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Ventres WB, Stone LA, LaVallee LA, Loxterkamp D, Brown JR, Waxman DM, Dorward PS, Cawse-Lucas J, Mauksch LB, Kieber-Emmons AM, Crabtree BF, Miller WL, Brohm VM, Daaleman TP, Bossenbroek Fedoriw K. Storylines of family medicine VI: ways of being-in the office with patients. Fam Med Community Health 2024; 12:e002793. [PMID: 38609089 PMCID: PMC11029328 DOI: 10.1136/fmch-2024-002793] [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] [Indexed: 04/14/2024] Open
Abstract
Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.
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Affiliation(s)
- William B Ventres
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Leslie A Stone
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Lisa A LaVallee
- MAHEC Family Medicine Residency, Mountain Area Health Education Center, Asheville, North Carolina, USA
| | | | - Jonisha R Brown
- Family Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - Dael M Waxman
- Family Medicine, Atrium Health, Charlotte, North Carolina, USA
| | | | - Jeanne Cawse-Lucas
- Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Larry B Mauksch
- Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Autumn M Kieber-Emmons
- Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Benjamin F Crabtree
- Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
- Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - William L Miller
- Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Veronica M Brohm
- Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Timothy P Daaleman
- Family Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA
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Goldberg DG, Owens-Jasey C, Haghighat S, Kavalloor S. Implementation strategies for large scale quality improvement initiatives in primary care settings: a qualitative assessment. BMC PRIMARY CARE 2023; 24:242. [PMID: 37978433 PMCID: PMC10655333 DOI: 10.1186/s12875-023-02200-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVES The EvidenceNOW: Advancing Heart Health in Primary Care was designed to assist primary care practices in the US in implementing evidence-based practices in cardiovascular care and building capacity for quality improvement. EvidenceNOW, NCT03054090, was registered with ClinicalTrials.gov on 15/02/2017. The goals of this study were to gain a comprehensive understanding of perspectives from research participants and research team members on the value of implementation strategies and factors that influenced the EvidenceNOW initiative in Virginia. METHODS In 2018, we conducted 25 focus groups with clinicians and staff at participating practices, including 80 physicians, advanced practice clinicians, practice managers and other practice staff. We also conducted face-to-face and telephone interviews with 22 research team members, including lead investigators, practice facilitators, physician expert consultants, and evaluators. We used the integrated-Promoting Action on Research Implementation in the Health Services (i-PARIHS) framework in our qualitative data analysis and organization of themes. RESULTS Implementation strategies valued by both practice representatives and research team members included the kick-off event, on-site practice facilitation, and interaction with physician expert consultants. Remote practice facilitation and web-based tools were used less frequently. Contextual factors that influence quality improvement efforts include leadership support, access to resources, previous quality improvement experience, and practice ownership type (independent compared to health system owned). Many clinicians and staff were overwhelmed by day-to-day activities and experience initiative fatigue, which hindered their ability to fully participate in the EvidenceNOW initiative. CONCLUSIONS This study provides details on how the practice environment plays an essential role in the implementation of evidence-based practices in primary care. Future efforts to improve quality in primary care practices should consider the context and environment of individual practices, with targeted implementation strategies to meet the needs of independent and health system owned practices. Future efforts to improve quality in primary care practices require strategies to address initiative fatigue among clinicians and practice staff. External support for building capacity for quality improvement could help primary care practices implement and sustain evidence-based practices and improve quality of care. TRIAL REGISTRATION This project was registered with ClinicalTrials.gov on 15/02/2017 and the identifier is NCT03054090.
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Affiliation(s)
- Debora Goetz Goldberg
- Department of Health Administration and Policy, Affiliate Faculty, Center for Evidence-Based Behavioral Health, Department of Psychology, George Mason University, 4400 University Drive MS IJ3, Fairfax, VA, 22030, USA.
| | - Constance Owens-Jasey
- Department of Health Administration and Policy, Affiliate Faculty, Center for Evidence-Based Behavioral Health, Department of Psychology, George Mason University, 4400 University Drive MS IJ3, Fairfax, VA, 22030, USA
| | - Sahar Haghighat
- Department of Sociology and Anthropology, College of Humanities and Social Sciences, George Mason University, 4400 University Drive, 3G5, Fairfax, VA, 22030, USA
| | - Sneha Kavalloor
- Department of Health Administration and Policy, Affiliate Faculty, Center for Evidence-Based Behavioral Health, Department of Psychology, George Mason University, 4400 University Drive MS IJ3, Fairfax, VA, 22030, USA
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3
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Naik AD. Pragmatic Evidence for Theory-Based Innovations in Diabetes Primary Care. Diabetes Care 2023; 46:1750-1752. [PMID: 37729505 DOI: 10.2337/dci23-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/01/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Aanand D Naik
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX
- Institute on Aging, University of Texas Health Science Center, Houston, TX
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX
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Cheng SH, Chen CC, Lin YY. Longitudinal care continuity and avoidable hospitalization: the application of claims-based measures. BMC Health Serv Res 2023; 23:554. [PMID: 37244982 DOI: 10.1186/s12913-023-09457-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 04/27/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Longitudinal continuity between a patient and his/her primary care physician is an important aspect in measuring continuity of care (COC). The majority of previous studies employed questionnaire surveys to patients to measure the continual relationship between patients and their physicians. This study aimed to construct a provider duration continuity index (PDCI) by using longitudinal claims data and to examine its agreement with commonly used COC measures. Then, this study investigated the effects of the various types of COC measure on the likelihood of avoidable hospitalization while considering the level of comorbidity. METHODS This study constructed a 4-year panel (from 2014 to 2017) of the nationwide health insurance claims data in Taiwan. In total, 328,044 randomly selected patients with 3 or more physician visits per year were analyzed. Two PDCIs were constructed to measure the duration of interaction between a patient and his/her physicians over time. The agreement between the PDCIs and three commonly used COC indicators, the Usual Provider of Care index, the Continuity of Care Index, and the Sequential Continuity Index, were examined. Generalized estimating equations were conducted to examine the association between COC and avoidable hospitalization by the level of comorbidity. RESULTS The results showed that the correlations among the three commonly used COC indicators were high (γ = 0.787 ~ 0.958) and the correlation between the two longitudinal continuity measures was moderate (γ = 0.577 ~ 0.579), but the correlations between the commonly used COC indicators and the two PDCIs were low (γ = 0.001 ~ 0.257). All COC measures, both the PDCIs and the three commonly used COC indicators, showed independent protective effects on the likelihood of avoidable hospitalization in three comorbidity groups. CONCLUSION The duration of interaction between patients and physicians is an independent domain in measuring COC and has a significant effect on health care outcomes.
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Affiliation(s)
- Shou-Hsia Cheng
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Room 618, 17, Hsu-Chow Road, Taipei, 100, Taiwan.
- Population Health Research Center, National Taiwan University, Taipei, Taiwan.
| | - Chi-Chen Chen
- Department of Public Health, College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Yueh-Yun Lin
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Room 618, 17, Hsu-Chow Road, Taipei, 100, Taiwan
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Mazevska D, Pearse J, Tierney S. Using a theoretical framework to inform implementation of the patient-centred medical home (PCMH) model in primary care: protocol for a mixed-methods systematic review. Syst Rev 2022; 11:249. [PMID: 36419135 PMCID: PMC9682798 DOI: 10.1186/s13643-022-02132-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/08/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The patient-centred medical home (PCMH) was conceived to address problems that primary care practices around the world are facing, particularly in managing the increasing numbers of patients with multiple chronic diseases. The problems include fragmentation, lack of access and poor coordination. The PCMH is a complex intervention combining high-quality primary care with evidence-based disease management. Becoming a PCMH takes time and resources, and there is a lack of empirically informed guidance for practices. Previous reviews of PCMH implementation have identified barriers and enablers but failed to analyse the complex relationships between factors involved in implementation. Using a theoretical framework can help with this, giving a better understanding of how and why interventions work or do not work. This review will aim to refine an existing theoretical framework for implementing organisational change - the Consolidated Framework for Implementation Research (CFIR) - to apply to the implementation of the PCMH in primary care. METHODS We will use the 'best-fit' framework approach to synthesise evidence for implementing the PCMH in primary care. We will analyse evidence from empirical studies against CFIR constructs. Where studies have identified barriers and enablers to implementing the PCMH not represented in the CFIR constructs, we will use thematic analysis to develop additional constructs to refine the CFIR. Searches will be undertaken in MEDLINE (Ovid), Embase (Ovid), Web of Science Core Collection (including Science Citation Index and Social Science Citation Index) and CINAHL. Gaps arising from the database search will be addressed through snowballing, citation tracking and review of reference lists of systematic reviews of the PCMH. We will accept qualitative, quantitative and mixed methods primary research studies published in peer-reviewed publications. A stakeholder group will provide input to the review. DISCUSSION The review will result in a refined theoretical framework that can be used by primary care practices to guide implementation of the PCMH. Narrative accompanying the refined framework will explain how the constructs (existing and added) work together to successfully implement the PCMH in primary care. The unpopulated CFIR constructs will be used to identify where further primary research may be needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021235960.
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Affiliation(s)
- Deniza Mazevska
- Health Policy Analysis, PO Box 403, St Leonards, NSW, 1590, Australia.
| | - Jim Pearse
- Health Policy Analysis, PO Box 403, St Leonards, NSW, 1590, Australia
| | - Stephanie Tierney
- Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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Ferrer RL, Schlenker CG, Cruz I, Noël PH, Palmer RF, Poursani R, Jaén CR. Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care. Ann Fam Med 2022; 20:438-445. [PMID: 36228078 PMCID: PMC9512562 DOI: 10.1370/afm.2848] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/08/2022] [Accepted: 05/10/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Improving patients' self-care for chronic disease is often elusive in the context of social deprivation. We evaluated whether a practice-integrated community health worker (CHW) intervention could encourage effective long-term self-management of type 2 diabetes mellitus (T2DM). METHODS This cohort study, in a safety-net primary care practice, enrolled patients with uncontrolled T2DM and psychosocial risk factors. Patients were identified through a practice diabetes registry or by clinicians' referrals. The CHWs engaged patients in trust building and sensemaking to understand their social context, identify goals, navigate health care, and connect to community resources. Primary outcome was progress through 3 prospectively defined stages of self-care: outreach (meeting face-to-face); stabilization (collaborating to address patients' life circumstances); and self-care generativity (achieving self-care competencies). Secondary outcomes were change in hemoglobin A1c (HbA1c) and need for urgent care, emergency department, or hospital visits. RESULTS Of 986 participating patients, 27% remained in outreach, 41% progressed to stabilization, and 33% achieved self-care generativity. Repeated measures ANOVA demonstrates an overall decline in HbA1c, without group differences, through the 4th HbA1c measurement (mean follow-up 703 days). Beginning at the 5th HbA1c measurement (mean 859 days), the self-care generativity group achieved greater declines in HbA1c, which widened through the 10th measurement (mean 1,365 days) to an average of 8.5% compared with an average of 8.8% in the outreach group and 9.0% in the stabilization group (P = .003). Rates of emergency department and hospital visits were lower in the self-care generativity group. CONCLUSIONS Practice-linked CHWs can sustainably engage vulnerable patients, helping them advance self-management goals in the context of formidable social disadvantage.
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Affiliation(s)
- Robert L Ferrer
- Department of Family and Community Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Carolina Gonzalez Schlenker
- Department of Family and Community Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Inez Cruz
- Department of Family and Community Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Polly Hitchcock Noël
- Department of Family and Community Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Raymond F Palmer
- Department of Family and Community Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Ramin Poursani
- Department of Family and Community Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Carlos Roberto Jaén
- Department of Family and Community Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, Texas
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Felizzola J, Pinho V, Funk D, Del Río-González AM, Zea MC, Sol C, Barker S. Transforming Latinx HIV Care: Mixed-Methods Evaluation of a Patient-Centered HIV Practice Transformation. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2022; 34:131-141. [PMID: 35438539 DOI: 10.1521/aeap.2022.34.2.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We conducted a mixed-method longitudinal evaluation of an HIV primary care practice transformation project in Washington, D.C. The project aimed to enhance organizational capacity to deliver culturally appropriate and patient-centered care for Latinxs living with HIV. Quantitative and qualitative data were simultaneously collected to capture the complex interactions among care providers, staff, and patients as well as to monitor practice changes that occurred as a result of the project implementation. The practice transformation intervention consisted of core competency workforce training, workflow redesign, and data-driven quality improvement strategies utilized to guide the intervention and to gather data from providers and patients. The mixed-methods approach facilitated meaningful change within the clinic that resulted in improved patient outcomes, patient experiences of care, and increases in staff's perceived level of knowledge of patient-centered care and improved efficiencies in HIV health care service delivery.
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Affiliation(s)
| | | | - Danielle Funk
- The Fenway Institute, Fenway Health, Boston, Massachusetts
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Kolko DJ, McGuier EA, Turchi R, Thompson E, Iyengar S, Smith SN, Hoagwood K, Liebrecht C, Bennett IM, Powell BJ, Kelleher K, Silva M, Kilbourne AM. Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial. Implement Sci 2022; 17:20. [PMID: 35193619 PMCID: PMC8862323 DOI: 10.1186/s13012-022-01195-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms. METHODS We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life. DISCUSSION This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home. TRIAL REGISTRATION ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.
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Affiliation(s)
- David J Kolko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Elizabeth A McGuier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Renee Turchi
- Department of Pediatrics, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Eileen Thompson
- PA Medical Home Program, PA Chapter, American Academy of Pediatrics, Media, PA, USA
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shawna N Smith
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kimberly Hoagwood
- Department of Child and Adolescent Psychiatry, New York University Langone Health, New York, NY, USA
| | - Celeste Liebrecht
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ian M Bennett
- Departments of Family Medicine and Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kelly Kelleher
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Nationwide Children's Hospital Research Institute, Columbus, OH, USA
| | - Maria Silva
- Allegheny Family Network, Pittsburgh, PA, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Fletcher SC, Humphrys E, Bellwood P, Hill TT, Cooper IR, McCracken RK, Price M. Team-based care Evaluation and Adoption Model (TEAM) Framework: Supporting the comprehensive evaluation of primary care transformation over time. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:897-904. [PMID: 34906936 PMCID: PMC8670636 DOI: 10.46747/cfp.6712897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To introduce the new Team-based care Evaluation and Adoption Model (TEAM) Framework. QUALITY OF EVIDENCE The initial TEAM Framework was derived from a series of reviews and consultations with academic and clinical experts. In a parallel process, team-based primary and community care evaluation in Canada was assessed through a structured review of academic literature, followed by a review of policy literature of existing primary care evaluation frameworks. MAIN MESSAGE The review of academic articles alongside an analysis of policy documents and existing evaluation frameworks in primary care resulted in the development of the 10-dimension TEAM Framework. CONCLUSION Primary care transformation requires evaluation over time. The TEAM Framework provides a comprehensive framework for assessing evidence needed to support short- and long-term actionable improvements for team-based primary and community care in Canada. This framework will inform the development of an evaluation tool kit for primary care teams.
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Affiliation(s)
- Sarah C Fletcher
- Program Manager in the Innovation Support Unit (ISU) in the Department of Family Practice at the University of British Columbia (UBC) in Vancouver.
| | - Elka Humphrys
- Research and Evaluation Lead in the ISU in the Department of Family Practice at UBC
| | | | - Tiffany T Hill
- Story and Justice Lead in the ISU in the Department of Family Practice at UBC and a doctoral student-activist at the Ontario Institute for Studies in Education at the University of Toronto
| | - Ian R Cooper
- Research Analyst in the ISU in the Department of Family Practice at UBC
| | - Rita K McCracken
- Scientific Director of the ISU in the Department of Family Practice at UBC and a family physician practising in Vancouver
| | - Morgan Price
- Director of the ISU, Associate Head of the Department of Family Practice and Associate Professor at UBC, an affiliate faculty member in the Division of Medical Sciences, Computer Science, and Health Information Science at the University of Victoria, and a family physician practising in a community health centre in Victoria
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Mitra G. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:812-815. [PMID: 34772707 PMCID: PMC8589142 DOI: 10.46747/cfp.6711812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Goldis Mitra
- Professeure adjointe de clinique au Département de pratique familiale de l’Université de la Colombie-Britannique à Vancouver
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Mitra G, Grudniewicz A, Lavergne MR, Fernandez R, Scott I. Alternative payment models: A path forward. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:805-807. [PMID: 34772705 PMCID: PMC8589129 DOI: 10.46747/cfp.6711805] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Goldis Mitra
- Clinical Assistant Professor in the Department of Family Practice at the University of British Columbia in Vancouver.
| | - Agnes Grudniewicz
- Assistant Professor in the Telfer School of Management at the University of Ottawa in Ontario
| | - M Ruth Lavergne
- Associate Professor in the Department of Family Medicine at Dalhousie University in Halifax, NS
| | - Renee Fernandez
- Clinical Assistant Professor in the Department of Family Practice at the University of British Columbia
| | - Ian Scott
- Associate Professor in the Department of Family Practice at the University of British Columbia
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Chattopadhyay S. Cost-efficiency in the patient centered medical home model: New evidence from federally qualified health centers. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2021; 21:295-316. [PMID: 33638724 DOI: 10.1007/s10754-021-09295-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/10/2021] [Indexed: 06/12/2023]
Abstract
This research analyzes the cost-efficiency of the Patient Centered Medical Home (PCMH) model vis-à-vis the traditional care delivery model in the Federally Qualified Health Centers (FQHC). We apply the three-stage least squares modeling approach on 2014 UDS data on all FQHCs to estimate per-visit and per-patient cost functions. Log-quadratic and linear-quadratic functional forms of cost are used for the analysis. The estimated models reveal substantial scale economies and cost advantages associated with PCMH status. Aggregate cost-saving impact of PCMH across all FQHCs in 2014 is estimated to be $1.05 billion. Simulations reveal that the PCMH impact on cost savings grows with the size of the patient population. Reaching the full cost-saving potential in PCMH-recognized FQHCs hinges on expanding the health workforce at all levels of care to meet the need of the growing patient population due to aging and Medicaid expansion. For FQHCs that are not PCMH-recognized, capacity/infrastructural expansion appears to be the immediate policy choice.
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Affiliation(s)
- Sudip Chattopadhyay
- San Francisco State University, San Francisco, USA.
- National Center for Health Workforce Analysis, Health Resources and Services Administration, 5600 Fishers Lane, , Rockville, MD, 20857, USA.
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13
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Apaydin EA, Rose DE, McClean MR, Yano EM, Shekelle PG, Nelson KM, Stockdale SE. Association between care coordination tasks with non-VA community care and VA PCP burnout: an analysis of a national, cross-sectional survey. BMC Health Serv Res 2021; 21:809. [PMID: 34384398 PMCID: PMC8361617 DOI: 10.1186/s12913-021-06769-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The scope of care coordination in VA primary care increased with the launch of the Veterans Choice Act, which aimed to increase access through greater use of non-VA Community Care. These changes may have overburdened already busy providers with additional administrative tasks, contributing to provider burnout. Our objective was to understand the role of challenges with care coordination in burnout. We analyzed relationships between care coordination challenges with Community Care reported by VA primary care providers (PCPs) and VA PCP burnout. METHODS Our cross-sectional survey contained five questions about challenges with care coordination. We assessed whether care coordination challenges were associated with two measures of provider burnout, adjusted for provider and facility characteristics. Models were also adjusted for survey nonresponse and clustered by facility. Trainee and executive respondents were excluded. 1,543 PCPs in 129 VA facilities nationwide responded to our survey (13 % response rate). RESULTS 51 % of our sample reported some level of burnout overall, and 46 % reported feeling burned out at least once a week. PCPs were more likely to be burned out overall if they reported more than average challenges with care coordination (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.58 to 2.63). These challenges include managing patients with outside prescriptions or obtaining outside tests or records. CONCLUSIONS VA primary care providers who reported greater than average care coordination challenges were more likely to be burned out. Interventions to improve care coordination could help improve VA provider experience.
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Affiliation(s)
- Eric A Apaydin
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., MC 152, Bldg. 206 Rm. 252, Los Angeles, CA, 90073, USA.
- RAND Corporation, Santa Monica, CA, USA.
| | - Danielle E Rose
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., MC 152, Bldg. 206 Rm. 252, Los Angeles, CA, 90073, USA
| | - Michael R McClean
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., MC 152, Bldg. 206 Rm. 252, Los Angeles, CA, 90073, USA
| | - Elizabeth M Yano
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., MC 152, Bldg. 206 Rm. 252, Los Angeles, CA, 90073, USA
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Paul G Shekelle
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., MC 152, Bldg. 206 Rm. 252, Los Angeles, CA, 90073, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Karin M Nelson
- Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., MC 152, Bldg. 206 Rm. 252, Los Angeles, CA, 90073, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Cook JA, Jonikas JA, Steigman P, Glover CM, Burke-Miller JK, Weidenaar J, O’Neill S, Pavick D, Jami A, Santos CJ. Registry-Managed Care Coordination and Education for Patients With Co-occurring Diabetes and Serious Mental Illness. Psychiatr Serv 2021; 72:912-919. [PMID: 33887953 PMCID: PMC10443902 DOI: 10.1176/appi.ps.202000096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Longitudinal changes in health outcomes of patients with serious mental illness and co-occurring diabetes were examined after introduction of an intervention involving electronic disease management, care coordination, and personalized patient education. METHODS This observational cohort study included 179 patients with serious mental illness and diabetes mellitus type 2 at a behavioral health home in Chicago. The intervention employed a care coordinator who used a diabetes registry to integrate services; patients also received personalized diabetes self-management education. Outcomes included glucose, lipid, and blood pressure levels as assessed by glycosylated hemoglobin, low-density lipoprotein, triglycerides, and systolic/diastolic values from electronic medical records and completion of specialty visits confirmed with optometrists and podiatrists. Interrupted time-series segmented random-effects regression models tested for level changes in the eight study quarters following intervention implementation compared with eight preimplementation study quarters, controlling for clinic site and preimplementation secular trends. RESULTS Significant declines were found in levels of glucose, lipids, and blood pressure postimplementation. In addition, completed optometry referrals increased by 44% and completed podiatry referrals increased by 60%. CONCLUSIONS Significant improvement in medical outcomes was found among patients of a behavioral health home who had comorbid diabetes and mental illness after introduction of a multicomponent care coordination intervention, regardless of which clinic they attended.
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Affiliation(s)
- Judith A. Cook
- University of Illinois at Chicago, Center on Mental Health Services Research and Policy, Chicago, IL
| | - Jessica A. Jonikas
- University of Illinois at Chicago, Center on Mental Health Services Research and Policy, Chicago, IL
| | - Pamela Steigman
- University of Illinois at Chicago, Center on Mental Health Services Research and Policy, Chicago, IL
| | - Crystal M. Glover
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL
| | - Jane K. Burke-Miller
- University of Illinois at Chicago, Center on Mental Health Services Research and Policy, Chicago, IL
| | - Joni Weidenaar
- University of Illinois at Chicago, Center on Mental Health Services Research and Policy, Chicago, IL
| | | | | | - Asma Jami
- University of Minnesota Medical Center-Fairview, Department of Psychiatry and Behavioral Sciences, Minneapolis, MN
| | - Charles J. Santos
- Departments of Internal Medicine and Psychiatry, Tulane University School of Medicine, New Orleans, LA
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15
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Edwards ST, Marino M, Solberg LI, Damschroder L, Stange KC, Kottke TE, Balasubramanian BA, Springer R, Perry CK, Cohen DJ. Cultural And Structural Features Of Zero-Burnout Primary Care Practices. Health Aff (Millwood) 2021; 40:928-936. [PMID: 34097508 DOI: 10.1377/hlthaff.2020.02391] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.
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Affiliation(s)
- Samuel T Edwards
- Samuel T. Edwards is an assistant professor of medicine at Oregon Health and Science University and a staff physician in the Section of General Internal Medicine, Veterans Affairs Portland Health Care System, both in Portland, Oregon
| | - Miguel Marino
- Miguel Marino is an associate professor of biostatistics in the Department of Family Medicine, Oregon Health and Science University, and at the OHSU-Portland State University School of Public Health, in Portland, Oregon
| | - Leif I Solberg
- Leif I. Solberg is a senior research investigator at HealthPartners Institute, in Minneapolis, Minnesota
| | - Laura Damschroder
- Laura Damschroder is an implementation research consultant through Implementation Pathways, LLC, and a research investigator in the Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, in Ann Arbor, Michigan
| | - Kurt C Stange
- Kurt C. Stange is the Dorothy Jones Weatherhead Professor of Medicine; a professor of family medicine and community health, population and quantitative health sciences, oncology, and sociology; and the director of the Center for Community Health Integration, Case Western Reserve University, in Cleveland, Ohio
| | - Thomas E Kottke
- Thomas E. Kottke is a senior research investigator at HealthPartners Institute
| | - Bijal A Balasubramanian
- Bijal A. Balasubramanian is an associate professor in the Department of Epidemiology, Human Genetics, and Environmental Sciences and regional dean of UTHealth School of Public Health, in Dallas, Texas
| | - Rachel Springer
- Rachel Springer is a biostatistician in the Department of Family Medicine, Oregon Health and Science University
| | - Cynthia K Perry
- Cynthia K. Perry is a professor in the School of Nursing, Oregon Health and Science University
| | - Deborah J Cohen
- Deborah J. Cohen is a professor of family medicine and vice chair of research in the Department of Family Medicine, Oregon Health and Science University
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Abstract
BACKGROUND Traditional clinic design supports a high-volume, hierarchical practice model. New design models are evolving to foster a high-functioning team delivery model. PURPOSE The goal of this study was to determine whether new design models, specifically colocation, improve care team development. METHODOLOGY/APPROACH A quasi-experimental design was used in this study to obtain validated teamwork development scores and patient satisfaction data to compare clinic design models. We took advantage of a difference in designs of primary care clinics among several clinics within the same care system in the Upper Midwest region of the United States. The participants were staff members of the primary care delivery teams in the studied clinics. The intervention was a redesign of staff space in the clinic. Our measures included a validated measure of team development and a commonly used patient satisfaction tool that were both in use at our institution at the time of the study. RESULTS Teamwork scores were significantly higher in clinics where the primary work space of the entire team was colocated than in clinics where providers were in spaces separate from other team members. The differences in scores held across team roles, including providers, registered nurses, and licensed practical nurses. Patient satisfaction was not different. CONCLUSION Colocation in clinic design appears to have a significant impact on team development across primary care team member roles. PRACTICE IMPLICATIONS Primary care practice leaders should consider colocated clinic designs if their goal is to optimize care team development in support of team-based care delivery models. A more precise understanding of colocation that includes aspects such as distance to and visibility to teammates might help improve design in the future.
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17
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Metusela C, Dijkmans-Hadley B, Mullan J, Gow A, Bonney A. Implementation of a patient centred medical home (PCMH) initiative in general practices in New South Wales, Australia. BMC FAMILY PRACTICE 2021; 22:120. [PMID: 34148554 PMCID: PMC8215740 DOI: 10.1186/s12875-021-01485-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND With an ageing population and an increase in chronic disease burden in Australia, Patient Centred Medical Home (PCMH) models of care have been identified as potential options for primary care reform and improving health care outcomes. Adoption of PCMH models are not well described outside of North America. We examined the experiences of seven general practices in an Australian setting that implemented projects aligned with PCMH values and goals supported by their local Primary Health Network (PHN). METHOD Qualitative and quantitative data were collected over a twelve month period, including semi-structured interviews, participant observation, and practice data to present a detailed examination of a subject of study; the implementation of PCMH projects in seven general practices. We conducted 49 interviews (24 pre and 25 post) with general practitioners, practice managers, practice nurses and PHN staff. Framework analysis deploying the domains of a logic model was used to synthesis and analyse the data. RESULTS Facilitators in implementing successful, sustainable change included the capacity and willingness of practices to undertake change; whole of practice engagement with a shared vision towards PCMH change; engaged leadership; training and support; and structures and processes required to provide team-based, data driven care. Barriers to implementation included change fatigue, challenges of continued engaged leadership and insufficient time to implement PCMH change. CONCLUSIONS Our study examined the experiences of implementing PCMH initiatives in an Australian general practice setting, describing facilitators and barriers to PCMH change. Our findings provide guidance for PHNs and practices within Australia, as well as general practice settings internationally, that are interested in undertaking similar quality improvement projects.
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Affiliation(s)
- Christine Metusela
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
| | | | - Judy Mullan
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
| | - Andrew Gow
- South Eastern New South Wales Primary Health Network, Wollongong, Australia
| | - Andrew Bonney
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
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18
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Primary Care Tasks Associated With Nursing Burnout: A Survey of Registered and Licensed Vocational Nurses in Veterans Health Administration Patient-Centered Medical Homes. J Ambul Care Manage 2021; 44:304-313. [PMID: 34054108 DOI: 10.1097/jac.0000000000000385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Using data from the Veterans Assessment and Improvement Laboratory for Patient-Centered Care (VAIL-PCC) Survey, this study investigated the relationship between registered nurses' (RNs') and licensed vocational nurses' (LVNs') report of responsibility for 14 distinct primary care tasks and burnout, taking into account of practice environment contexts. RNs reported higher levels of burnout than LVNs. The task of "following up on referrals" was associated with significantly higher levels of RN burnout, whereas "responding to prescription requests" was associated with higher levels of LVN burnout. "True collaboration" was associated with significantly lower levels of burnout for both RNs and LVNs.
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19
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Patient Activation, Depressive Symptoms, and Self-Rated Health: Care Management Intervention Effects among High-Need, Medically Complex Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115690. [PMID: 34073277 PMCID: PMC8198245 DOI: 10.3390/ijerph18115690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/20/2021] [Accepted: 05/23/2021] [Indexed: 11/17/2022]
Abstract
The purpose of this randomized controlled trial (n = 268) at a Federally Qualified Health Center was to evaluate the outcomes of a care management intervention versus an attention control telephone intervention on changes in patient activation, depressive symptoms and self-rated health among a population of high-need, medically complex adults. Both groups had similar, statistically significant improvements in patient activation and self-rated health. Both groups had significant reductions in depressive symptoms over time; however, the group who received the care management intervention had greater reductions in depressive symptoms. Participants in both study groups who had more depressive symptoms had lower activation at baseline and throughout the 12 month study. Findings suggest that patients in the high-need, medically complex population can realize improvements in patient activation, depressive symptoms, and health status perceptions even with a brief telephone intervention. The importance of treating depressive symptoms in patients with complex health conditions is highlighted.
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20
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Schuttner L, Coleman K, Ralston J, Parchman M. The role of organizational learning and resilience for change in building quality improvement capacity in primary care. Health Care Manage Rev 2021; 46:E1-E7. [PMID: 33630509 PMCID: PMC7541444 DOI: 10.1097/hmr.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown. PURPOSE The aim of the study was to examine the association of AR and development of QI capacity. METHODOLOGY One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined. RESULTS Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure. CONCLUSIONS Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity. PRACTICE IMPLICATIONS Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts.
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21
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Wissow LS, Platt R, Sarvet B. Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth. Acad Pediatr 2021; 21:401-407. [PMID: 32858263 PMCID: PMC7445486 DOI: 10.1016/j.acap.2020.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 08/09/2020] [Accepted: 08/18/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Lawrence S Wissow
- University of Washington School of Medicine/Seattle Children's Hospital (LS Wissow), Seattle, Wash.
| | - Rheanna Platt
- Division of Child and Adolescent Psychiatry, Johns Hopkins School of Medicine (R Platt), Baltimore, Md
| | - Barry Sarvet
- University of Massachusetts Medical School - Baystate (B Sarvet), Springfield, Mass
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22
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Trankle SA, Usherwood T, Abbott P, Roberts M, Crampton M, Girgis CM, Riskallah J, Chang Y, Saini J, Reath J. Key stakeholder experiences of an integrated healthcare pilot in Australia: a thematic analysis. BMC Health Serv Res 2020; 20:925. [PMID: 33028299 PMCID: PMC7542969 DOI: 10.1186/s12913-020-05794-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 10/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Australia and other developed countries, chronic illness prevalence is increasing, as are costs of healthcare, particularly hospital-based care. Integrating healthcare and supporting illness management in the community can be a means of preventing illness, improving outcomes and reducing unnecessary hospitalisation. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health funded a range of key strategies through the Western Sydney Integrated Care Program (WSICP) to integrate care across hospital and community settings for patients with these illnesses. Complementing our previously reported analysis related to specific WSICP strategies, this research provided information concerning overall experiences and perspectives of WSICP implementation and integrated care generally. METHODS We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners and primary care nurses, and program managers. Half of the participants (n = 42) were interviewed twice. We conducted an inductive, thematic analysis on the interview transcripts. RESULTS Key themes related to the set-up and operationalising of WSICP; challenges encountered; and the added value of the program. Implementing WSICP was a large and time consuming undertaking but challenges including those with staffing and information technology were being addressed. The WSICP was considered valuable in reducing hospital admissions due to improved patient self-management and a focus on prevention, greater communication and collaboration between healthcare providers across health sectors and an increased capacity to manage chronic illness in the primary care setting. CONCLUSIONS Patients, carers and health providers experienced the WSICP as an innovative integrated care model and valued its patient-centred approach which was perceived to improve access to care, increase patient self-management and illness prevention, and reduce hospital admissions. Long-term sustainability of the WSICP will depend on retaining key staff, more effectively sharing information including across health sectors to support enhanced collaboration, and expanding the suite of activities into other illness areas and locations. Enhanced support for general practices to manage chronic illness in the community, in collaboration with hospital specialists is critical. Timely evaluation informs ongoing program implementation.
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Affiliation(s)
- Steven A Trankle
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
| | - Tim Usherwood
- Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Western Sydney Local Health District (Westmead Hospital), Sydney, Australia
- George Institute for Global Health, Sydney, Australia
| | - Penelope Abbott
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
| | - Mary Roberts
- Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Western Sydney Local Health District (Westmead Hospital), Sydney, Australia
| | | | - Christian M Girgis
- Westmead Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Western Sydney Local Health District (Westmead Hospital), Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - John Riskallah
- Western Sydney Local Health District (Blacktown Hospital), Sydney, Australia
| | - Yashu Chang
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
- Western Sydney Local Health District (Blacktown Hospital), Sydney, Australia
| | - Jaspreet Saini
- Western Sydney Primary Health Network, Sydney, Australia
| | - Jennifer Reath
- Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
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23
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Apaydin EA, Rose D, Meredith LS, McClean M, Dresselhaus T, Stockdale S. Association Between Difficulty with VA Patient-Centered Medical Home Model Components and Provider Emotional Exhaustion and Intent to Remain in Practice. J Gen Intern Med 2020; 35:2069-2075. [PMID: 32291716 PMCID: PMC7352025 DOI: 10.1007/s11606-020-05780-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) model is intended to improve primary care, but evidence of its effects on provider well-being is mixed. Investigating the relationships between specific PCMH components and provider burnout and potential attrition may help improve the efficacy of the care model. OBJECTIVE We analyzed provider attitudes toward specific components of PCMH in the Veterans Health Administration (VA) and their relation to emotional exhaustion (EE)-a central component of burnout-and intent to remain in VA primary care. DESIGN Logistic regression analysis of a cross-sectional survey. SUBJECTS 116 providers (physicians; nurse practitioners; physician assistants) in 21 practices between September 2015 and January 2016 in one VA region. MAIN MEASURES Outcomes: burnout as measured with the emotional exhaustion (EE) subscale of the Maslach Burnout Inventory and intent to remain in VA primary care for the next 2 years; predictors: difficulties with components of PCMH, demographic characteristics. KEY RESULTS Forty percent of providers reported high EE (≥ 27 points) and 63% reported an intent to remain in VA primary care for the next 2 years. Providers reporting high difficultly with PCMH elements were more likely to report high EE, for example, coordinating with specialists (odds ratio [OR] 8.32, 95% confidence interval [CI] 3.58-19.33), responding to EHR alerts (OR 6.88; 95% CI 1.93-24.43), and managing unscheduled visits (OR 7.53, 95% CI 2.01-28.23). Providers who reported high EE were also 87% less likely to intend to remain in VA primary care. CONCLUSIONS To reduce EE and turnover in PCMH, primary care providers may need additional support and training to address challenges with specific aspects of the model.
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Affiliation(s)
- Eric A Apaydin
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. (151), Los Angeles, CA, 90073, USA. .,RAND Corporation, Santa Monica, CA, USA.
| | - Danielle Rose
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. (151), Los Angeles, CA, 90073, USA
| | - Lisa S Meredith
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. (151), Los Angeles, CA, 90073, USA.,RAND Corporation, Santa Monica, CA, USA
| | - Michael McClean
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. (151), Los Angeles, CA, 90073, USA
| | - Timothy Dresselhaus
- VA San Diego Healthcare System, San Diego, CA, USA.,School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Susan Stockdale
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd. (151), Los Angeles, CA, 90073, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
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24
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Mead KH, Raskin S, Willis A, Arem H, Murtaza S, Charney L, Pratt-Chapman M. Identifying patients' priorities for quality survivorship: conceptualizing a patient-centered approach to survivorship care. J Cancer Surviv 2020; 14:939-958. [PMID: 32607715 DOI: 10.1007/s11764-020-00905-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/14/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE This study explored cancer survivors' experiences with and priorities for cancer survivorship care to describe a patient-centered approach to quality survivorship care. METHODS We conducted 22 focus groups with 170 adult survivors of breast, prostate, and colorectal cancer from six cities across the country and online. We used thematic analysis to identify participants' principles and priorities for quality survivorship care. RESULTS Based on our analysis of a limited group of cancer survivors, we identified two core principles that underlie participants' expectations for survivorship care and 11 practice priorities that reflect opportunities to improve patient-centeredness at the individual, interpersonal, and organizational levels. The principles reflect participants' desire to be better prepared for and equipped to accept and manage their chronic care needs post-cancer treatment. The priorities reflect practices that patients, providers, and cancer centers can engage in to ensure survivors' goals for post-treatment care are met. CONCLUSIONS Results from the study suggest the need to expand conceptualization of high-quality survivorship care. The survivor principles and practice priorities identified in this study challenge the field to organize a more patient-centered survivorship care system that empowers and respects patients and provides a holistic approach to survivors' chronic and long-term needs. IMPLICATIONS FOR CANCER SURVIVORS Quality cancer survivorship care must reflect patients' priorities. The findings from this study can be used to develop a patient-centered framework for survivorship care that can be used in conjunction with quality guidelines to ensure survivorship care is organized to achieve both clinical and patient-centered outcomes.
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Affiliation(s)
- K Holly Mead
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave., Washington, DC, 20052, USA.
| | - Sarah Raskin
- L. Douglas Wilder School of Government and Public Affairs, Virginia Commonwealth University, 1001 W. Franklin St., Richmond, VA, 23284, USA
| | - Anne Willis
- Cystic Fibrosis Foundation, 4550 Montgomery Ave., Bethesda, MD, 20814, USA
| | - Hannah Arem
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave., Washington, DC, 20052, USA
| | - Sarah Murtaza
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave., Washington, DC, 20052, USA
| | - Laura Charney
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave., Washington, DC, 20052, USA
| | - Mandi Pratt-Chapman
- George Washington University Cancer Center, George Washington University, 2600 Virginia Ave., NW, #300, Washington, DC, 20037, USA
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25
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Yoon J, Leung LB, Rubenstein LV, Nelson K, Rose DE, Chow A, Stockdale SE. Greater patient-centered medical home implementation was associated with lower attrition from VHA primary care. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100429. [PMID: 32553525 DOI: 10.1016/j.hjdsi.2020.100429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/23/2020] [Accepted: 04/22/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patient-centered medical home models such as the Veterans Health Administration (VHA) Patient Aligned Care Team (PACT) model aim to improve primary care through accessible, comprehensive, continuous team-based care. Practices that adhere to patient-centered medical home principles have been found to exhibit higher patient satisfaction, possibly leading to higher retention of patients longitudinally and reducing attrition from care. We examined whether greater PACT implementation was related to lower attrition from VHA primary care. METHODS A national cohort of 1.5 million nonelderly patients with chronic conditions and using VHA primary care in the baseline year (fiscal year 2015) was identified. Attrition was measured as not receiving primary care over two subsequent years. PACT implementation in 863 VHA primary care practices was measured by the PACT Implementation Progress Index (Pi2) across 8 domains. RESULTS Overall, the attrition rate was 4.4%. Predicted attrition was highest for patients treated in practices with the lowest PACT implementation scores (4.8%) compared to 4.0% among patients in practices with the highest PACT implementation scores (difference = -0.8 (95% CI: -1.3, -0.2)). Better performance on most PACT domains was significantly associated with lower attrition. CONCLUSIONS Primary care practices that facilitate easier access to providers as well as provide more seamless care coordination, better communication with providers, and support for self-management appear to positively affect patients' decisions to stay in VHA care. IMPLICATIONS Provision of accessible, comprehensive, team-based primary care, as measured in this study, is likely to be a determinant of patient retention in VHA care. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Jean Yoon
- VA Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA; Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA.
| | - Lucinda B Leung
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Karin Nelson
- Seattle-Denver Center of Innovation in Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Danielle E Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Adam Chow
- VA Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
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Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
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Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
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Crabtree BF, Miller WL, Howard J, Rubinstein EB, Tsui J, Hudson SV, O'Malley D, Ferrante JM, Stange KC. Cancer Survivorship Care Roles for Primary Care Physicians. Ann Fam Med 2020; 18:202-209. [PMID: 32393555 PMCID: PMC7213992 DOI: 10.1370/afm.2498] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/27/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODS We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge. CONCLUSIONS This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.
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Affiliation(s)
- Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey .,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | - Jenna Howard
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Denalee O'Malley
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Jeanne M Ferrante
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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Metusela C, Usherwood T, Lawson K, Angus L, Kmet W, Ferdousi S, Reath J. Patient Centred Medical Home (PCMH) transitions in western Sydney, Australia: a qualitative study. BMC Health Serv Res 2020; 20:285. [PMID: 32252751 PMCID: PMC7137239 DOI: 10.1186/s12913-020-05123-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 03/18/2020] [Indexed: 12/05/2022] Open
Abstract
Background Patient Centred Medical Homes (PCMHs), increasingly evidenced to provide high quality primary care, are new to Australia. To learn how this promising new healthcare model works in an Australian setting we explored experiences of healthcare providers in outer urban Sydney, where a number of practices are transitioning from traditional Australian general practice models to incorporate elements of PCMH approaches. Methods We collected qualitative data from semi-structured interviews with healthcare providers working in a range of transitioning practices and thematically analysed the data. We interviewed 35 participants including general practitioners, practice managers and practice nurses from 25 purposively sampled general practices in western Sydney, Australia, seeking maximal variation in practice size, patient demographics and type of engagement in practice transformation. Results Interviewees described PCMH transformation highlighting the importance of whole of practice engagement with a shared vision; key strategies for transformation to PCMH models of care including leadership, training and supportive information technology; structures and processes required to provide team-based, data-driven care; and constraints such as lack of space and the current Australian fee-for-service general practice funding model. They also reported their perceptions of early outcomes of the PCMH model of care, describing enhanced patient and staff satisfaction and also noting fewer hospital admissions, as likely to reduce costs of care. Conclusions Our study exploring the experience of early adopters of PCMH models of care in Australia, informs the international movement towards PCMH models of care. Our findings provide guidance for practices considering similar transitions and describe the challenges of such transitions within a fee-for-service payment system.
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Affiliation(s)
- Christine Metusela
- Department of General Practice, School of Medicine, Western Sydney University, Building 30.3.24 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
| | - Tim Usherwood
- General Practice, School of Medicine, University of Sydney, Sydney, Australia
| | - Kenny Lawson
- Translational Health Research Institute, Western Sydney University, Sydney, Australia
| | - Lisa Angus
- Providence Center for Outcomes Research & Education, Portland, OR, USA
| | - Walter Kmet
- Macquarie University Hospital and Clinical Services, Sydney, Australia
| | - Shahana Ferdousi
- WentWest Ltd, Western Sydney Primary Health Network, Blacktown, Australia
| | - Jennifer Reath
- Department of General Practice, School of Medicine, Western Sydney University, Building 30.3.24 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
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Leue C, van Schijndel M, Keszthelyi D, van Koeveringe G, Ponds R, Kathol R, Rutten B. The multi-disciplinary arena of psychosomatic medicine – Time for a transitional network approach. EUROPEAN JOURNAL OF PSYCHIATRY 2020. [DOI: 10.1016/j.ejpsy.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Caldwell KL, Vicidomini D, Wells R, Wolever RQ. Engaging Patients in their Health Care: Lessons From a Qualitative Study on the Processes Health Coaches Use to Support an Active Learning Paradigm. Glob Adv Health Med 2020; 9:2164956120904662. [PMID: 32110473 PMCID: PMC7016303 DOI: 10.1177/2164956120904662] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 11/25/2022] Open
Abstract
Background While recent health-care trends rely on activated patients, few studies report direct observations of how to engage and activate patients to be full participants in their own health care. The interpersonal processes and communication strategies used in integrative health coaching (IHC) may offer important insight into how clinicians can help patients step into a more active learning model rather than more typical passive roles. Objective This study uses verbatim transcripts of medical patients’ first few IHC sessions to identify the actual processes used to help patients embrace this more active learning role. Methods A thematic analysis was conducted of 72 verbatim transcripts from IHC sessions of 26 patients with severe dysfunction from tinnitus. The patients participated in 6 months of IHC as part of a larger integrative intervention in a randomized, controlled pilot designed to assess feasibility for a larger randomized, controlled trial on the clinical effectiveness of an integrative intervention. Results Four themes emerged: (1) Describing the Health Coaching Process to patients; (2) Using Key Procedures for Action Planning—optimal health future self-visualization, Wheel of Health, and exploration of the gap between current and desired states to help patients set goals for themselves; (3) Supporting Action and Building Momentum—the creation and support of action steps with frequent reinforcement of self-efficacy; and (4) Active Listening and Inviting the Patient to Articulate Learning—coaches’ active listening process included reflection, clarifying questions, turning patient questions back to the patients, highlighting values, identifying potential barriers and resources, and inviting patients to articulate what they were learning. Conclusion The processes identified in IHC incorporate key principles of adult learning theory and engage patients’ innate resources of goal orientation, self-direction, and intrinsic motivation. These interpersonal processes help patients embrace a more active learning role, with implications for patient engagement in other clinical contexts.
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Affiliation(s)
- Karen L Caldwell
- Department of Human Development and Psychological Counseling, Appalachian State University, Boone, North Carolina
| | - Delia Vicidomini
- Department of Human Development and Psychological Counseling, Appalachian State University, Boone, North Carolina
| | - Reese Wells
- Department of Human Development and Psychological Counseling, Appalachian State University, Boone, North Carolina
| | - Ruth Q Wolever
- Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,School of Nursing, Vanderbilt University, Nashville, Tennessee
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Rauscher EA, Hesse C, Campbell-Salome G. Applying Family Communication Patterns to Patient-provider Communication: Examining Perceptions of Patient Involvement, Satisfaction, and Medical Adherence. JOURNAL OF HEALTH COMMUNICATION 2020; 25:180-189. [PMID: 32116144 DOI: 10.1080/10810730.2020.1728596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This study investigates patient perceptions of patient-provider communication and family communication patterns theory (FCPT). Using FCPT, the study predicts that family communicative environment relates to patient perceptions of patient involvement in care as well as patient satisfaction and medical adherence. Further, this study tests new measures of conformity orientation (warm and cold conformity) to investigate the multi-faceted nature of the variable. The results show significant relationships between FCPT and patient perceptions and outcomes. Specifically, warm conformity was the strongest and most reliable predictor of patient perceptions and outcomes across the three FCPT variables tested in the model. Additionally, results show differences between how warm and cold conformity predict patient perception and outcome variables. Finally, tests of the interaction between conversation orientation and both types of conformity indicate relationships between interaction variables and patient involvement in care, but not satisfaction or adherence. Practical implications and future research ideas are also discussed.
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Affiliation(s)
- Emily A Rauscher
- Department of Communication, University of Utah, Salt Lake City, UT, USA
| | - Colin Hesse
- Department of Speech Communication, Oregon State University, Corvallis, OR, USA
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Abstract
The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.
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Affiliation(s)
- Michel Burnier
- From the Service of Nephrology and Hypertension, Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.B.)
| | - Brent M Egan
- Department of Medicine, Care Coordination Institute, University of South Carolina School of Medicine, Greenville, SC (B.M.E.)
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Pujalte GGA, Pantin SA, Waller TA, Maruoka Nishi LY, Willis FB, Jethwa TP, Presutti RJ. Patient-Centered Medical Home With Colocation: Observations and Insights From an Academic Family Medicine Clinic. J Prim Care Community Health 2020; 11:2150132720902560. [PMID: 31994429 PMCID: PMC6990603 DOI: 10.1177/2150132720902560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is a movement in the United States to transform family medicine practices from single physician–based patient care to team-based care. These teams are usually composed of multiple disciplines, including social workers, pharmacists, registered nurses, physician assistants, nurse practitioners, and physicians. The teams support patients and their families, provide holistic care to patients of all ages, and allow their members to work to the highest level of their training in an integrated fashion. Grouping care team members together within visual and auditory distance of each other is likely to enhance communication and teamwork, resulting in more efficient care for patients. This grouping is termed colocation. The authors describe how the use of colocation can lead to clearer, faster communication between care team members. This practice style has the potential to be expanded into various clinical settings in any given health system and to almost all clinical specialties and practices.
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Elements of the healthy work environment associated with lower primary care nurse burnout. Nurs Outlook 2020; 68:14-25. [DOI: 10.1016/j.outlook.2019.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/26/2019] [Accepted: 06/21/2019] [Indexed: 11/20/2022]
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Trankle SA, Usherwood T, Abbott P, Roberts M, Crampton M, Girgis CM, Riskallah J, Chang Y, Saini J, Reath J. Integrating health care in Australia: a qualitative evaluation. BMC Health Serv Res 2019; 19:954. [PMID: 31829215 PMCID: PMC6907151 DOI: 10.1186/s12913-019-4780-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 11/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses. METHODS We aimed to investigate the WSICP's effectiveness through a qualitative evaluation focused on the 10 WSICP strategies using a framework analysis. We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners (GPs) and primary care nurses, and program managers. Most participants (71%) were interviewed twice. We analysed data within a framework describing how strategies were implemented and used, the experiences around these, their perceived value, facilitators and barriers, and participant-identified suggestions for improvement. RESULTS Care facilitators helped patients access services within the hospital and in primary care and connected general practices with hospital specialists and services. Rapid access and stabilisation clinics with their patient hotlines assisted patients and carers to self-manage chronic illness while connecting GPs to specialists through the GP support-line. Action plans from the hospital informed GPs and their shared care plans which could be accessed by other community health professionals and patients. HealthPathways provided GPs with local, evidence-based guidelines for managing patients. Difficulties persisted in effective widespread access to shared records and electronic communication across sectors. CONCLUSIONS The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research.
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Affiliation(s)
- Steven A. Trankle
- School of Medicine, Department General Practice, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751 Australia
| | - Tim Usherwood
- School of Medicine, Sydney University, Sydney, Australia
- George Institute for Global Health, Sydney, Australia
| | - Penny Abbott
- School of Medicine, Department General Practice, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751 Australia
| | - Mary Roberts
- Western Sydney Local Health District (Westmead Hospital), North Parramatta, Australia
| | | | - Christian M. Girgis
- School of Medicine, Sydney University, Sydney, Australia
- Western Sydney Local Health District (Westmead Hospital), North Parramatta, Australia
- Royal North Shore Hospital, Leonards, Australia
| | - John Riskallah
- Western Sydney Local Health District (Blacktown Hospital), Parramatta, Australia
| | - Yashu Chang
- School of Medicine, Department General Practice, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751 Australia
- Western Sydney Local Health District (Blacktown Hospital), Parramatta, Australia
| | - Jaspreet Saini
- Western Sydney Primary Health Network, Blacktown, Australia
| | - Jennifer Reath
- School of Medicine, Department General Practice, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751 Australia
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Frey R, Balmer D, Boyd M, Robinson J, Gott M. Palliative care nurse specialists' reflections on a palliative care educational intervention in long-term care: an inductive content analysis. BMC Palliat Care 2019; 18:103. [PMID: 31744507 PMCID: PMC6864945 DOI: 10.1186/s12904-019-0488-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/12/2019] [Indexed: 12/02/2022] Open
Abstract
Background Older people in long-term care facilities are at a greater risk of receiving care at the end of life that does not adequately meet their needs, yet staff in long-term care are often unprepared to provide palliative care. The objective of the study was to explore palliative care nurse specialists’ experiences regarding the benefits of and barriers to the implementation of a palliative care educational intervention, Supportive Hospice Aged Residential Exchange (SHARE) in 20 long-term care facilities. Methods Reflective logs (465), recorded over the course of the yearlong SHARE intervention by the three palliative care nurse specialists from two local hospices, who were the on-site mentors, were qualitatively analyzed by two researchers utilizing inductive content analysis. Results Categories emerging from the logs include the importance of relationships, knowledge exchange, communication, and the challenges of providing palliative care in a long-term care setting. Conclusion Evidence from the logs indicated that sustained relationships between the palliative care nurse specialists and staff (registered nurses, healthcare assistants) as well as reciprocal learning were key factors supporting the implementation of this palliative care educational intervention. Challenges remain however in relation to staffing levels, which further emphasizes the importance of palliative care nurse specialist presence as a point of stability.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand.
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
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Abstract
Explorations of workflow development within primary care allow us to understand initial steps in the pace of knowledge and practice acclimatization within clinics. This study describes use of practice facilitation as an implementation strategy to communicate shared project goals and monitor and support refinement of practice behavior. This study engaged eight health care organizations, including 55 primary care practices, ≈380 clinicians, and ≈620 nursing and support staff in a guideline implementation project regarding United States Preventive Services Task Force use of aspirin recommendations for primary prevention of cardiovascular events.
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Davis MM, Gunn R, Pham R, Wiser A, Lich KH, Wheeler SB, Coronado GD. Key Collaborative Factors When Medicaid Accountable Care Organizations Work With Primary Care Clinics to Improve Colorectal Cancer Screening: Relationships, Data, and Quality Improvement Infrastructure. Prev Chronic Dis 2019; 16:E107. [PMID: 31418685 PMCID: PMC6716418 DOI: 10.5888/pcd16.180395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose Accountable Care Organizations (ACOs) are implementing interventions to achieve triple-aim objectives of improved quality and experience of care while maintaining costs. Partnering across organizational boundaries is perceived as critical to ACO success. Methods We conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics using public performance data, key informant interviews, and consultation field notes. We focused on how ACOs work with clinics to improve colorectal cancer (CRC) screening — one incentivized performance metric. Results ACOs implemented a broad spectrum of multi-component interventions designed to increase CRC screening. The most common interventions focused on reducing structural barriers (n = 12 ACOs), delivering provider assessment and feedback (n = 11), and providing patient reminders (n = 7). ACOs developed their processes and infrastructure for working with clinics over time. Facilitators of successful collaboration included a history of and commitment to collaboration (partnership); the ability to provide accurate data to prioritize action and monitor improvement (performance data), and supporting clinics’ reflective learning through facilitation, learning collaboratives; and support of ACO as well as clinic-based staffing (quality improvement infrastructure). Two unintended consequences of ACO–clinic partnership emerged: potential exclusion of smaller clinics and metric focus and fatigue. Conclusion Our findings identified partnership, performance data, and quality improvement infrastructure as critical dimensions when Medicaid ACOs work with primary care to improve CRC screening. Findings may extend to other metric targets.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-based Research Network, Portland, Oregon.,Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L222, Portland, OR 97239.
| | - Rose Gunn
- Oregon Rural Practice-based Research Network, Portland, Oregon
| | - Robyn Pham
- Oregon Rural Practice-based Research Network, Portland, Oregon
| | - Amy Wiser
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Parchman ML, Anderson ML, Dorr DA, Fagnan LJ, O'Meara ES, Tuzzio L, Penfold RB, Cook AJ, Hummel J, Conway C, Cholan R, Baldwin LM. A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care. Ann Fam Med 2019; 17:S40-S49. [PMID: 31405875 PMCID: PMC6827661 DOI: 10.1370/afm.2407] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/06/2018] [Accepted: 01/09/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. METHODS Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. RESULTS Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). CONCLUSIONS Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.
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Affiliation(s)
- Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Melissa L Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - David A Dorr
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Lyle J Fagnan
- Oregon Rural Practice Research Network, Oregon Health & Sciences University, Port-land, Oregon
| | - Ellen S O'Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Cullen Conway
- Oregon Rural Practice Research Network, Oregon Health & Sciences University, Port-land, Oregon
| | - Raja Cholan
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Laura-Mae Baldwin
- Department of Family Medicine, Institute of Translational Health Sciences, University of Washington, Seattle, Washington
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Grumbach K, Knox M, Huang B, Hammer H, Kivlahan C, Willard-Grace R. A Longitudinal Study of Trends in Burnout During Primary Care Transformation. Ann Fam Med 2019; 17:S9-S16. [PMID: 31405871 PMCID: PMC6827663 DOI: 10.1370/afm.2406] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/16/2018] [Accepted: 12/21/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The quadruple aim of primary care transformation includes promoting well-being among the primary care workforce. We longitudinally assessed burnout among clinicians and staff in 2 health delivery organizations engaged in primary care redesign guided by a shared transformation model. METHODS We conducted a descriptive longitudinal study, using repeated cross-sectional measures from 6 waves of surveys of employed primary care clinicians (physicians, nurse practitioners, physician assistants) and staff conducted between 2012 to 2018 in the San Francisco Health Network and in UCSF Health. The 2018 wave had 613 respondents (response rate 88%). Outcome measures were scores on the Maslach Burnout Inventory emotional exhaustion and cynicism subscales. We used regression models to test for time trends in mean scores. RESULTS Trends in burnout differed by system and occupation. In one system, mean clinician scores steadily improved for emotional exhaustion (P = .04) and cynicism (P = .07). In the other system, clinician burnout scores initially worsened and then returned to baseline levels. In both systems, burnout trends among staff tended to move in the opposite direction from trends among clinicians. CONCLUSIONS The divergent trends of steady reduction in clinician burnout in one system and clinician burnout getting worse before getting better in the other system suggest that the effects of primary care transformation are influenced by the organizational context. Moreover, practice changes that reduce clinician burnout may not decrease-and may potentially even worsen-burnout among staff. Primary care transformation requires continuing efforts to promote meaningful work and sustainable workloads among all members of the primary care team.
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Affiliation(s)
- Kevin Grumbach
- Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California San Francisco, San Francisco, California
| | - Margae Knox
- Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California San Francisco, San Francisco, California
| | - Beatrice Huang
- Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California San Francisco, San Francisco, California
| | - Hali Hammer
- San Francisco Health Network and Department of Family & Community Medicine, University of California San Francisco, San Francisco, California
| | - Coleen Kivlahan
- UCSF Health and Department of Family & Community Medicine, University of California San Francisco, San Francisco, California
| | - Rachel Willard-Grace
- Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California San Francisco, San Francisco, California
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Parchman ML, Anderson ML, Coleman K, Michaels LA, Schuttner L, Conway C, Hsu C, Fagnan LJ. Assessing quality improvement capacity in primary care practices. BMC FAMILY PRACTICE 2019; 20:103. [PMID: 31345167 PMCID: PMC6657073 DOI: 10.1186/s12875-019-1000-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/18/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Healthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation. METHODS To guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors. RESULTS The QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2-5 clinicians had lower QICA scores.. CONCLUSIONS The QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality. TRIAL REGISTRATION This trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.
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Affiliation(s)
- Michael L. Parchman
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Melissa L. Anderson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Katie Coleman
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Le Ann Michaels
- Oregon Rural Practice Research Network, Oregon Health Sciences University, Portland, OR USA
| | | | - Cullen Conway
- Oregon Rural Practice Research Network, Oregon Health Sciences University, Portland, OR USA
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave Ste 1600, Seattle, WA 98101 USA
| | - Lyle J. Fagnan
- Oregon Rural Practice Research Network, Oregon Health Sciences University, Portland, OR USA
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Kalu ME, Maximos M, Sengiad S, Dal Bello-Haas V. The Role of Rehabilitation Professionals in Care Transitions for Older Adults: A Scoping Review. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2019. [DOI: 10.1080/02703181.2019.1621418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Michael E. Kalu
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Melody Maximos
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sirirat Sengiad
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Vanina Dal Bello-Haas
- Physical Therapy Program, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
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Ayanlade O, Oyebisi T, Kolawole B. Health Information Technology Acceptance Framework for diabetes management. Heliyon 2019; 5:e01735. [PMID: 31193710 PMCID: PMC6539785 DOI: 10.1016/j.heliyon.2019.e01735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 04/09/2019] [Accepted: 05/10/2019] [Indexed: 12/25/2022] Open
Abstract
This study examined the level of acceptance of Health Information Technology (HIT) as tools for diabetes care and management, in six selected tertiary hospitals in southwestern zone of Nigeria. Using both quantitative and qualitative methods, this study was conducted amongst selected healthcare stakeholders namely Nurses, Doctors, Laboratory Scientists, Pharmacists, ICT unit Professionals, Medical Record Officers, and Type-2 diabetes out-patients available in the designated hospitals. Adapting Technology Acceptance and Chronic Care Models, the level of HIT acceptance by the respondents in the study area was measured in terms of Perceived Ease-of-Use, Perceived Usefulness, and the Perceived Unintended Consequences relating to HIT, while also considering the roles of the government, community and healthcare organizations. One hundred and fifty (150) respondents were examined, each for both Staff and Patients, and the factor variables studied on a 5-point Likert rating scale of measurement from 1 (Strongly Disagree) to 5 (Strongly Agree). The results revealed strong perception of Staff and Patients about HIT implementation and acceptance and showed that in some cases, the perception of Staff and patients about HIT acceptance are the same, while different in some. The study concluded that for acceptability of HIT, hospitals have to embark on 'continuous' training for the HIT users, so that users would familiarize themselves with the system, and it will be fully incorporated into their workflow. Based on the findings, a conceptual Health Information Technology Acceptance Framework for Chronic diseases' management, especially for diabetes mellitus was developed.
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Affiliation(s)
- O.S. Ayanlade
- African Institute for Science Policy and Innovation (AISPI), Obafemi Awolowo University, Ile-Ife, Nigeria
| | - T.O. Oyebisi
- African Institute for Science Policy and Innovation (AISPI), Obafemi Awolowo University, Ile-Ife, Nigeria
| | - B.A. Kolawole
- Department of Medicine, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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Miller WL, Rubinstein EB, Howard J, Crabtree BF. Shifting Implementation Science Theory to Empower Primary Care Practices. Ann Fam Med 2019; 17:250-256. [PMID: 31085529 PMCID: PMC6827625 DOI: 10.1370/afm.2353] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 11/12/2018] [Accepted: 12/18/2018] [Indexed: 11/09/2022] Open
Abstract
Observers of the past 10 to 15 years have witnessed the simultaneous growth of dramatic changes in the practice of primary care and the emergence of a new field of dissemination and implementation science (D&I). Most current implementation science research in primary care assumes practices are not meeting externally derived standards and need external support to meet these demands. After a decade of initiatives, many stakeholders now question the return on their investments. Overall improvements in quality metrics, utilization cost savings, and patient experience have been less than anticipated. While recently conducting a research project in primary care practices, we unexpectedly discovered 3 practices that profoundly shifted our thinking about the sources and directionality of practice change and the underlying assumptions of D&I. Inspired by these practices-along with systems thinking, complexity theory, action research, and the collaborative approaches of community-based participatory research-we propose a reimagining of D&I theory to empower practices. We shift the emphasis regarding the source and direction of change from outside-in to inside-out Such a shift has the potential to open a new frontier in the science of dissemination and implementation and inform better health policy.
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Affiliation(s)
- William L Miller
- Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Ellen B Rubinstein
- Department of Sociology & Anthropology, North Dakota State Universiry, Fargo, North Dakota
| | - Jenna Howard
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Doarn CR, Vonder Meulen MB, Pallerla H, Acquavita SP, Regan S, Elder N, Tubb MR. Challenges in the Development of e-Quit worRx: An iPad App for Smoking Cessation Counseling and Shared Decision Making in Primary Care. JMIR Form Res 2019; 3:e11300. [PMID: 30924783 PMCID: PMC6460307 DOI: 10.2196/11300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 01/09/2019] [Accepted: 01/27/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Smoking is the leading preventable cause of morbidity and mortality in the United States, killing more than 450,000 Americans. Primary care physicians (PCPs) have a unique opportunity to discuss smoking cessation evidence in a way that enhances patient-initiated change and quit attempts. Patients today are better equipped with technology such as mobile devices than ever before. OBJECTIVE The aim of this study was to evaluate the challenges in developing a tablet-based, evidence-based smoking cessation app to optimize interaction for shared decision making between PCPs and their patients who smoke. METHODS A group of interprofessional experts developed content and a graphical user interface for the decision aid and reviewed these with several focus groups to determine acceptability and usability in a small population. RESULTS Using a storyboard methodology and subject matter experts, a mobile app, e-Quit worRx, was developed through an iterative process. This iterative process helped finalize the content and ergonomics of the app and provided valuable feedback from both patients and provider teams. Once the app was made available, other technical and programmatic challenges arose. CONCLUSIONS Subject matter experts, although generally amenable to one another's disciplines, are often challenged with effective interactions, including language, scope, clinical understanding, technology awareness, and expectations. The successful development of this app and its evaluation in a clinical setting highlighted those challenges and reinforced the need for effective communications and team building.
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Affiliation(s)
- Charles R Doarn
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Mary Beth Vonder Meulen
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Harini Pallerla
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Shauna P Acquavita
- School of Social Work, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Saundra Regan
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Nancy Elder
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Matthew R Tubb
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH, United States
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Riley AR, Freeman KA. Impacting Pediatric Primary Care: Opportunities and Challenges for Behavioral Research in a Shifting Healthcare Landscape. BEHAVIOR ANALYSIS (WASHINGTON, D.C.) 2019; 19:23-38. [PMID: 31206011 PMCID: PMC6567998 DOI: 10.1037/bar0000114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Behavior analysts have long recognized the potential of a partnership with pediatric medicine as an opportunity to expand the influence of behavior analysis and positively impact population health. Despite significant achievements in this domain, the impact of behavioral science on the daily practice of pediatrics has been limited. In this commentary, the authors argue that the current health care and research environments are ripe for a renewed focus on behavioral modification in pediatric primary care, with a particular emphasis on the study of high-frequency, low-intensity problems. They provide some analysis of why behavioral pediatrics has failed to gain traction in primary care, describe aspects of the current primary care practice and research landscapes that provide opportunities for an expanded portfolio of research, identify several exemplars from the behavior analytic literature that have influenced pediatric primary care or have the potential to do so, and make recommendations for producing influential data.
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Affiliation(s)
- Andrew R Riley
- Institute on Development & Disability, Department of Pediatrics, Oregon Health and Science University
| | - Kurt A Freeman
- Institute on Development & Disability, Department of Pediatrics, Oregon Health and Science University
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Cohen DJ, Dorr DA, Knierim K, DuBard CA, Hemler JR, Hall JD, Marino M, Solberg LI, McConnell KJ, Nichols LM, Nease DE, Edwards ST, Wu WY, Pham-Singer H, Kho AN, Phillips RL, Rasmussen LV, Duffy FD, Balasubramanian BA. Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement. Health Aff (Millwood) 2019; 37:635-643. [PMID: 29608365 DOI: 10.1377/hlthaff.2017.1254] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.
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Affiliation(s)
- Deborah J Cohen
- Deborah J. Cohen ( ) is a professor of family medicine and vice chair of research in the Department of Family Medicine at Oregon Health & Science University, in Portland
| | - David A Dorr
- David A. Dorr is a professor and vice chair of medical informatics and clinical epidemiology, both at Oregon Health & Science University
| | - Kyle Knierim
- Kyle Knierim is an assistant research professor of family medicine and associate director of the Practice Innovation Program, both at the University of Colorado School of Medicine, in Aurora
| | - C Annette DuBard
- C. Annette DuBard is vice president of Clinical Strategy at Aledade, Inc., in Bethesda, Maryland
| | - 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, in New Brunswick, New Jersey
| | - Jennifer D Hall
- Jennifer D. Hall is a research associate in family medicine at Oregon Health & Science University
| | - Miguel Marino
- Miguel Marino is an assistant professor of family medicine at Oregon Health & Science University
| | - Leif I Solberg
- Leif I. Solberg is a senior adviser and director for care improvement research at HealthPartners Institute, in Minneapolis, Minnesota
| | - K John McConnell
- K. John McConnell is a professor of emergency medicine and director of the Center for Health Systems Effectiveness, both at Oregon Health & Science University
| | - Len M Nichols
- Len M. Nichols is director of the Center for Health Policy Research and Ethics and a professor of health policy at George Mason University, in Fairfax, Virginia
| | - Donald E Nease
- Donald E. Nease Jr is an associate professor of family medicine at the University of Colorado School of Medicine, in Aurora
| | - Samuel T Edwards
- Samuel T. Edwards is an assistant research professor 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, Veterans Affairs Portland Health Care System
| | - Winfred Y Wu
- Winfred Y. Wu is clinical and scientific director in the Primary Care Information Project at the New York City Department of Health and Mental Hygiene, in Long Island City, New York
| | - Hang Pham-Singer
- Hang Pham-Singer is senior director of quality improvement in the Primary Care Information Project at the New York City Department of Health and Mental Hygiene
| | - Abel N Kho
- Abel N. Kho is an associate professor and director of the Center for Health Information Partnerships, Northwestern University, in Chicago, Illinois
| | - Robert L Phillips
- Robert L. Phillips Jr is vice president for research and policy at the American Board of Family Medicine, in Washington, D.C
| | - Luke V Rasmussen
- Luke V. Rasmussen is a clinical research associate in the Department of Preventive Medicine, Northwestern University
| | - F Daniel Duffy
- F. Daniel Duffy is professor of medical informatics and internal medicine at the University of Oklahoma School of Community Medicine-Tulsa
| | - Bijal A Balasubramanian
- Bijal A. Balasubramanian is an associate professor in the Department of Epidemiology, Human Genetics, and Environmental Sciences, and regional dean of UTHealth School of Public Health, in Dallas, Texas
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Tran B, Falster M, Jorm L. Claims-based measures of continuity of care have non-linear associations with health: data linkage study. Int J Popul Data Sci 2018; 3:463. [PMID: 34095520 PMCID: PMC8142963 DOI: 10.23889/ijpds.v3i1.463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Continuity of care (CoC) is considered a central element of good primary care and is often measured using medical claims data. Possible values of CoC depend on the number of claims which is related to health status. This study investigated the relationships between CoC and health status and risk of emergency hospitalisation. Methods Health insurance claims for consultations with general practitioners (GPs) in the 24 months following entry to the 45 and Up Study were used to calculate usual provider continuity (UPC) and the Continuity of Care Index (CoC Index). Relationships of CoC with number of claims, self-rated health and emergency hospitalisation were investigated using descriptive statistics and logistic regression models. Results Both measures of CoC were strongly related to number of claims and to measures of health status, which were in turn highly associated. Multivariable logistic regression models showed a weak positive relationship between CoC and odds of emergency hospitalisation for those with CoC less than 1, while individuals with perfect CoC had significantly lower odds of hospitalisation compared to all other categories of CoC. However, analyses stratified by, or adjusting for, number of claims showed no clear associations between CoC and risk of hospitalisation. Conclusions The pattern of association between CoC categories and emergency hospitalisation was non-linear and was confounded by the effect of number of claims. Future studies should apply caution in using claims-based measures of CoC as a continuous variable or employing an arbitrary cut-point, and should adjust for number of claims.
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Affiliation(s)
- Bich Tran
- Centre for Big Data Research in Health, UNSW Australia Sydney NSW 2052, Australia
| | - Michael Falster
- Centre for Big Data Research in Health, UNSW Australia Sydney NSW 2052, Australia
| | - Louisa Jorm
- Centre for Big Data Research in Health, UNSW Australia Sydney NSW 2052, Australia
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Edwards ST, Marino M, Balasubramanian BA, Solberg LI, Valenzuela S, Springer R, Stange KC, Miller WL, Kottke TE, Perry CK, Ono S, Cohen DJ. Burnout Among Physicians, Advanced Practice Clinicians and Staff in Smaller Primary Care Practices. J Gen Intern Med 2018; 33:2138-2146. [PMID: 30276654 PMCID: PMC6258608 DOI: 10.1007/s11606-018-4679-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/06/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Burnout among primary care physicians, advanced practice clinicians (nurse practitioners and physician assistants [APCs]), and staff is common and associated with negative consequences for patient care, but the association of burnout with characteristics of primary care practices is unknown. OBJECTIVE To examine the association between physician-, APC- and staff-reported burnout and specific structural, organizational, and contextual characteristics of smaller primary care practices. DESIGN Cross-sectional analysis of survey data collected from 9/22/2015-6/19/2017. SETTING Sample of smaller primary care practices in the USA participating in a national initiative focused on improving the delivery of cardiovascular preventive services. PARTICIPANTS 10,284 physicians, APCs and staff from 1380 primary care practices. MAIN MEASURE Burnout was assessed with a validated single-item measure. KEY RESULTS Burnout was reported by 20.4% of respondents overall. In a multivariable analysis, burnout was slightly more common among physicians and APCs (physician vs. non-clinical staff, adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI], 1.05-1.49, APC vs. non-clinical staff, aOR = 1.34, 95% CI, 1.10-1.62). Other multivariable correlates of burnout included non-solo practice (2-5 physician/APCs vs. solo practice, aOR = 1.71; 95% CI, 1.35-2.16), health system affiliation (vs. physician/APC-owned practice, aOR = 1.42; 95%CI, 1.16-1.73), and Federally Qualified Health Center status (vs. physician/APC-owned practice, aOR = 1.36; 95%CI, 1.03-1.78). Neither the proportion of patients on Medicare or Medicaid, nor practice-level patient volume (patient visits per physician/APC per day) were significantly associated with burnout. In analyses stratified by professional category, practice size was not associated with burnout for APCs, and participation in an accountable care organization was associated with burnout for clinical and non-clinical staff. CONCLUSIONS Burnout is prevalent among physicians, APCs, and staff in smaller primary care practices. Members of solo practices less commonly report burnout, while members of health system-owned practices and Federally Qualified Health Centers more commonly report burnout, suggesting that practice level autonomy may be a critical determinant of burnout.
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Affiliation(s)
- Samuel T Edwards
- Section of General Internal Medicine, Veterans Affairs (VA) Portland Health Care System, Portland, OR, USA.
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA.
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
- Biostatistics Group, School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR, USA
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX, USA
| | | | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Kurt C Stange
- Center for Community Health Integration, Case Western Reserve University, Cleveland, OH, USA
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | | | - Cynthia K Perry
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
| | - Sarah Ono
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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Misra-Hebert AD, Perzynski A, Rothberg MB, Fox J, Mercer MB, Liu X, Hu B, Aron DC, Stange KC. Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system. J Gen Intern Med 2018; 33:1928-1936. [PMID: 30084018 PMCID: PMC6206362 DOI: 10.1007/s11606-018-4611-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/07/2018] [Accepted: 07/19/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care. OBJECTIVE To identify practice setting components contributing to uptake of new team-based care models. DESIGN Convergent mixed-methods design. PARTICIPANTS Employees and patients of primary care practices implementing two team-based models in a large, integrated health system. MAIN MEASURES Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team. KEY RESULTS Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups-high, partial, and low uptake of new team-based models. Uptake was related to (1) practices' responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices' ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices. CONCLUSION Uptake of new team-based care delivery models is related to practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.
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Affiliation(s)
- Anita D Misra-Hebert
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA. .,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA. .,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Adam Perzynski
- Center for Health Care Research and Policy, Case Western Reserve University at MetroHealth, Cleveland, OH, USA
| | - Michael B Rothberg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jaqueline Fox
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Beth Mercer
- Office of Patient Experience, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaobo Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - David C Aron
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
| | - Kurt C Stange
- Center for Community Health Integration, and Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, Oncology and Sociology, Case Western Reserve University, Cleveland, OH, USA
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