Comparing the implementation of team approaches for improving diabetes care in community health centers

Contains fulltext : 139071.pdf (publisher's version ) (Open Access)BackgroundPatient panel management and community-based care management may be viable strategies for community health centers to improve the quality of diabetes care for vulnerable patient populations. The objective of our study was to clarify implementation processes and experiences of integrating office-based medical assistant (MA) panel management and community health worker (CHW) community-based management into routine care for diabetic patients.MethodsMixed methods study with interviews and surveys of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health coaching for improving diabetes care. Participants included 24 key informants in five role categories and 249 clinicians and staff survey respondents from 14 participating practices. We conducted thematic analyses of key informant interview transcripts to clarify implementation processes and describe barriers to integrating the new roles into practice. We surveyed clinicians and staff to assess differences in practice culture among intervention and control groups. We triangulated findings to identify concordant and disparate results across data sources.ResultsImplementation processes and experiences varied considerably among the practices implementing CHW and MA team-based approaches, resulting in differences in the organization of health coaching and self-management support activities. Importantly, CHW and MA responsibilities converged over time to focus on health coaching of diabetic patients. MA health coaches experienced difficulty in allocating dedicated time due to other MA responsibilities that often crowded out time for diabetic patient health coaching. Time constraints also limited the personal introduction of patients to health coaches by clinicians. Participants highlighted the importance of a supportive team climate and proactive leadership as important enablers for MAs and CHWs to implement their health coaching responsibilities and also promoted professional growth.ConclusionImplementation of team-based strategies to improve diabetes care for vulnerable populations was diverse, however all practices converged in their foci on health coaching roles of CHWs and MAs. Our study suggests that a flexible approach to implementing health coaching is more important than fidelity to rigid models that do not allow for variable allocation of responsibilities across team members. Clinicians play an instrumental role in supporting health coaches to grow into their new patient care responsibilities

A positive deviance approach to understanding key features to improving diabetes care in the medical home

Contains fulltext : 118403.pdf (publisher's version ) (Open Access)PURPOSE The medical home has gained national attention as a model to reorganize primary care to improve health outcomes. Pennsylvania has undertaken one of the largest state-based, multipayer medical home pilot projects. We used a positive deviance approach to identify and compare factors driving the care models of practices showing the greatest and least improvement in diabetes care in a sample of 25 primary care practices in southeast Pennsylvania. METHODS We ranked practices into improvement quintiles on the basis of the average absolute percentage point improvement from baseline to 18 months in 3 registry-based measures of performance related to diabetes care: glycated hemoglobin concentration, blood pressure, and low-density lipoprotein cholesterol level. We then conducted surveys and key informant interviews with leaders and staff in the 5 most and least improved practices, and compared their responses. RESULTS The most improved/higher-performing practices tended to have greater structural capabilities (eg, electronic health records) than the least improved/lower-performing practices at baseline. Interviews revealed striking differences between the groups in terms of leadership styles and shared vision; sense, use, and development of teams; processes for monitoring progress and obtaining feedback; and presence of technologic and financial distractions. CONCLUSIONS Positive deviance analysis suggests that primary care practices' baseline structural capabilities and abilities to buffer the stresses of change may be key facilitators of performance improvement in medical home transformations. Attention to the practices' structural capabilities and factors shaping successful change, especially early in the process, will be necessary to improve the likelihood of successful medical home transformation and better care

Satisfied to death: a spurious result?

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A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies

Recent developments in health reform related to the passage of the Affordable Care Act and ensuing regulations encourage delivery systems to engage in shared decision making, in which patients and providers together make health care decisions that are informed by medical evidence and tailored to the specific characteristics and values of the patient. To better understand how delivery systems can implement shared decision making, we interviewed representatives of eight primary care sites participating in a demonstration funded and coordinated by the Informed Medical Decisions Foundation. Barriers to shared decision making included overworked physicians, insufficient provider training, and clinical information systems incapable of prompting or tracking patients through the decision-making process. Methods to improve shared decision making included using automatic triggers for the distribution of decision aids and engaging team members other than physicians in the process. We conclude that substantial investments in provider training, information systems, and process reengineering may be necessary to implement shared decision making successfully

Effect of a multipayer patient-centered medical home on health care utilization and quality: the rhode island chronic care sustainability initiative pilot program

Item does not contain fulltextIMPORTANCE The patient-centered medical home is advocated to reduce health care costs and improve the quality of care. OBJECTIVE To evaluate the effects of the pilot program of a multipayer patient-centered medical home on health care utilization and quality. DESIGN An interrupted time series design with propensity score-matched comparison practices, including multipayer claims data from 2 years before (October 1, 2006-September 30, 2008) and 2 years after (October 1, 2008-September 30, 2010) the launch of the pilot program. Uptake of the intervention was measured with audit data from the National Committee for Quality Assurance patient-centered medical home recognition process. SETTING Five independent primary care practices and 3 private insurers in the Rhode Island Chronic Care Sustainability Initiative. PARTICIPANTS Patients in 5 pilot and 34 comparison practices. INTERVENTIONS Financial support, care managers, and technical assistance for quality improvement and practice transformation. MAIN OUTCOMES AND MEASURES Hospital admissions, emergency department visits, and 6 process measures of quality of care (3 for diabetes mellitus and 3 for colon, breast, and cervical cancer screening). RESULTS The mean National Committee for Quality Assurance recognition scores of the pilot practices increased from 42 to 90 points of a possible 100 points. The pilot and comparison practices had statistically indistinguishable baseline patient characteristics and practice patterns, except for higher numbers of attributed member months per year in the pilot practices (31 130 per practice vs 14 779, P = .01) and lower rates of cervical cancer screening in the comparison practices. Although estimates of the emergency department visits and inpatient admissions of patients in the pilot practices trended toward lower utilization, the only significant difference was a lower rate of ambulatory care sensitive emergency department visits in the pilot practices. The Chronic Care Sustainability Initiative pilot program was associated with a reduction in ambulatory care-sensitive emergency department visits of approximately 0.8 per 1000 member months or approximately 11.6% compared with the baseline rate of 6.9 for emergency department visits per 1000 member months (P = .002). No significant improvements were found in any of the quality measures. CONCLUSION AND RELEVANCE After 2 years, a pilot program of a patient-centered medical home was associated with substantial improvements in medical home recognition scores and a significant reduction in ambulatory care sensitive emergency department visits. Although not achieving significance, there were downward trends in emergency department visits and inpatient admissions

Development and Psychometric Analysis of the Revised Patient Perceptions of Integrated Care Survey

This article describes the development and psychometric testing of the Patient Perceptions of Integrated Care (PPIC 2.1) survey, which we administered to 12,364 Medicare beneficiaries who received treatment from 150 randomly selected physician organizations, receiving 3,067 responses (26%). Psychometric analyses, performed using two methods to adjust for respondent inherent optimism (as a measure of response tendency), supported a 6-factor, 22-item model with excellent fit. These factors were (1) Staff Knowledge about the Patient's Medical History, (2) Provider Support for the Patient's Self-Directed Care, (3) Test Result Communication, (4) Provider Knowledge of the Patient, (5) Provider Support for Medication Adherence and Home Health Management, and (6) Specialist Knowledge about the Patient's Medical History. Per Spearman-Brown prophesy calculations, reliability would exceed 0.7 for all factors at 33 or more responses per organization. The PPIC 2.1 survey can distinguish six dimensions of integrated patient care with high physician organization-level reliability at reasonable sample sizes