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Sandesara UN, Carson SL, Dopp A, Perez LG, Sadia A, Wali S, Park NJ, Casillas A, Kim G, Morales MG, Ntekume E, Song S, Gandhi P, Wafford T, Brown AF. Community and Healthcare Perspectives on Implementing Hypertension Interventions for a Multiethnic Safety-Net Population. Ethn Dis 2023; DECIPHeR:68-80. [PMID: 38846736 PMCID: PMC11099525 DOI: 10.18865/ed.decipher.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Objective To synthesize community and healthcare informants' perspectives on contextual considerations and tailoring recommendations for high-quality, sustainable implementation of evidence-based practices (EBPs) for managing hypertension (HTN) in a multiethnic safety-net population. Design Structured focus-group discussions and semistructured qualitative interviews. Background High-quality, sustainable implementation of HTN-related EBPs can promote equitable care. Implementation challenges extend beyond individual patients to span multiple levels of context. Few studies have systematically engaged community and healthcare perspectives to inform the design of HTN intervention trials. Setting A large safety-net healthcare system. Participants/Methods We conducted four structured discussions with each of five race- or ethnicity-specific community action boards (CABs) to understand community members' HTN-related norms, assets, needs, and experiences across local healthcare systems. We interviewed 41 personnel with diverse roles in our partnered healthcare system to understand the system's HTN-related strengths and needs. We solicited EBP tailoring recommendations from both groups. We summarized the findings using rapid content analysis. Results Participants identified contextual considerations spanning seven themes: social determinants, healthcare engagement, clinical interaction, system operations, standardization, patient education, and partnerships and funding. They offered tailoring recommendations spanning nine themes: addressing complex contexts, addressing social needs, system operations, healthcare system training and resources, linguistic and cultural tailoring, behavioral engagement, relational engagement, illness-course engagement, and community partnerships. Conclusions Engaging community and healthcare informants can ground implementation in the policy, community, healthcare system, clinical, and interpersonal contexts surrounding diverse patients at risk for disparities. Such grounding can reframe inequitable implementation as a multilevel social problem facing communities and healthcare systems, rather than individuals.
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Affiliation(s)
- Utpal N. Sandesara
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
| | - Savanna L. Carson
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
| | - Alex Dopp
- Department of Behavioral and Policy Sciences, RAND Corporation, Santa Monica, CA
| | - Lilian G. Perez
- Department of Behavioral and Policy Sciences, RAND Corporation, Santa Monica, CA
| | - Atkia Sadia
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
| | - Soma Wali
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA
| | - Nina J. Park
- Department of Population Health Management, Los Angeles County Department of Health Services, Los Angeles, CA
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
| | - Gloria Kim
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
| | - Maria G. Morales
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
| | - Ejiro Ntekume
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
| | - Sarah Song
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | | | - Tony Wafford
- I Choose Life Health and Wellness Center, Inglewood, CA
| | - Arleen F. Brown
- Division of General Internal Medicine and Health Services Research, University of California—Los Angeles, Los Angeles, CA
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Walker TR, Bochner RE, Alaiev D, Talledo J, Tsega S, Krouss M, Cho HJ. Reducing low-value ED coags across 11 hospitals in a safety net setting. Am J Emerg Med 2023; 73:88-94. [PMID: 37633078 DOI: 10.1016/j.ajem.2023.08.016] [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: 04/03/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Prothrombin/international normalized ratio and activated partial thromboplastin time (PT/INR and aPTT) are frequently ordered in emergency departments (EDs), but rarely affect management. They offer limited utility outside of select indications. Several quality improvement initiatives have shown reduction in ED use of PT/INR and aPTT using multifaceted interventions in well-resourced settings. Successful reduction of these low-value tests has not yet been shown using a single intervention across a large hospital system in a safety net setting. This study aims to determine if an intervention of two BPAs is associated with a reduction in PT/INR and aPTT usage across a large safety net system. METHODS This initiative was set at a large safety net system in the United States with 11 acute care hospitals. Two Best Practice Advisories (BPAs) discouraging inappropriate PT/INR and aPTT use were implemented from March 16, 2022-August 30, 2022. Order rate per 100 ED patients during the pre-intervention period was compared to the post-intervention period on both the system and individual hospital level. Complete blood count (CBC) testing served as a control, and packed red blood cell transfusions served as a balancing measure. An interrupted time series regression analysis was performed to capture immediate and temporal changes in ordering for all tests in the pre and post-intervention periods. RESULTS PT/INR tests exhibited an absolute decline of 4.11 tests per 100 ED encounters (95% confidence interval -5.17 to -3.05; relative reduction of 18.9%). aPTT tests exhibited absolute decline of 4.03 tests per 100 ED encounters (95% CI -5.10 to -2.97; relative reduction of 19.8%). The control measure, CBC, did not significantly change (-0.43, 95% CI -2.83 to 1.96). Individual hospitals showed variable response, with absolute reductions from 2.02 to 9.6 tests per 100 ED encounters for PT/INR (relative reduction 12.1%-30.5%) and 2.07 to 10.04 for aPTT (relative reduction 12.1%-31.4%). Regression analysis showed that the intervention caused an immediate 25.7% decline in PT/INR and 24.7% decline in aPTT tests compared to the control measure. The slope differences (rate of order increase pre vs post intervention) did not significantly decline compared to the control. CONCLUSIONS This BPA intervention reduced PT/INR and aPTT use across 11 EDs in a large, urban, safety net system. Further study is needed in implementation to other non-safety net settings.
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Affiliation(s)
- Talia R Walker
- NYC Health + Hospitals/Lincoln, Department of Emergency Medicine, 234 E 149th Street, Bronx, NY 10451, United States of America.
| | - Risa E Bochner
- NYC Health + Hospitals/Harlem, Department of Pediatrics, 506 Lenox Ave, New York, NY 10037, United States of America.
| | - Daniel Alaiev
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America.
| | - Joseph Talledo
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America.
| | - Surafel Tsega
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America; NYC Health + Hospitals/Kings County, Department of Internal Medicine, 451 Clarkson Avenue, Brooklyn, NY 11203, United States of America.
| | - Mona Krouss
- NYC Health + Hospitals, Department of Quality & Safety, 50 Water Street, 16(th) Floor, New York, NY, United States of America; NYC Health + Hospitals/Elmhurst, Department of Internal Medicine, 79-01 Broadway, Elmhurst, NY 11373, United States of America.
| | - Hyung J Cho
- Brigham and Women's Hospital, Department of Quality & Safety, 75 Francis St, Boston, MA 02115, United States of America
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Wang MC, Bangaru S, Zhou K. Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective. Healthcare (Basel) 2023; 11:2725. [PMID: 37893800 PMCID: PMC10606794 DOI: 10.3390/healthcare11202725] [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: 09/01/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease-including end-stage manifestations of cirrhosis and liver cancer-is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings.
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Affiliation(s)
- Mark C Wang
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Saroja Bangaru
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
| | - Kali Zhou
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Los Angeles General Medical Center, Los Angeles, CA 90033, USA
- Research Center for Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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Ochoa-Dominguez CY, Chan RY, Cervantes L, Banegas MP, Miller KA. Social support experiences of hispanic/latino parents of childhood cancer survivors in a safety-net hospital: a qualitative study. J Psychosoc Oncol 2023; 42:398-411. [PMID: 37787073 PMCID: PMC10987392 DOI: 10.1080/07347332.2023.2259365] [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: 10/04/2023]
Abstract
PURPOSE To describe the social support experiences of Hispanic/Latino parents while caregiving for childhood cancer survivors. RESEARCH APPROACH Semi-structured one-on-one interviews were conducted among 15 caregivers from a safety-net hospital in Los Angeles. A thematic analysis approach was used to analyze data. FINDINGS The positive influence of social support throughout their caregiving experience included (1) sharing information-enhanced knowledge, (2) receiving comfort and encouragement, (3) receiving tangible assistance reducing the caregiving burden, and (4) enhancing caregiving empowerment/self-efficacy. Sub-themes regarding the lack of social support included (1) being a single parent and (2) family and friends withdrawing after the child's cancer diagnosis. CONCLUSION We found Hispanic/Latino parents strongly value social support as it enables them to have essential resources that support caregiving for their child and themselves. Efforts should ensure that caregivers are routinely screened to identify their supportive needs so that support services for caregivers can be optimized and tailored, as those with a lack of social support may experience excessive caregiver burden.
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Affiliation(s)
- Carol Y. Ochoa-Dominguez
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Randall Y. Chan
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lissette Cervantes
- Department of Medicine, Division of Hospital Medicine, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Matthew P. Banegas
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Kimberly A. Miller
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Leuchter RK, Sarkisian CA, Trotzky-Sirr R, Wei EK, Carrillo CA, Vangala S, Coffey C, Spellberg B, Melamed O, Jeng AC, Mafi JN. Choosing Wisely interventions to reduce antibiotic overuse in the safety net. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:488-496. [PMID: 37870542 PMCID: PMC10994234 DOI: 10.37765/ajmc.2023.89367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVES Physician pay-for-performance (P4P) programs frequently target inappropriate antibiotics. Yet little is known about P4P programs' effects on antibiotic prescribing among safety-net populations at risk for unintended harms from reducing care. We evaluated effects of P4P-motivated interventions to reduce antibiotic prescriptions for safety-net patients with acute respiratory tract infections (ARTIs). STUDY DESIGN Interrupted time series. METHODS A nonrandomized intervention (5/28/2015-2/1/2018) was conducted at 2 large academic safety-net hospitals: Los Angeles County+University of Southern California (LAC+USC) and Olive View-UCLA (OV-UCLA). In response to California's 2016 P4P program to reduce antibiotics for acute bronchitis, 5 staggered Choosing Wisely-based interventions were launched in combination: audit and feedback, clinician education, suggested alternatives, procalcitonin, and public commitment. We also assessed 5 unintended effects: reductions in Healthcare Effectiveness Data and Information Set (HEDIS)-appropriate prescribing, diagnosis shifting, substituting antibiotics with steroids, increasing antibiotics for ARTIs not penalized by the P4P program, and inappropriate withholding of antibiotics. RESULTS Among 3583 consecutive patients with ARTIs, mean antibiotic prescribing rates for ARTIs decreased from 35.9% to 22.9% (odds ratio [OR], 0.60; 95% CI, 0.39-0.93) at LAC+USC and from 48.7% to 27.3% (OR, 0.81; 95% CI, 0.70-0.93) at OV-UCLA after the intervention. HEDIS-inappropriate prescribing rates decreased from 28.9% to 19.7% (OR, 0.69; 95% CI, 0.39-1.21) at LAC+USC and from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at OV-UCLA. There was no evidence of unintended consequences. CONCLUSIONS These real-world multicomponent interventions responding to P4P incentives were associated with substantial reductions in antibiotic prescriptions for ARTIs in 2 safety-net health systems without unintended harms.
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Affiliation(s)
- Richard K Leuchter
- Division of General Internal Medicine & Health Services Research, Department of Internal Medicine, David Geffen School of Medicine at UCLA, 1100 Glendon Ave, Ste 726, Los Angeles, CA 90024.
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Chen JC, Gutierrez G, Kamran R, Terry J, Telliyan A, Zaks C, Carson SL, Brown A, Kim K. Evaluation of COVID-19 vaccine implementation in a large safety net health system. FRONTIERS IN HEALTH SERVICES 2023; 3:1152523. [PMID: 37342796 PMCID: PMC10277563 DOI: 10.3389/frhs.2023.1152523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023]
Abstract
Objectives To evaluate rapid COVID-19 vaccine clinic implementation from January-April 2021 in the Los Angeles County Department of Health Services (LACDHS), the second-largest US safety net health system. During initial vaccine clinic implementation, LACDHS vaccinated 59,898 outpatients, 69% of whom were Latinx (exceeding the LA County Latinx population of 46%). LACDHS is a unique safety net setting to evaluate rapid vaccine implementation due to system size, geographic breadth, language/racial/ethnic diversity, limited health staffing resources, and socioeconomic complexity of patients. Methods Implementation factors were assessed through semi-structured interviews of staff from all twelve LACDHS vaccine clinics from August-November 2021 using the Consolidated Framework for Implementation Research (CFIR) and themes analyzed using rapid qualitative analysis. Results Of 40 potential participants, 25 health professionals completed an interview (27% clinical providers/medical directors, 23% pharmacist, 15% nursing staff, and 35% other). Qualitative analysis of participant interviews yielded ten narrative themes. Implementation facilitators included bidirectional communication between system leadership and clinics, multidisciplinary leadership and operations teams, expanded use of standing orders, teamwork culture, use of active and passive communication structures, and development of patient-centered engagement strategies. Barriers to implementation included vaccine scarcity, underestimation of resources needed for patient outreach, and numerous process challenges encountered. Conclusion Previous studies focused on robust advance planning as a facilitator and understaffing and high staff turnover as barriers to implementation in safety net health systems. This study found facilitators that can mitigate lack of advance planning and staffing challenges present during public health emergencies such as the COVID-19 pandemic. The ten identified themes may inform future implementations in safety net health systems.
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Affiliation(s)
- Jennifer C. Chen
- Ambulatory Care Network, Los Angeles County Department of Health Services, Los Angeles, CA, United States
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Griselda Gutierrez
- Harbor-UCLA Medical Center, Los Angeles County Department of Health Services, Los Angeles, CA, United States
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Rachel Kamran
- Fielding School of Public Health Graduate Program, University of California, Los Angeles, CA, United States
| | - Jill Terry
- Pharmacy Affairs, Los Angeles County Department of Health Services, Los Angeles, CA, United States
- Adjunct Faculty, USC School of Pharmacy, Los Angeles, CA, United States
| | - Armenui Telliyan
- Adjunct Nursing Faculty, Glendale Community College, Glendale, CA, United States
- Adjunct Nursing Faculty, West Coast University, Los Angeles, CA, United States
| | - Camilo Zaks
- Division of Street Medicine, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Savanna L. Carson
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Arleen Brown
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Karen Kim
- Population Health Management, Los Angeles County Department of Health Services, Los Angeles, CA, United States
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Tamlyn AL, Tjilos M, Bosch NA, Barnett KG, Perkins RB, Walkey A, Assoumou SA, Linas BP, Drainoni M. At the intersection of trust and mistrust: A qualitative analysis of motivators and barriers to research participation at a safety-net hospital. Health Expect 2023; 26:1118-1126. [PMID: 36896842 PMCID: PMC10154811 DOI: 10.1111/hex.13726] [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] [Received: 11/14/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 03/11/2023] Open
Abstract
INTRODUCTION The underrepresentation of Black, Indigenous, and People of Color (BIPOC) individuals in healthcare research limits generalizability and contributes to healthcare inequities. Existing barriers and attitudes toward research participation must be addressed to increase the representation of safety net and other underserved populations. METHODS We conducted semi-structured qualitative interviews with patients at an urban safety net hospital, focusing on facilitators, barriers, motivators, and preferences for research participation. We conducted direct content analysis guided by an implementation framework and used rapid analysis methods to generate final themes. RESULTS We completed 38 interviews and identified six major themes related to preferences for engagement in research participation: (1) wide variation in research recruitment preferences; (2) logistical complexity negatively impacts willingness to participate; (3) risk contributes to hesitation toward research participation; (4) personal/community benefit, interest in study topic, and compensation serve as motivators for research participation; (5) continued participation despite reported shortcomings of informed consent process; and (6) mistrust could be overcome by relationship or credibility of information sources. CONCLUSION Despite barriers to participation in research studies among safety-net populations, there are also facilitators that can be implemented to increase knowledge and comprehension, ease of participation, and willingness to join research studies. Study teams should vary recruitment and participation methods to ensure equal access to research opportunities. PATIENT/PUBLIC CONTRIBUTION Our analysis methods and study progress were presented to individuals within the Boston Medical Center healthcare system. Through this process community engagement specialists, clinical experts, research directors, and others with significant experience working with safety-net populations supported data interpretation and provided recommendations for action following the dissemination of data.
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Affiliation(s)
| | - Maria Tjilos
- Boston Medical Center, Section of Infectious DiseaseBostonMAUSA
| | - Nicholas A. Bosch
- Boston Medical Center, The Pulmonary Center, Department of MedicineBostonMAUSA
- Boston University Chobanian & Avedisian School of Medicine, Section of Pulmonary, Allergy, Sleep, & Critical Care, Department of MedicineBostonMAUSA
| | - Katherine Gergen Barnett
- Boston Medical Center, Department of Family MedicineBostonMAUSA
- Boston University Chobanian & Avedisian School of Medicine, Department of Family MedicineBostonMAUSA
- Harvard Center for Primary Care, Center for Primary CareBostonMAUSA
- Aspen Health InnovationWashingtonDCUSA
| | - Rebecca B. Perkins
- Boston Medical Center, Department of Obstetrics and GynecologyBostonMAUSA
- Boston University Chobanian & Avedisian School of Medicine, Department of Obstetrics and GynecologyBostonMAUSA
| | - Allan Walkey
- Boston Medical Center, The Pulmonary Center, Department of MedicineBostonMAUSA
- Boston University Chobanian & Avedisian School of Medicine, Section of Pulmonary, Allergy, Sleep, & Critical Care, Department of MedicineBostonMAUSA
- Boston University School of Public Health, Department of Health Law Policy & ManagementBostonMAUSA
| | - Sabrina A. Assoumou
- Boston Medical Center, Section of Infectious DiseaseBostonMAUSA
- Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of MedicineBostonMAUSA
| | - Benjamin P. Linas
- Boston Medical Center, Section of Infectious DiseaseBostonMAUSA
- Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of MedicineBostonMAUSA
- Boston University School of Public Health, Department of EpidemiologyBostonMAUSA
| | - Mari‐Lynn Drainoni
- Boston University School of Public Health, Department of Health Law Policy & ManagementBostonMAUSA
- Boston University Chobanian & Avedisian School of Medicine, Section of Infectious Disease Department of MedicineBostonMAUSA
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Calcaterra SL, Butler M, Olson K, Blum J. The Impact of a PDMP-EHR Data Integration Combined With Clinical Decision Support on Opioid and Benzodiazepine Prescribing Across Clinicians in a Metropolitan Area. J Addict Med 2022; 16:324-332. [PMID: 34392255 PMCID: PMC8831644 DOI: 10.1097/adm.0000000000000905] [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: 01/03/2023]
Abstract
INTRODUCTION Despite inconclusive evidence that prescription drug monitoring programs (PDMP) reduce opioid-related mortality, guidelines recommend PDMP review with opioid prescribing. Some reported barriers to use include time-consuming processes to obtain data and workflow disruptions. METHODS We provided access to a PMDP-electronic health record (EHR) integrated program to 123 clinicians in one healthcare system. Remaining clinicians within the healthcare system and metropolitan area did not receive PDMP-EHR integration program access. We identified changes in opioid prescribing by linking prescription data available in the state PMDP database to individual clinicians. The primary outcome was change in receipt of high dose opioid prescriptions (>90 mg morphine equivalents) by Colorado residents before and after program integration. Secondary outcomes included changes in long-acting opioid receipt and overlapping opioid and benzodiazepine prescription days. Next, we surveyed clinicians to assess their perspectives on PDMP data acquisition before and after PDMP-EHR integration program access. RESULTS High-dose opioid receipt decreased significantly across all 3 clinician groups [PDMP-EHR integration program access (27.6%, to 6.9%, P < 0.001); no program access in the same healthcare system (4.8% to 2.9%, P < 0.001), and no program access across the metropolitan area (13.5% to 6.1%, P < 0.001)]. Clinicians reported improved access to PDMP data using the PDMP-EHR integrated program compared to the state PDMP website (98.6%). CONCLUSIONS Further study of PDMP-EHR integration programs on patient and clinician outcomes may illuminate the role of this technology in public health and in clinical practice.
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Affiliation(s)
- Susan L. Calcaterra
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA
| | - Maria Butler
- Colorado Department of Public Health and Environment, Prevention Services Division, Denver, CO, USA
| | - Katie Olson
- Colorado Department of Public Health and Environment, Prevention Services Division, Denver, CO, USA
| | - Joshua Blum
- Ambulatory Care Services, Denver Health and Hospital Authority, Denver, Colorado, USA
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Hopper W, Fox J, Dimucci-Ward J. Assessment of Glycemic Control at St. Luke's Free Medical Clinic: Retrospective Chart Review. Interact J Med Res 2022; 11:e31123. [PMID: 35072636 PMCID: PMC8822431 DOI: 10.2196/31123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/09/2021] [Accepted: 12/10/2021] [Indexed: 01/07/2023] Open
Abstract
Background A free clinic is a health care delivery model that provides primary care and pharmaceutical services exclusively to uninsured patients. With a multidisciplinary volunteer clinical staff, which includes physicians, social workers, dieticians, and osteopathic medical students, St. Luke’s Free Medical Clinic (SLFMC) cares for over 1700 patients annually in Spartanburg, South Carolina. Objective This study aims to measure the change, over time, in patient hemoglobin A1c measurements at the SLFMC to quantify the success of the clinic’s diabetes treatment program. Methods A prospective-retrospective chart review of patients (n=140) enrolled at the SLFMC between January 1, 2018, and January 1, 2021, was performed. Patients were stratified as having controlled (hemoglobin A1c<7.0, n=53) or uncontrolled (hemoglobin A1c≥7.0, n=87) diabetes relative to a therapeutic hemoglobin A1c target of 7.0, which is recommended by the American Diabetes Association. For both controlled and uncontrolled groups, baseline hemoglobin A1c values were compared to subsequent readings using a Wilcoxon matched-pairs signed rank test. Results from the SLFMC population were compared to the published literature on hemoglobin A1c from other free clinics. Results Patients with uncontrolled diabetes experienced significant reductions in median hemoglobin A1c at both 6 months (P=.006) and 1 year (P=.002) from baseline. Patients with controlled diabetes showed no significant changes. Black and Hispanic patients with uncontrolled diabetes experienced a 1.0% mean improvement in hemoglobin A1c over the study window. The SLFMC’s wholly uninsured patient population showed a population rate of controlled diabetes (42%), which was similar to recent nationwide averages for adults with diabetes (51% to 56%), as reported by the National Health and Nutrition Examination Survey. The clinic’s Hispanic population (n=47) showed the greatest average improvement in hemoglobin A1c of any ethnic group from baseline. Additionally, 61% of the SLFMC’s Black population (n=33) achieved a hemoglobin A1c of <7.0 by the end of the study window, which surpassed the nationwide averages for glycemic control. Conclusions We present free clinic hemoglobin A1c outcomes obtained through a retrospective chart review. Uninsured patients treated for diabetes at the SLFMC show a reduction in hemoglobin A1c, which is comparable to nationwide standards, although average hemoglobin A1c levels in this study were higher than nationwide averages. Black and Hispanic patients with uncontrolled diabetes showed a mean 1% improvement in hemoglobin A1c levels. These results represent some of the first in the literature emerging from a free clinic that is not affiliated with a major medical school.
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Affiliation(s)
- Wade Hopper
- Department of Surgery, Edward Via College of Osteopathic Medicine - Carolinas, Spartanburg, SC, United States
| | - Justin Fox
- Department of Surgery, Edward Via College of Osteopathic Medicine - Carolinas, Spartanburg, SC, United States
| | - JuliSu Dimucci-Ward
- Department of Preventive Medicine and Public Health, Edward Via College of Osteopathic Medicine - Carolinas, Spartanburg, SC, United States
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Fort MP, Reid M, Russell J, Santos CJ, Running Bear U, Begay RL, Smith SL, Morrato EH, Manson SM. Diabetes Prevention and Care Capacity at Urban Indian Health Organizations. Front Public Health 2021; 9:740946. [PMID: 34900897 PMCID: PMC8661087 DOI: 10.3389/fpubh.2021.740946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
American Indian and Alaska Native (AI/AN) people suffer a disproportionate burden of diabetes and cardiovascular disease. Urban Indian Health Organizations (UIHOs) are an important source of diabetes services for urban AI/AN people. Two evidence-based interventions-diabetes prevention (DP) and healthy heart (HH)-have been implemented and evaluated primarily in rural, reservation settings. This work examines the capacity, challenges and strengths of UIHOs in implementing diabetes programs. Methods: We applied an original survey, supplemented with publicly-available data, to assess eight organizational capacity domains, strengths and challenges of UIHOs with respect to diabetes prevention and care. We summarized and compared (Fisher's and Kruskal-Wallis exact tests) items in each organizational capacity domain for DP and HH implementers vs. non-implementers and conducted a thematic analysis of strengths and challenges. Results: Of the 33 UIHOs providing services in 2017, individuals from 30 sites (91% of UIHOs) replied to the survey. Eight UIHOs (27%) had participated in either DP (n = 6) or HH (n = 2). Implementers reported having more staff than non-implementers (117.0 vs. 53.5; p = 0.02). Implementers had larger budgets, ~$10 million of total revenue compared to $2.5 million for non-implementers (p = 0.01). UIHO strengths included: physical infrastructure, dedicated leadership and staff, and community relationships. Areas to strengthen included: staff training and retention, ensuring sufficient and consistent funding, and data infrastructure. Conclusions: Strengthening UIHOs across organizational capacity domains will be important for implementing evidence-based diabetes interventions, increasing their uptake, and sustaining these interventions for AI/AN people living in urban areas of the U.S.
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Affiliation(s)
- Meredith P Fort
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Margaret Reid
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jenn Russell
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Cornelia J Santos
- Environmental Studies-Indigenous Sustainability Studies Program, Bemidji State University, Bemidji, MN, United States
| | - Ursula Running Bear
- Department of Population Health, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Rene L Begay
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Savannah L Smith
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elaine H Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, United States
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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11
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Sarkar U, Lee JE, Nguyen KH, Lisker S, Lyles CR. Barriers and Facilitators to the Implementation of Virtual Reality as a Pain Management Modality in Academic, Community, and Safety-Net Settings: Qualitative Analysis. J Med Internet Res 2021; 23:e26623. [PMID: 34550074 PMCID: PMC8495579 DOI: 10.2196/26623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/26/2021] [Accepted: 05/25/2021] [Indexed: 12/23/2022] Open
Abstract
Background Prior studies have shown that virtual reality (VR) is an efficacious treatment modality for opioid-sparing pain management. However, the majority of these studies were conducted among primarily White, relatively advantaged populations and in well-resourced settings. Objective We conducted a qualitative, theory-informed implementation science study to assess the readiness for VR in safety-net settings. Methods Using the theoretical lens of the Consolidated Framework for Implementation Research (CFIR) framework, we conducted semistructured interviews with current VR users and nonusers based in safety-net health systems (n=15). We investigated barriers and facilitators to a commercially available, previously validated VR technology platform AppliedVR (Los Angeles, CA, USA). We used deductive qualitative analysis using the overarching domains of the CFIR framework and performed open, inductive coding to identify specific themes within each domain. Results Interviewees deemed the VR intervention to be useful, scalable, and an appealing alternative to existing pain management approaches. Both users and nonusers identified a lack of reimbursement for VR as a significant challenge for adoption. Current users cited positive patient feedback, but safety-net stakeholders voiced concern that existing VR content may not be relevant or appealing to diverse patients. All respondents acknowledged the challenge of integrating and maintaining VR in current pain management workflows across a range of clinical settings, and this adoption challenge was particularly acute, given resource and staffing constraints in safety-net settings. Conclusions VR for pain management holds interest for frontline pain management clinicians and leadership in safety-net health settings but will require significant tailoring and adaption to address the needs of diverse populations. Integration into complex workflows for pain management is a significant barrier to adoption, and participants cited structural cost and reimbursement concerns as impediments to initial implementation and scaling of VR use.
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Affiliation(s)
- Urmimala Sarkar
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.,Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States
| | - Jane E Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.,Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States
| | - Kim H Nguyen
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.,Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
| | - Sarah Lisker
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.,Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States
| | - Courtney R Lyles
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.,Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States
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12
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Leidner C, Vennedey V, Hillen H, Ansmann L, Stock S, Kuntz L, Pfaff H, Hower KI. Implementation of patient-centred care: which system-level determinants matter from a decision maker's perspective? Results from a qualitative interview study across various health and social care organisations. BMJ Open 2021; 11:e050054. [PMID: 34489287 PMCID: PMC8422499 DOI: 10.1136/bmjopen-2021-050054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The healthcare system is characterised by a high degree of complexity and involves various actors at different institutional levels and in different care contexts. To implement patient-centred care (PCC) successfully, a multidimensional consideration of influencing factors is required. Our qualitative study aims to identify system-level determinants of PCC implementation from the perspective of different health and social care organisations (HSCOs). DESIGN A qualitative study using n=20 semistructured face-to-face interviews with n=24 participants was carried out between August 2017 and May 2018. Interview data were analysed based on concepts of qualitative content analysis using an inductive and deductive approach. SETTING AND PARTICIPANTS Interviews were conducted with clinical and managerial decision makers from multiple HSCOs in the model region of Cologne, Germany. Participants were recruited via networks of practice partners and cold calling. RESULTS This study identified various determinants on the system level that are associated with PCC implementation. Decision makers described external regulations as generating an economically controlled alignment of the healthcare system. The availability and qualification of staff resources and patient-related incentives of financial resources were identified as an eminent requirement for providers to deliver PCC. Participants considered the strict separation of financing and delivery of healthcare into inpatient and outpatient sectors to be a barrier to PCC. Interorganisational collaboration and information exchange were identified as facilitators of PCC, as they enable continuous patient care cycles. CONCLUSION The results showed the necessity of enforcing paradigm changes at the system level from disease-centredness to patient-centredness while aligning policy and reimbursement decisions directly with patient needs and values. A systematic, long-term planned strategy that extends across all organisations is lacking, rather each organisation seeks its own possibilities to implement PCC activities under external restrictions.Trial registration numberDRKS00011925.
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Affiliation(s)
| | - Vera Vennedey
- Institute for Health Economics and Clinical Epidemiology, University Hospital Cologne, Cologne, Germany
| | - Hendrik Hillen
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Lena Ansmann
- Department of Health Services Research, School of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany, University of Oldenburg, Oldenburg, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, University Hospital Cologne, Cologne, Germany
| | - Ludwig Kuntz
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), Faculties of Human Sciences and Medicine, University of Cologne, Cologne, Germany
| | - Kira Isabel Hower
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), Faculties of Human Sciences and Medicine, University of Cologne, Cologne, Germany
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13
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Tavrow P, Bloom B, Withers M. Challenges of Using Videos in Exam Rooms of Safety-Net Clinics to Encourage Patient Self-Disclosure of Intimate Partner Violence and to Increase Provider Screening. Violence Against Women 2021; 27:2990-3010. [PMID: 33860700 DOI: 10.1177/10778012211000136] [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
Identifying intimate partner violence (IPV) in clinics allows for early intervention. We tested a comprehensive approach in five safety-net clinics to encourage female victims to self-identify and providers to screen. The main components were (a) short, multilingual videos for female patients; (b) provider training; and (c) management tools. Although videos were viewed 2,150 times, only 9% of eligible patients watched them. IPV disclosure increased slightly (6%). Lack of internal champions, high turnover, increased patient load, and technological challenges hindered outcomes. Safety-net clinics need feasible methods to encourage IPV screening. Management champions and IT support are essential for video-based activities.
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Affiliation(s)
| | - Brittnie Bloom
- San Diego State University, CA, USA.,University of California, San Diego, USA
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14
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Bolton RE, Bokhour BG, Dvorin K, Wu J, Elwy AR, Charns M, Taylor SL. Garnering Support for Complementary and Integrative Health Implementation: A Qualitative Study of VA Healthcare Organization Leaders. J Altern Complement Med 2021; 27:S81-S88. [PMID: 33788605 DOI: 10.1089/acm.2020.0383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: Healthcare organization leaders' support is critical for successful implementation of new practices, including complementary and integrative health (CIH) therapies. Yet little is known about how to garner this support and what motivates leaders to support these therapies. We examined reasons leaders provided or withheld support for CIH therapy implementation, using a multilevel lens to understand motivations influenced by individual, interpersonal, organizational, and system determinants. Design and setting: We conducted qualitative interviews with leaders in seven Veterans Health Administration medical centers that offered at least three CIH therapies to Veterans and were identified as early adopters of CIH therapies. Subjects: Participants included 12 executive leaders and 34 leaders of key clinical services, including primary care, mental health, physical medicine and rehabilitation, and pain. Measures: We used a thematic analysis to examine leaders' narratives of barriers and facilitators to implementation including their attitudes toward CIH therapies, perceptions of evidence, engagement in implementation, and decisions to provide concrete support for CIH therapies. Drawing from Greenhalgh's Diffusion of Innovation framework, we organized themes according to the influence of individual determinants, two levels of inner setting, and outer system context on CIH implementation. Results: Leaders' decisions to provide or withhold support were driven by considerations across multiple levels including (1) individual attitudes/knowledge, perceptions of evidence, and personal experiences; (2) interpersonal interactions with trusted brokers, patients, and loved ones/colleagues/staff; (3) organizational concerns surrounding relative priorities, local resources, and metrics/quality/safety; and (4) system-level policy, bureaucracy, and interorganizational networks. These considerations interacted across levels, with components at organizational and system levels sometimes prevailing over individual perceptions and experiences. Conclusions: Garnering leaders' support for CIH therapy implementation should address their considerations at multiple levels. Implementation strategies designed to shift individual attitudes alone may be insufficient for securing leaders' support without attention to broader organizational and system-level contextual issues.
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Affiliation(s)
- Rendelle E Bolton
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Bedford, MA, USA
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Barbara G Bokhour
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kelly Dvorin
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Bedford, MA, USA
| | - Juliet Wu
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Bedford, MA, USA
| | - Anashua Rani Elwy
- VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Bedford, MA, USA
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Martin Charns
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Boston, MA, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Stephanie L Taylor
- Greater Los Angeles VA Medical Center, HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, US Department of Veterans Affairs, Los Angeles, CA, USA
- Department of Medicine and University of California Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, University of California Los Angeles, Los Angeles, CA, USA
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15
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Changes in Healthcare Encounter Rates Possibly Related to Cannabis or Alcohol following Legalization of Recreational Marijuana in a Safety-Net Hospital: An Interrupted Time Series Analysis. J Addict Med 2020; 13:201-208. [PMID: 30475257 DOI: 10.1097/adm.0000000000000480] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Liberalization of marijuana laws in Colorado contributed to increases in cannabis-related adverse events over time. We examined characteristics of patients with healthcare encounters possibly related to cannabis and assessed the temporal association between legalization of recreational marijuana and healthcare encounters possibly attributed to cannabis. METHODS Annual encounter rates possibly related to cannabis and alcohol were compared using negative binomial regression. Two-time intervals, pre/post-recreational marijuana legalization (January 2009 to December 2013 and January 2014 to December 2015, respectively) were used to examine changes in monthly rates of emergency encounters and hospitalizations possibly related to cannabis. Level and trend changes on encounter rates by legalization period were assessed using interrupted time series analyses. Encounters possibly related to alcohol were used as a comparator group. RESULTS Most encounters identified during the study period had alcohol-related International Classification of Diseases Diagnosis and Procedural Codes (ICD-9/10-CM) codes (94.8% vs 5.2% for cannabis). Patients with encounters possibly related to cannabis were younger, more likely to be hospitalized and more likely to be admitted to the psychiatric unit than patients with encounters possibly related to alcohol. Initial and sustained effects of encounter rates possibly related to cannabis demonstrated an increased trend in slope before and after recreational marijuana legalization. The slope became more abrupt following legalization with a significant increase in trend during the post-legalization period (β = 2.7, standard error = 0.3, ρ < 0.0001). No significant change was noted for encounters possibly related to alcohol. CONCLUSIONS Additional research should identify patients at highest risk of an adverse health event related to cannabis and quantify costs associated with cannabis-related healthcare delivery.
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16
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Crable EL, Biancarelli D, Walkey AJ, Drainoni ML. Barriers and facilitators to implementing priority inpatient initiatives in the safety net setting. Implement Sci Commun 2020; 1:35. [PMID: 32885192 PMCID: PMC7427845 DOI: 10.1186/s43058-020-00024-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 02/28/2020] [Indexed: 02/03/2023] Open
Abstract
Background Safety net hospitals, which serve vulnerable and underserved populations and often operate on smaller budgets than non-safety net hospitals, may experience unique implementation challenges. We sought to describe common barriers and facilitators that affect the implementation of improvement initiatives in a safety net hospital, and identify potentially transferable lessons to enhance implementation efforts in similar settings. Methods We interviewed leaders within five inpatient departments and asked them to identify the priority inpatient improvement initiative from the last year. We then conducted individual, semi-structured interviews with 25 stakeholders across the five settings. Interviewees included individuals serving in implementation oversight, champion, and frontline implementer roles. The Consolidated Framework for Implementation Research informed the discussion guide and a priori codes for directed content analysis. Results Despite pursuing diverse initiatives in different clinical departments, safety net hospital improvement stakeholders described common barriers and facilitators related to inner and outer setting dynamics, characteristics of individuals involved, and implementation processes. Implementation barriers included (1) limited staffing resources, (2) organizational recognition without financial investment, and (3) the use of implementation strategies that did not adequately address patients’ biopsychosocial complexities. Facilitators included (1) implementation approaches that combined passive and active communication styles, (2) knowledge of patient needs and competitive pressure to perform well against non-SNHs, (3) stakeholders’ personal commitment to reduce health inequities, and (4) the use of multidisciplinary task forces to drive implementation activities. Conclusion Inner and outer setting dynamics, individual’s characteristics, and process factors served as implementation barriers and facilitators within the safety net. Future work should seek to leverage findings from this study toward efforts to enact positive change within safety net hospitals.
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Affiliation(s)
- Erika L Crable
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA
| | - Dea Biancarelli
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA
| | - Allan J Walkey
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA.,The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA USA
| | - Mari-Lynn Drainoni
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2030, Boston, 02118 MA USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA USA.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA USA
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17
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Ponce AN, Rowe M. Citizenship and Community Mental Health Care. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2018; 61:22-31. [PMID: 29323416 DOI: 10.1002/ajcp.12218] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Citizenship is an approach to supporting the social inclusion and participation in society of people with mental illnesses. It is receiving greater attention in community mental health discourse and literature in parallel with increased awareness of social determinants of health and concern over the continued marginalization of persons with mental illness in the United States. In this article, we review the definition and principles of our citizenship framework with attention to social participation and access to resources as well as rights and responsibilities that society confers on its members. We then discuss our citizenship research at both individual and social-environmental levels, including previous, current, and planned efforts. We also discuss the role of community psychology and psychologists in advancing citizenship and other themes relevant to a citizenship perspective on mental health care and persons with mental illness.
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Affiliation(s)
- Allison N Ponce
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Michael Rowe
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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18
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A stakeholder visioning exercise to enhance chronic care and the integration of community pharmacy services. Res Social Adm Pharm 2018; 15:31-44. [PMID: 29496521 DOI: 10.1016/j.sapharm.2018.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/22/2017] [Accepted: 02/15/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Collaboration between relevant stakeholders in health service planning enables service contextualization and facilitates its success and integration into practice. Although community pharmacy services (CPSs) aim to improve patients' health and quality of life, their integration in primary care is far from ideal. Key stakeholders for the development of a CPS intended at preventing cardiovascular disease were identified in a previous stakeholder analysis. Engaging these stakeholders to create a shared vision is the subsequent step to focus planning directions and lay sound foundations for future work. OBJECTIVES This study aims to develop a stakeholder-shared vision of a cardiovascular care model which integrates community pharmacists and to identify initiatives to achieve this vision. METHODS A participatory visioning exercise involving 13 stakeholders across the healthcare system was performed. A facilitated workshop, structured in three parts (i.e., introduction; developing the vision; defining the initiatives towards the vision), was designed. The Chronic Care Model inspired the questions that guided the development of the vision. Workshop transcripts, researchers' notes and materials produced by participants were analyzed using qualitative content analysis. RESULTS Stakeholders broadened the objective of the vision to focus on the management of chronic diseases. Their vision yielded 7 principles for advanced chronic care: patient-centered care; multidisciplinary team approach; shared goals; long-term care relationships; evidence-based practice; ease of access to healthcare settings and services by patients; and good communication and coordination. Stakeholders also delineated six environmental factors that can influence their implementation. Twenty-four initiatives to achieve the developed vision were defined. CONCLUSIONS The principles and factors identified as part of the stakeholder shared-vision were combined in a preliminary model for chronic care. This model and initiatives can guide policy makers as well as healthcare planners and researchers to develop and integrate chronic disease services, namely CPSs, in real-world settings.
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19
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Gold MR. Critical Challenges in Making Health Services Research Relevant to Decision Makers. Health Serv Res 2015; 51:9-15. [PMID: 26647782 DOI: 10.1111/1475-6773.12407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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