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Weppner WG, Singh MK, Wipf JE, Shunk R, Woodard L, Brienza R. Culture change and lessons learned from ten years in the VA centers of excellence in primary care education. BMC MEDICAL EDUCATION 2024; 24:457. [PMID: 38671440 PMCID: PMC11047004 DOI: 10.1186/s12909-024-05390-6] [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: 11/07/2023] [Accepted: 04/03/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Team-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments. METHODS A review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home design RESULTS: Each site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration. CONCLUSIONS Aligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training. TRIAL REGISTRATION This evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.
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Affiliation(s)
- William G Weppner
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA.
- School of Medicine, University of Washington, Boise VAMC, MSO-111, 500 W. Fort St, 83702; 208.695.0454, Boise, ID, USA.
| | - Mamta K Singh
- Primary Care Service, VA Northeast Ohio Health Care System, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Joyce E Wipf
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Rebecca Shunk
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - LeChauncy Woodard
- Tilman J. Fertitta Family College of Medicine, Humana Integrated Health System Sciences Institute, University of Houston, Houston, TX, USA
| | - Rebecca Brienza
- Division of General Internal Medicine, Yale School of Medicine, West Haven, CT, USA
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Salm C, Mentzel A, Sofroniou M, Metzner G, Farin E, Voigt-Radloff S, Maun A. Analysis of the key themes in the healthcare of older people with multimorbidity in Germany: a framework analysis as part of the LoChro trial. BMJ Open 2023; 13:e069814. [PMID: 37527899 PMCID: PMC10394557 DOI: 10.1136/bmjopen-2022-069814] [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] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES Multimorbidity challenges healthcare systems. In Germany, coordination of healthcare for older multimorbid patients remains unstructured.This study aims to identify key themes in the healthcare of these patients and the inter-relationships between them. DESIGN Framework analysis of six cases based on 1-year data of primary and secondary care, patient-answered questionnaires and video material. SETTING Southern Germany. PARTICIPANTS Six multimorbid older patients participating in a randomised controlled trial that compared usual care with a local, collaborative, stepped and personalised care management approach for older people with chronic diseases (LoChro-trial). The LoChro care intervention involved a care manager who assisted participants in self-management. The primary outcome was a composite of functional health and depressive symptoms at 12 and 18 months. The LoChro-intervention had no effect on the primary outcome. PRIMARY OUTCOME MEASURE Key themes in the healthcare of older patients with multimorbidity and the inter-relationships between them. METHODS One-year data included diagnoses, treatment plans, examinations, assessments and discharge reports. Patient perspectives were assessed using the Patient Assessment of Chronic Illness Care. In three cases, videos of the LoChro intervention showed patients describing their health needs. These data were evaluated by three doctors and public health researchers. Using framework analysis, recurring themes influencing the healthcare situation of multimorbid older patients and their inter-relationships were identified. RESULTS Participants had an average age of 77, with 13 diagnoses, taking eight medications regularly. The five key themes describing the healthcare situation of these multimorbid patients were as follows: insufficient coordination, overuse and underuse of medical care, doctor and patient roles. Each theme covered three to four subcategories. The most significant inter-relationships between these themes were a lack of coordination leading to overuse and underuse of medical care. These were characterised by redundant inpatient stays, potential prescribing omissions and missed examinations. Deficiencies in vaccinations and secondary prevention were also demonstrated. CONCLUSION Coordination of care for multimorbid older patients in Germany is still deficient. Future healthcare arrangements should be explored with the participation of physicians and patients. TRIAL REGISTRATION NUMBER LoChro trial: DRKS00013904.
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Affiliation(s)
- Claudia Salm
- Institute of General Practice/Family Medicine, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Anja Mentzel
- Institute of General Practice/Family Medicine, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Mario Sofroniou
- Institute of General Practice/Family Medicine, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Gloria Metzner
- Section of Health Care Research and Rehabilitation Research, Institute of Medical Biometry and Statistics, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Erik Farin
- Section of Health Care Research and Rehabilitation Research, Institute of Medical Biometry and Statistics, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Sebastian Voigt-Radloff
- Section of Health Care Research and Rehabilitation Research, Institute of Medical Biometry and Statistics, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
- Center for Geriatric Medicine and Gerontology Freiburg, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Andy Maun
- Institute of General Practice/Family Medicine, Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Germany
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Ezell JM, Hamdi S, Borrero N. Approaches to Addressing Nonmedical Services and Care Coordination Needs for Older Adults. Res Aging 2021; 44:323-333. [PMID: 34291677 DOI: 10.1177/01640275211033929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Non-medical services care coordination for daily activities of living is crucial in improving older adults' health and enabling them to age in place, but little is known about specific practices and barriers in this space. METHODS Semi-structured interviews were conducted with 41 professionals serving older adults in greater Chicago, Illinois-which consists of diverse urban, suburban, and semi-rural communities-to contextualize non-medical services needs and care coordination processes. RESULTS In-home care, home-delivered meals, non-emergency transportation, and housing support were cited as the most commonly needed services, all requiring complex coordination support. Respondents noted a reliance on inefficient phone/fax usage for referral-making and cited major challenges in inter-professional communication, service funding/reimbursement, and HIPAA. CONCLUSIONS Non-medical services delivery for older adults is severely impacted by general siloing throughout the care continuum. Interventions are needed to enhance communication pathways and improve the salience and interdisciplinarity of non-medical services coordination for this population.
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Affiliation(s)
- Jerel M Ezell
- Africana Studies and Research Center, Cornell University, Ithaca, NY, USA.,Cornell Center for Health Equity, Cornell University, Ithaca, NY, USA
| | - Samiha Hamdi
- Department of Global Development, Cornell University, Ithaca, NY, USA
| | - Natasha Borrero
- Department of Family and Social Medicine, Montefiore Medical System, Bronx, NY, USA
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Bilazarian A, Hovsepian V, Kueakomoldej S, Poghosyan L. A Systematic Review of Primary Care and Payment Models on Emergency Department Use in Patients Classified as High Need, High Cost. J Emerg Nurs 2021; 47:761-777.e3. [PMID: 33744017 DOI: 10.1016/j.jen.2021.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/21/2021] [Accepted: 01/28/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Reducing costly and harmful ED use by patients classified as high need, high cost is a priority across health care systems. The purpose of this systematic review was to evaluate the impact of various primary care and payment models on ED use and overall costs in patients classified as high need, high cost. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search was performed from January 2000 to March 2020 in 3 databases. Two reviewers independently appraised articles for quality. Studies were eligible if they evaluated models implemented in the primary care setting and in patients classified as high need, high cost in the United States. Outcomes included all-cause and preventable ED use and overall health care costs. RESULTS In the 21 articles included, 4 models were evaluated: care coordination (n = 8), care management (n = 7), intensive primary care (n = 4), and alternative payment models (n = 2). Statistically significant reductions in all-cause ED use were reported in 10 studies through care coordination, alternative payment models, and intensive primary care. Significant reductions in overall costs were reported in 5 studies, and 1 reported a significant increase. Care management and care coordination models had mixed effects on ED use and overall costs. DISCUSSION Studies that significantly reduced ED use had shared features, including frequent follow-up, multidisciplinary team-based care, enhanced access, and care coordination. Identifying primary care models that effectively enhance access to care and improve ongoing chronic disease management is imperative to reduce costly and harmful ED use in patients classified as high need, high cost.
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Fujino H, Matsumura T, Saito T, Fujimura H, Imura O. Psychological Case Conference Following the Death of a Patient With Neuromuscular Disease: A Source of Emotional Support for Participating Medical Staff. J Patient Exp 2020; 7:713-716. [PMID: 33294606 PMCID: PMC7705834 DOI: 10.1177/2374373519892413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Healthcare professionals involved in the treatment and care of patients with intractable diseases, such as muscular dystrophy, increasingly encounter situations that can elicit emotional distress for them as well as the patients. Therefore, medical professionals also need support. This article describes a psychological case conference of multidisciplinary professionals involved in the treatment of a deceased patient with Duchenne muscular dystrophy. The conference aimed to support medical professionals in reflecting on and sharing their thoughts, feelings, and conflicts. Such a practice could support medical professionals in reflecting patients' thoughts and sharing their personal experiences with other staff members, which may alleviate emotional and personal conflicts. Reflecting on their interactions and dealings with patients serves this supportive function. Psychological case conferences for medical staff may serve as an opportunity for participants to feel emotionally supported and may perhaps help prevent burnout.
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Affiliation(s)
- Haruo Fujino
- Department of Special Needs Education, Oita University, Oita, Japan.,Graduate School of Human Sciences, Osaka University, Osaka, Japan
| | - Tsuyoshi Matsumura
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center, Osaka, Japan
| | - Toshio Saito
- Division of Child Neurology, National Hospital Organization Osaka Toneyama Medical Center, Toyonaka, Osaka, Japan
| | - Harutoshi Fujimura
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center, Osaka, Japan
| | - Osamu Imura
- Graduate School of Human Sciences, Osaka University, Osaka, Japan.,Faculty of Social Studies, Nara University, Nara, Japan
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Bilazarian A. High-need high-cost patients: A Concept Analysis. Nurs Forum 2020; 56:127-133. [PMID: 32851669 DOI: 10.1111/nuf.12500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/05/2020] [Accepted: 08/16/2020] [Indexed: 11/28/2022]
Abstract
High-need high-cost (HNHC) patients are variously defined in the literature as the small subset of the population who account for the majority of US health care costs. Lack of consensus on the defining attributes of HNHC patients has challenged the effectiveness of interventions aimed to improve disease management and reduce costs. Guided by the Walker and Avant method of concept analysis, a literature review of 2 databases (PubMed and CINAHL) was conducted. Three main subgroups of HNHC patients were identified: adults with multiple chronic conditions and functional disability, the frail elderly, and patients under 65 years old with a disability or behavioral health condition. HNHC patients are categorized by a feedback loop of acute-on-chronic health conditions, preventable health service utilization, and fragmented care. Antecedents that predispose becoming a HNHC patient include challenges accessing timely care, low socioeconomic status, unmet support, and social factors such as isolation and inadequate.
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Affiliation(s)
- Ani Bilazarian
- Columbia University School of Nursing, New York, New York, USA
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Sheinfeld Gorin S, Haggstrom D. The coordination of chronic care: an introduction. Transl Behav Med 2018. [DOI: 10.1093/tbm/iby048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sherri Sheinfeld Gorin
- New York Physicians against Cancer (NYPAC), New York, NY, USA
- The University of Michigan, Ann Arbor, MI, USA
| | - David Haggstrom
- VA HSR&D Center for Health Information and Communication, Indianapolis, IN, USA
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
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