthcare System , Ann Arbor , Michigan , USA
| | - Lauren E Weston
- a VA Ann Arbor Healthcare System , Ann Arbor , Michigan , USA
| | - Claire Robinson
- a VA Ann Arbor Healthcare System , Ann Arbor , Michigan , USA
| | - Adam Tremblay
- a VA Ann Arbor Healthcare System , Ann Arbor , Michigan , USA.,b Department of Internal Medicine , University of Michigan , Ann Arbor , Michigan , USA
| | - Clinton L Greenstone
- a VA Ann Arbor Healthcare System , Ann Arbor , Michigan , USA.,b Department of Internal Medicine , University of Michigan , Ann Arbor , Michigan , USA
| | - Jane Forman
- a VA Ann Arbor Healthcare System , Ann Arbor , Michigan , USA
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Coker TR, Chacon S, Elliott MN, Bruno Y, Chavis T, Biely C, Bethell CD, Contreras S, Mimila NA, Mercado J, Chung PJ. A Parent Coach Model for Well-Child Care Among Low-Income Children: A Randomized Controlled Trial. Pediatrics 2016; 137:e20153013. [PMID: 26908675 PMCID: PMC4771128 DOI: 10.1542/peds.2015-3013] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal of this study was to examine the effects of a new model for well-child care (WCC), the Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT), on WCC quality and health care utilization among low-income families. METHODS PARENT includes 4 elements designed by using a stakeholder-engaged process: (1) a parent coach (ie, health educator) to provide anticipatory guidance, psychosocial screening and referral, and developmental/behavioral guidance and screening at each well-visit; (2) a Web-based tool for previsit screening; (3) an automated text message service to provide periodic, age-specific health messages to families; and (4) a brief, problem-focused encounter with the pediatric clinician. The Promoting Healthy Development Survey-PLUS was used to assess receipt of recommended WCC services at 12 months' postenrollment. Intervention effects were examined by using bivariate analyses. RESULTS A total of 251 parents with a child aged ≤12 months were randomized to receive either the control (usual WCC) or the intervention (PARENT); 90% completed the 12-month assessment. Mean child age at enrollment was 4.5 months; 64% had an annual household income less than $20,000. Baseline characteristics for the intervention and control groups were similar. Intervention parents scored higher on all preventive care measures (anticipatory guidance, health information, psychosocial assessment, developmental screening, and parental developmental/behavioral concerns addressed) and experiences of care measures (family-centeredness, helpfulness, and overall rating of care). Fifty-two percent fewer intervention children had ≥2 emergency department visits over the 12-month period. There were no significant differences in WCC or sick visits/urgent care utilization. CONCLUSIONS A parent coach-led model for WCC may improve the receipt of comprehensive WCC for low-income families, and it may potentially lead to cost savings by reducing emergency department utilization.
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Affiliation(s)
- Tumaini R. Coker
- UCLA Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California;,RAND, Santa Monica, California
| | - Sandra Chacon
- UCLA Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | | | - Christopher Biely
- UCLA Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Sandra Contreras
- UCLA Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Naomi A. Mimila
- UCLA Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jeffrey Mercado
- UCLA Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Paul J. Chung
- UCLA Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California;,RAND, Santa Monica, California;,UCLA Fielding School of Public Health, Los Angeles, California
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Hooker RS, Brock DM, Cook ML. Characteristics of nurse practitioners and physician assistants in the United States. J Am Assoc Nurse Pract 2015; 28:39-46. [PMID: 26331690 DOI: 10.1002/2327-6924.12293] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/19/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nurse practitioners (NP) and physician assistants (PA) serve as independent or semiautonomous providers and as fundamental members of healthcare teams. PURPOSE Differentiating roles of health professionals is needed for optimal employment utilization. Clinically practicing PAs and NPs were characterized. METHODOLOGY Data included wage and workforce projections to 2022.Variables included number practicing, age, gender, race, ethnicity, education, principal employer, practice specialty, and wages. RESULTS Health delivery establishments employed 88,110 PA and 113,370 NP clinicians in 2013. Both were predominantly female: NPs were older (49 years) on average than PAs (38 years). A significant number of them practiced in physicians' offices or in acute care hospitals. Median wages were at parity. Growth predictions from 2012 to 2022 were 31%-35%. CONCLUSIONS PAs and NPs constitute 20% of the composite clinician labor force (MD, DO, PA, NP). Labor market analysis suggests they are in demand. A majority of NPs and a third of PAs work in primary care fields. Their collective projected growth suggests a solution to emerging workforce shortages and an ability to help meet healthcare demands. IMPLICATIONS FOR PRACTICE Adaptability to changing roles, especially in primary care and underserved areas, makes them facile responders to market demands in a continuously evolving healthcare environment.
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Affiliation(s)
- Roderick S Hooker
- Northern Arizona University College of Health and Human Services, Phoenix Biomedical Campus, Phoenix, AZ
| | | | - Michelle L Cook
- AANP Network for Research, American Association of Nurse Practitioners, Austin, TX
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Abstract
OBJECTIVE Examine availability of physician assistants (PAs) or nurse practitioners (NPs) in primary care physician practices by state and by state PA and NP scope-of-practice laws. METHODS Availability of PAs and NPs in primary care practices was examined in multivariate analysis using a 2012 state-based, nationally representative survey of office-based physicians. Covariates included practice characteristics, state, and in a separate model, PA and NP scope-of-practice variables. RESULTS After controlling for practice characteristics, higher use of PAs and NPs was found in three states (Minnesota, Montana, and South Dakota). In a separate model, higher use of PAs or NPs was associated with favorable PA scope-of-practice laws, but not with NP scope-of-practice laws. CONCLUSIONS Higher availability of PAs or NPs was associated with favorable PA scope-of-practice laws. Lack of association between PA or NP availability and NP scope-of-practice laws requires further investigation.
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Affiliation(s)
- Esther Hing
- Esther Hing is a survey statistician with the CDC's National Center for Health Statistics, Division of Health Care Statistics, in Hyattsville, Md. At the time this study was done, Chun-Ju Hsiao was a health scientist at the National Center for Health Statistics. He now is a health scientist administrator with the Agency for Healthcare Research and Quality's Center for Quality Improvement and Patient Safety in Rockville, Md. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the CDC the Agency for Healthcare Research and Quality
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Pelak M, Pettit AR, Terwiesch C, Gutierrez JC, Marcus SC. Rethinking primary care visits: how much can be eliminated, delegated or performed outside of the face-to-face visit? J Eval Clin Pract 2015; 21:591-6. [PMID: 25756943 DOI: 10.1111/jep.12341] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2015] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Office visits represent the core component of primary care practice, but little is known about what percentage of primary care provider (PCP) visit time could be suitable for reassignment to another medical home team member or to a non-face-to-face modality (e.g. secure messaging) in order to optimize face-to-face PCP visit time. METHOD We videotaped 121 PCP office visits at four Veterans Health Administration Medical Centers and divided visits into discrete activity segments. Two physicians reviewed each visit recording and provided independent clinical judgments regarding which segments might be suitable for reassignment. We examined the activity category distribution of visit time rated as needing face-to-face time with a PCP. RESULTS Reviewers judged 53% of the 5398 minutes of rated visit time as suitable for reassignment to another team member or modality. The percentage of time rated as needing face-to-face PCP care varied greatly by activity category, from a high of 73.9% (for examining patients) to a low of 16.2% (for medication review). Rater agreement regarding tasks' suitability for reassignment varied across activity categories. CONCLUSIONS These data offer an example of how face-to-face PCP visit time might be optimized as practices seek to shift components of patient care to other team members and other modalities. Given variations in provider preferences and judgments, successful redesign efforts will need to involve stakeholders in decisions about how to best utilize medical home resources.
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Affiliation(s)
- Mary Pelak
- Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
| | | | - Christian Terwiesch
- Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.,The Wharton School and Professor of Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer C Gutierrez
- Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Steven C Marcus
- Center for Evaluation of Patient Aligned Care Teams (CEPACT), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.,University of Pennsylvania School of Social Policy and Practice, Philadelphia, PA, USA
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Ho CK, Maselli JH, Terrault NA, Gonzales R. High Rate of Hospital Admissions Among Patients with Cirrhosis Seeking Care in US Emergency Departments. Dig Dis Sci 2015; 60:2183-9. [PMID: 25724166 PMCID: PMC4797948 DOI: 10.1007/s10620-015-3594-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/17/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIMS Emergency Departments (ED) can serve as a gateway to specialty care for patients with cirrhosis with limited care access. We described the rates and characteristics of patients with cirrhosis who access United States (US) EDs, and identified factors associated with subsequent hospitalization. METHODS Using data from the National Hospital Ambulatory Medical Care Survey, cirrhosis-related ED from 2000 to 2009 were identified and compared to all other ED visits. RESULTS From 2000 to 2009, there were an estimated 1,029,693 cirrhosis and 877 million non-cirrhosis visits. Compared to the general ED population, those with cirrhosis were more frequently male (58 vs. 44 %, p = 0.02), Hispanic (18.6 vs. 10.6 %, p < 0.05), seeking care in urban areas (91.6 vs. 73.4 %, p < 0.05) and had Medicaid/no insurance (43 vs. 35 %, p < 0.01). Patients with cirrhosis were more frequently triaged immediately or emergently (72.3 vs. 54.2 %, p < 0.01). The majority were admitted or transferred to another hospital (66.8 vs. 17.4 %, p < 0.01). Among patients with cirrhosis, patients with age ≥ 65 years were more likely to be admitted (adjusted OR 2.49, 95 % CI 1.08-5.73), and Medicaid/uninsured (adjusted OR 0.34; 95 % CI 0.17-0.67) were less likely to be admitted, after adjusting for patient demographics, hospital characteristics, and triage score. CONCLUSIONS Patient with cirrhosis account for approximately 100,000 US ED visits annually. The higher admission rates among patients with cirrhosis indicate a high acuity of illness. Older age among those admitted may reflect poorer functional status. Finally, high visit but low admission rates among those with Medicaid/no insurance suggest a gap in specialty care.
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Affiliation(s)
- Chanda K. Ho
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA, USA
- 2340 Clay Street, 3rd Floor, San Francisco, CA 94115, USA
| | - Judith H. Maselli
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Division of Hospital Medicine, University of California, San Francisco, 533 Parnassus Avenue, UC Hall, San Francisco, CA 94143, USA
| | - Norah A. Terrault
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA, USA
- 513 Parnassus Avenue, GI Division Room S-357, San Francisco, CA 94143, USA
| | - Ralph Gonzales
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
- 400 Parnassus Avenue, San Francisco, CA 94143, USA
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Crotty BH, Mostaghimi A, O'Brien J, Bajracharya A, Safran C, Landon BE. Prevalence and Risk Profile Of Unread Messages To Patients In A Patient Web Portal. Appl Clin Inform 2015; 6:375-82. [PMID: 26171082 DOI: 10.4338/aci-2015-01-cr-0006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/17/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Excitement around the adoption of electronic communication between physicians and patients is tempered by the possibility of increased clinical and legal risk. If patients do not read messages in a timely fashion, duplicative communication efforts may be required and patient safety may be jeopardized. OBJECTIVE We sought to assess the prevalence and risk profile of unread messages in a mature patient portal. METHODS We analyzed six years of messages (2005-2010) from physicians to patients to determine the prevalence and associated characteristics of unread messages in a patient portal. We focused on clinical messages, and excluded announcements. Because some physicians sent clinical messages to groups of patients, we labeled messages sent to more than 5 patients as "outreach" messages and excluded them from general analyses. We performed a chart review of 75 clinical messages to assess for harm. RESULTS We found that 3% of clinical messages were unread after 21 days. Messages arriving outside of business hours were slightly more likely to go unread (RR 1.15 95% CI 1.11-1.19). Patients who were male (OR 1.14 CI 1.04-1.26) African American (OR 1.69 CI 1.29-2.22) or Hispanic (OR 1.74 CI 1.17-2.59), or in the lowest income group (OR 1.72 CI 1.19-2.49) were more likely to have unread messages. Chart review showed no evidence of harm, but 13% of sampled unread messages were associated with potential delays in care. Incidentally, we found 50% of the physician-initiated outreach messages were unread. CONCLUSIONS Overall, secure messaging appears a safe form of communication, but systems to notify senders when messages are unread may have value. While most clinical messages were read, many outreach messages were not, providing caution for relying on such systems for information dissemination. Similar to other studies, differences by race and income were observed and require further study.
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Affiliation(s)
- B H Crotty
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center , Boston, MA ; Harvard Medical School , Boston, MA
| | - A Mostaghimi
- Harvard Medical School , Boston, MA ; Department of Dermatology, Brigham & Women's Hospital , Boston MA
| | - J O'Brien
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center , Boston, MA
| | - A Bajracharya
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center , Boston, MA ; Harvard Medical School , Boston, MA
| | - C Safran
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center , Boston, MA ; Harvard Medical School , Boston, MA
| | - B E Landon
- Harvard Medical School , Boston, MA ; Department of Health Care Policy, Harvard Medical School , Boston, MA
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No moment wasted: the primary-care visit for adults with diabetes and low socio-economic status. Prim Health Care Res Dev 2015; 17:18-32. [PMID: 25991075 PMCID: PMC4697285 DOI: 10.1017/s1463423615000134] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIM To better understand the type and range of health issues initiated by patients and providers in 'high-quality' primary-care for adults with diabetes and low socio-economic status (SES). BACKGROUND Although quality of care guidelines are straightforward, diabetes visits in primary care are often more complex than adhering to guidelines, especially in adults with low SES who experience many financial and environmental barriers to good care. METHODS We conducted a qualitative study using direct observation of primary-care diabetes visits at an exemplar safety net practice in 2009-2010. Findings In a mainly African American (93%) low-income population with fair cardiovascular control (mean A1c 7.5%, BP 134/81 mmHg, and low-density lipoprotein cholesterol 100 mg/dL), visits addressed a variety of bio-psychosocial health issues [median: 25 problems/visit (range 13-32)]. Physicians most frequently initiated discussions about chronic diseases, prevention, and health behavior. Patients most frequently initiated discussions about social environment and acute symptoms followed by prevention and health behavior. CONCLUSIONS Primary-care visits by diabetes patients with low SES address a surprising number and diversity of problems. Emerging new models of primary-care delivery and quality measurement should allow adequate time and resources to address the range of tasks necessary for integrating biomedical and psychosocial concerns to improve the health of socio-economically disadvantaged patients.
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Gilbert F, Denis JL, Lamothe L, Beaulieu MD, D'amour D, Goudreau J. Reforming primary healthcare: from public policy to organizational change. J Health Organ Manag 2015; 29:92-110. [DOI: 10.1108/jhom-12-2012-0237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– Governments everywhere are implementing reform to improve primary care. However, the existence of a high degree of professional autonomy makes large-scale change difficult to achieve. The purpose of this paper is to elucidate the change dynamics and the involvement of professionals in a primary healthcare reform initiative carried out in the Canadian province of Quebec.
Design/methodology/approach
– An empirical approach was used to investigate change processes from the inception of a public policy to the execution of changes in professional practices. The data were analysed from a multi-level, combined contextualist-processual perspective. Results are based on a longitudinal multiple-case study of five family medicine groups, which was informed by over 100 interviews, questionnaires, and documentary analysis.
Findings
– The results illustrate the multiple processes observed with the introduction of planned large-scale change in primary care services. The analysis of change content revealed that similar post-change states concealed variations between groups in the scale of their respective changes. The analysis also demonstrated more precisely how change evolved through the introduction of “intermediate change” and how cycles of prescribed and emergent mechanisms distinctively drove change process and change content, from the emergence of the public policy to the change in primary care service delivery.
Research limitations/implications
– This research was conducted among a limited number of early policy adopters. However, given the international interest in turning to the medical profession to improve primary care, the results offer avenues for both policy development and implementation.
Practical implications
– The findings offer practical insights for those studying and managing large-scale transformations. They provide a better understanding of how deliberate reforms coexist with professional autonomy through an intertwining of change content and processes.
Originality/value
– This research is one of few studies to examine a primary care reform from emergence to implementation using a longitudinal multi-level design.
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Reckrey JM, Soriano TA, Hernandez CR, DeCherrie LV, Chavez S, Zhang M, Ornstein K. The team approach to home-based primary care: restructuring care to meet individual, program, and system needs. J Am Geriatr Soc 2015; 63:358-64. [PMID: 25645568 DOI: 10.1111/jgs.13196] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound.
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Affiliation(s)
- Jennifer M Reckrey
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai School of Medicine, New York City, New York; Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai School of Medicine, New York City, New York
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Magnan EM, Palta M, Mahoney JE, Pandhi N, Bolt DM, Fink J, Greenlee RT, Smith MA. The relationship of individual comorbid chronic conditions to diabetes care quality. BMJ Open Diabetes Res Care 2015; 3:e000080. [PMID: 26217492 PMCID: PMC4513351 DOI: 10.1136/bmjdrc-2015-000080] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Multimorbidity affects 26 million persons with diabetes, and care for comorbid chronic conditions may impact diabetes care quality. The aim of this study was to determine which chronic conditions were related to lack of achievement or achievement of diabetes care quality goals to determine potential targets for future interventions. RESEARCH DESIGN AND METHODS This is an exploratory retrospective analysis of electronic health record data for 23 430 adults, aged 18-75, with diabetes who were seen at seven Midwestern US health systems. The main outcome measures were achievement of six diabetes quality metrics in the reporting year, 2011 (glycated haemoglobin (HbA1c) control and testing, low-density lipoprotein control and testing, blood pressure control, kidney testing). Explanatory variables were 62 chronic condition indicators. Analyses were adjusted for baseline patient sociodemographic and healthcare utilization factors. RESULTS The 62 chronic conditions varied in their relationships to diabetes care goal achievement for specific care goals. Congestive heart failure was related to lack of achievement of cholesterol management goals. Obesity was related to lack of HbA1c and BP control. Mental health conditions were related to both lack of achievement and achievement of different care goals. Three conditions were related to lack of cholesterol testing, including congestive heart failure and substance-use disorders. Of 17 conditions related to achieving control goals, 16 were related to achieving HbA1c control. One-half of the comorbid conditions did not predict diabetes care quality. CONCLUSIONS Future interventions could target patients at risk for not achieving diabetes care for specific care goals based on their individual comorbidities.
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Affiliation(s)
- Elizabeth M Magnan
- Department of Family and Community Medicine, University of California, Davis, Sacramento, California, USA
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mari Palta
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jane E Mahoney
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nancy Pandhi
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Daniel M Bolt
- Department of Educational Psychology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer Fink
- Department of Health Informatics and Administration, College of Health Sciences, University Wisconsin Milwaukee, Milwaukee, Wisconsin, USA
- Center for Urban Population Health, Milwaukee, Wisconsin, USA
- Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin, USA
| | - Robert T Greenlee
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Freund T, Everett C, Griffiths P, Hudon C, Naccarella L, Laurant M. Skill mix, roles and remuneration in the primary care workforce: who are the healthcare professionals in the primary care teams across the world? Int J Nurs Stud 2014; 52:727-43. [PMID: 25577306 DOI: 10.1016/j.ijnurstu.2014.11.014] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 11/10/2014] [Accepted: 11/27/2014] [Indexed: 10/24/2022]
Abstract
World-wide, shortages of primary care physicians and an increased demand for services have provided the impetus for delivering team-based primary care. The diversity of the primary care workforce is increasing to include a wider range of health professionals such as nurse practitioners, registered nurses and other clinical staff members. Although this development is observed internationally, skill mix in the primary care team and the speed of progress to deliver team-based care differs across countries. This work aims to provide an overview of education, tasks and remuneration of nurses and other primary care team members in six OECD countries. Based on a framework of team organization across the care continuum, six national experts compare skill-mix, education and training, tasks and remuneration of health professionals within primary care teams in the United States, Canada, Australia, England, Germany and the Netherlands. Nurses are the main non-physician health professional working along with doctors in most countries although types and roles in primary care vary considerably between countries. However, the number of allied health professionals and support workers, such as medical assistants, working in primary care is increasing. Shifting from 'task delegation' to 'team care' is a global trend but limited by traditional role concepts, legal frameworks and reimbursement schemes. In general, remuneration follows the complexity of medical tasks taken over by each profession. Clear definitions of each team-member's role may facilitate optimally shared responsibility for patient care within primary care teams. Skill mix changes in primary care may help to maintain access to primary care and quality of care delivery. Learning from experiences in other countries may inspire policy makers and researchers to work on efficient and effective teams care models worldwide.
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Affiliation(s)
- Tobias Freund
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Germany.
| | - Christine Everett
- Health Innovation Program, University of Wisconsin-Madison, United States
| | - Peter Griffiths
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex) and University of Southampton Centre of innovation and Leadership in Health Sciences, United Kingdom
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Québec, Canada
| | - Lucio Naccarella
- The Australian Health Workforce Institute, Melbourne School of Population and Global Health, The University of Melbourne, Australia
| | - Miranda Laurant
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre and Knowledge Centre of Sustainable Healthcare, Nijmegen, The Netherlands; HAN University of Applied Sciences, Nijmegen, The Netherlands
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Gofin J, Gofin R, Stimpson JP. Community-oriented primary care (COPC) and the affordable care act: an opportunity to meet the demands of an evolving health care system. J Prim Care Community Health 2014; 6:128-33. [PMID: 25351764 DOI: 10.1177/2150131914555908] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Community-oriented primary care (COPC) is a model of health care delivery that tightly integrates primary care and public health. This model of care, applied around the globe, could be more widely adopted in the United States as clinical delivery systems respond to the growing demand for population health management, which has been driven largely by various provisions of the Affordable Care Act (ACA). For that purpose, there is need for changes in capacitating health professionals and changes in organizational structures that will address the needs and health priorities of the population, considering individual care management in the context of population health for a defined population. This article presents how the Affordable Care Act is an appropriate framework for COPC to succeed and the way forward to develop COPC through practical alternatives for the delivery of primary care within a population context.
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Affiliation(s)
- Jaime Gofin
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Rosa Gofin
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jim P Stimpson
- College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
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Auerbach DI, Chen PG, Friedberg MW, Reid R, Lau C, Buerhaus PI, Mehrotra A. Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff (Millwood) 2014; 32:1933-41. [PMID: 24191083 DOI: 10.1377/hlthaff.2013.0596] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Numerous forecasts have predicted shortages of primary care providers, particularly in light of an expected increase in patient demand resulting from the Affordable Care Act. Yet these forecasts could be inaccurate because they generally do not allow for changes in the way primary care is delivered. We analyzed the impact of two emerging models of care--the patient-centered medical home and the nurse-managed health center--both of which use a provider mix that is richer in nurse practitioners and physician assistants than today's predominant models of care delivery. We found that projected physician shortages were substantially reduced in plausible scenarios that envisioned greater reliance on these new models, even without increases in the supply of physicians. Some less plausible scenarios even eliminated the shortage. All of these scenarios, however, may require additional changes, such as liberalized scope-of-practice laws; a larger supply of medical assistants, licensed practical nurses, and aides; and payment changes that reward providers for population health management.
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Kennedy BM, Cerise F, Horswell R, Griffin WP, Willis KH, Moody-Thomas S, Besse JA, Katzmarzyk PT. Obtaining the Patient's Voice from within Three Patient-Centered Medical Homes. Clin Transl Sci 2014; 8:367-75. [PMID: 25066616 DOI: 10.1111/cts.12192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The purpose of this qualitative program was to determine if a trend exists across three LSU medical homes according to patient feedback concerning their experiences within the medical home for ongoing disease management and quality healthcare; and to obtain recommendations for the most effective way to involve patients in shaping system policies, procedures, and practices consistent with patient and family-centered care principles. A total of 94 adult patients participated in either cognitive interviews (n = 45) or structured focus groups (n = 49) using the Nominal Group Technique (NGT). Exit surveys collected demographic information and feedback from patients about opportunities for their involvement in shaping medical homes. Cognitive interviews and NGT sessions both revealed some patient-perceived gratifications (i.e., friendliness and helpfulness of the clinic staff), and deficiencies (i.e., improving scheduling of appointments and reducing wait time in the clinic) within these medical homes. However, the perceived gratifications far exceeded the deficiencies found within each of three LSU medical homes.
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Affiliation(s)
- Betty M Kennedy
- The Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Frederick Cerise
- The LSU Health Sciences Center School of Medicine, New Orleans, Louisiana, USA
| | - Ronald Horswell
- The Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Willene P Griffin
- The Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Kathleen H Willis
- The LSU Health System Lallie Kemp Medical Center, Independence, Louisiana, USA
| | - Sarah Moody-Thomas
- The Louisiana State University (LSU) Health Sciences Center School of Public Health, New Orleans, Louisiana, USA
| | - Jay A Besse
- The LSU Health Care Services Division, Louisiana, USA
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Thom DH, Hessler D, Willard-Grace R, Bodenheimer T, Najmabadi A, Araujo C, Chen EH. Does health coaching change patients' trust in their primary care provider? PATIENT EDUCATION AND COUNSELING 2014; 96:135-138. [PMID: 24776175 DOI: 10.1016/j.pec.2014.03.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/03/2014] [Accepted: 03/22/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess the impact of health coaching on patients' in their primary care provider. METHODS Randomized controlled trial comparing health coaching with usual care. PARTICIPANTS Low-income English or Spanish speaking patients age 18-75 with poorly controlled type 2 diabetes, hypertension and/or hyperlipidemia. MAIN OUTCOME MEASURE Patient trust in their primary care provider measured by the 11-item Trust in Physician Scale, converted to a 0-100 scale. ANALYSIS Linear mixed modeling. RESULTS A total of 441 patients were randomized to receive 12 months of health coaching (n=224) vs. usual care (n=217). At baseline, the two groups were similar to those in the usual care group with respect to demographic characteristics and levels of trust in their provider. After 12 months, the mean trust level had increased more in patients receiving health coaching (3.9 vs. 1.5, p=0.47), this difference remained significant after adjustment for number of visits to primary care providers (adjusted p=.03). CONCLUSIONS Health coaching appears to increase patients trust in their primary care providers. PRACTICE IMPLICATIONS Primary care providers should consider adding health coaches to their team as a way to enhance their relationship with their patients.
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Affiliation(s)
- David H Thom
- University of California, San Francisco School of Medicine, Department of Family and Community Medicine, San Francisco, USA.
| | - Danielle Hessler
- University of California, San Francisco School of Medicine, Department of Family and Community Medicine, San Francisco, USA
| | - Rachel Willard-Grace
- University of California, San Francisco School of Medicine, Department of Family and Community Medicine, San Francisco, USA
| | - Thomas Bodenheimer
- University of California, San Francisco School of Medicine, Department of Family and Community Medicine, San Francisco, USA
| | - Adriana Najmabadi
- University of California, San Francisco School of Medicine, Department of Family and Community Medicine, San Francisco, USA
| | - Christina Araujo
- University of California, San Francisco School of Medicine, Department of Family and Community Medicine, San Francisco, USA
| | - Ellen H Chen
- University of California, San Francisco School of Medicine, Department of Family and Community Medicine, San Francisco, USA
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