92 research outputs found

    Understanding primary care-oncology relationships within a changing healthcare environment.

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    BACKGROUND: Management of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment. METHODS: Through a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10-12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive immersion/crystallization analysis process. RESULTS: Nine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond. CONCLUSIONS: With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships

    Environmental and Contextual Differences Affecting Cervical Cancer Survivorship in Hispanic Women in Three Texas Counties

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    Context: Cervical cancer is preventable and curable, yet Hispanic populations in certain areas of the country have higher mortality rates from invasive cervical cancer than non-Hispanic white women. Objective: Our study aims to identify contextual and environmental features at the county level that are acting as barriers or facilitators of cervical cancer long-term survival in Hispanic women. Study Design: This is a mixed methods exploratory study utilizing fRAP (focused Rapid Assessment Process) methodology to uncover modifiable differences in cervical cancer survivorship contributing to mortality differences. We investigate multi-level community, medical and policy contextual elements within a county through both quantitative GIS mapping of ZCTA level data linked to fieldwork and key informant interviews. This poster highlights the qualitative Phase II of our methods, including participant observation in three Texas counties. Setting or Dataset: Phase II of fRAP includes qualitative data collected by the lead author during fieldwork from three Texas counties. Counties chosen for inclusion in the study due to differences in mortality rates between Hispanic and non-Hispanic white women were identified during Phase I GIS mapping of the study. They include Bexar, Dallas and Tarrant, all of which hold a unique disparity profile based on mortality rates. Population studied: Participants for key informant interviews identified during fieldwork visits to each county and stratified by level of interest: community, medical systems, policy, e.g. a community resource executive director, a practicing gynecologic oncologist and a county-level payment plan manager. Outcome Measures: Qualitative transcripts analyzed for themes across levels within a county, and across counties based on level. Results: Research to date has uncovered modifiable environmental and contextual differences within each of the three Texas counties contributing to how Hispanic cervical cancer survivors experience care. Outcomes to be Reported: Cross comparison of themes within a county across multiple levels and across counties within levels will allow us to identify environmental and contextual features unique to each of the three counties that contribute to their particular cervical cancer disparity profile seen on mapping. Next stages of fRAP include evaluation of modifiable features found for possible policy change targets to address disparities in care

    Shifting Implementation Science Theory to Empower Primary Care Practices.

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    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 fro

    Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions.

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    Background: Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients\u27 needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective: The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods: Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach. Results: Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team\u27s production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team\u27s activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion: The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes

    Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension.

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    Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services

    Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries.

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    Background: Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. Objective: To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. Methods: An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. Results: Seven common levers influence a jurisdiction\u27s ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations\u27 attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. Conclusion: The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC

    Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices

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    PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from −28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system–owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models

    A mixed-methods analysis of the capacity of the Patient-Centered Medical Home to implement care coordination services for cancer survivors.

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    There are currently 15.5 million cancer survivors in USA who are increasingly relying on primary care providers for their care. Patient-Centered Medical Homes (PCMHs) have the potential to meet the unique needs of cancer survivors; but, few studies have examined PCMH attributes as potential resources for delivering survivorship care. This study assesses the current care coordination infrastructure in advanced PCMHs, known to be innovative, and explores their capacity to provide cancer survivorship care. We conducted comparative case studies of a purposive sample (n = 9) of PCMHs to examine current care coordination infrastructure and capacity through a mixed- methods analysis. Data included qualitative interviews, quantitative surveys, and fieldnotes collected during 10- to 12-day onsite observations at each practice. Case studies included practices in five states with diverse business models and settings. Eight of the nine practices had National Committee for Quality Assurance Level 3 PCMH recognition. No practices had implemented a systematic approach to cancer survivorship care. We found all practices had a range of electronic population health management tools, care coordinator roles in place for chronic conditions, and strategies or protocols for tracking and managing complex disease groups. We identified potential capacity, as well as barriers, to provide cancer survivorship care using existing care coordination infrastructure developed for other chronic conditions. This existing infrastructure suggests the potential to translate care coordination elements within primary care settings to accelerate the implementation of systematic survivorship care
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