Practice redesign and the patient-centered medical home: history, promises, and challenges

Contributions of Key Components of a Medical Home on Child Health Outcomes

OBJECTIVES

The medical home model is a widely accepted model of team-based primary care. We examined five components of the medical home model in order to better understand their unique contributions to child health outcomes.

METHODS

We analyzed data from the 2016-2017 National Survey of Children's Health (NSCH) to assess five key medical home components - usual source of care, personal doctor/nurse, family-centered care, referral access, and coordinated care - and their associations with child outcomes. Health outcomes included emergency department (ED) visits, unmet health care needs, preventive medical visits, preventive dental visits, health status, and oral health status. We used multivariate regression controlling for child characteristics including age, sex, primary household language, race/ethnicity, income, parental education, health insurance coverage, and special healthcare needs.

RESULTS

Children who were not white, living in non-English households, with less family income or education, or who were uninsured had lower rates of access to a medical home and its components. A medical home was associated with beneficial child outcomes for all six of the outcomes and the family-centered care component was associated with better results in five outcomes. ED visits were less likely for children who received care coordination (aOR 0.81, CI 0.70-0.94).

CONCLUSIONS FOR PRACTICE

Our study highlights the role of key components of the medical home and the importance of access to family-centered health care that provides needed coordination for children. Health care reforms should consider disparities in access to a medical home and specific components and the contributions of each component to provide quality primary care for all children.

Cost analysis of a Patient-Centred Medical Home for community-dwelling older adults with complex needs in Singapore

INTRODUCTION

The Patient-Centred Medical Home (PCMH) demonstration in Singapore, launched in November 2016, aimed to deliver integrated and patient-centred care for patients with biopsychosocial needs. Implementation was based on principles of comprehensiveness, coordinated care and shared decision-making.

METHOD

We conducted a prospective single-arm pre-post study design, which aimed to perform cost analysis of PCMH from the perspectives of patients, healthcare providers and society. We assessed short-to-intermediate-term health-related costs by analysing data on resource use and unit costs of resources.

RESULTS

We analysed 165 participants enrolled in PCMH from November 2017 to April 2020, with mean age of 77 years. Compared to the 3-month period before enrolment, mean total direct and indirect participant costs and total health system costs increased, but these were not statistically significant. There was a significant decrease in mean cost for primary care (government primary care and private general practice) in the first 3-month and second 3-month periods after enrolment, accompanied by a significant decrease in service utilisation and mean costs for PCMH services in the second 3-month period post-enrolment. This suggested a shift in resource costs from primary care to community-based care provided by PCMH, which had added benefits of both clinic-based primary care and home-based care management. Findings were consistent with a lower longer-term cost trajectory for PCMH after the initial onboarding period. Indirect caregiving costs remained stable.

CONCLUSION

The PCMH care model was associated with reduced costs to the health system and patients for usual primary care, and did not significantly change societal costs.

The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model

Care for patients with inflammatory bowel disease (IBD) can be complex and costly. Care delivery models to address these challenges and improve care quality are essential. The patient-centered medical home (PCMH), which was developed in the primary care setting, has recently been applied successfully to the adult IBD population. Following the tenets of the PCMH, this specialty medical home (SMH) emphasizes team-based care that is accessible, comprehensive, patient/family-centered, coordinated, compassionate, and continuous and has demonstrated improved patient outcomes. Children and young adults with IBD have equally complex care needs, with additional challenges not faced by the adult population such as growth, physical and psychosocial development, and transition of care from pediatric to adult providers. Thus, we advocate that the components of the PCMH are equally-if not more-important in caring for the pediatric patient population. In this article, we review what is known about the application of the PCMH model in adult IBD care, describe care delivery within the Center for Pediatric and Adolescent IBD at Nationwide Children's Hospital as an example of a pediatric IBD medical home, and propose a research agenda to further the development and dissemination of comprehensive care delivery for children and adolescents with IBD.

A double-edged sword: The effects of social network ties on job satisfaction in primary care organizations

BACKGROUND

Social ties between health care workers may be an important driver of job satisfaction; however, research on this topic is limited.

PURPOSE

We used social network methods to collect data describing two types of social ties, (a) instrumental ties (i.e., exchange of advice that enables work) and (b) expressive ties (i.e., exchange of social support), and related those ties to workers' job satisfaction.

METHODOLOGY

We surveyed 456 clinicians and staff at 23 primary care practices about their social networks and workplace attitudes. We used multivariable linear regression to estimate the relationship between an individual's job satisfaction and two network properties: (a) eigenvector centrality (a measure of the importance of an individual in a network) and (b) ego network density (a measure of the cohesiveness of an individual's network). We examined this relationship for both instrumental and expressive ties.

RESULTS

Individuals who were more central in the expressive network were less satisfied in their job, b = -0.40 (0.19), p < .05, whereas individuals who had denser instrumental networks were more satisfied in their job, b = 0.49 (0.21), p < .05.

CONCLUSION

Workplace relationships affect worker well-being. Centrality in an expressive network may require greater emotional labor, increasing workers' risk for job dissatisfaction. On the other hand, a dense instrumental network may promote job satisfaction by strengthening workers' access to full information, supporting competence and confidence.

PRACTICE IMPLICATIONS

Efforts to increase job satisfaction should consider both the positive and negative effects of social networks on workers' sense of well-being.

Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations

Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. “Diffusion of innovations” emerged as an overarching theory to contextualize PCMH in its early implementation. Three core “innovations” differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to “adopt” and “assimilate” the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).

Mobile Electronic Devices as Means of Facilitating Patient Activation and Health Professional Empowerment Related to Information Seeking on Chronic Conditions and Medications: Qualitative Study

BACKGROUND

Patient activation has an impact on the management of patients' health, clinical outcomes, and treatment costs. Mobile electronic devices (MEDs) have shown the potential to engage patients in wellness behavior. Furthermore, the potentially positive role of MEDs is evident in supporting health professionals in their practice.

OBJECTIVE

This study aims to explore the impact of MEDs on patient activation to search for information on chronic conditions and medications and the impact of MEDs on the empowerment of health professionals or future health professionals.

METHODS

We conducted 6 focus groups-2 with health sciences students, 2 with health professionals, and 2 with hospitalized patients with chronic conditions. A protocol comprising eight questions was used to guide discussions. Audio-recorded data were transcribed verbatim and analyzed thematically; a ranking system was used to analyze the relevance of identified themes and subthemes, using a coding system depicted by the + symbol, to indicate different relevance levels.

RESULTS

Our results suggest that MEDs can positively affect patient activation to search for chronic conditions and medication information by facilitating patients' information-seeking behavior. Key drivers leading to patients' activation to seek information related to chronic conditions and medications through MEDs were the accessibility and abundance of available and detailed information, reduced search time, information updates, and convenience in finding information at any time and place. The lack of accurate information in one's native language, access to incorrect information, and limited access to the internet were key obstacles to seeking information related to chronic conditions and medications via MEDs. In addition, findings of this study suggest that MEDs in general and mobile apps, in particular, may have a positive impact on the work routine of health care professionals as they enable them to make quicker decisions by accessing the required information faster, thus improving practice efficiency. Furthermore, the appropriate usage of MEDs by patients for seeking information about their chronic conditions and medications may positively impact the physician-patient relationship. All focus groups recognized the questionable reliability of health information on the internet and its potential negative effects on patients. Therefore, our findings suggest the need for an additional role of health professionals in assisting patients in using MEDs to search for health and medication information, such as providing reliable websites and mobile apps where patients can safely search for health-related information on the web.

CONCLUSIONS

The use of MEDs may help activate patients to seek chronic conditions and medication-related information, potentially leading to better management of their chronic conditions and medications. Our findings also highlight the positive impact MEDs may have on empowering health professionals in their practice and the need for health professionals to help patients through specific education that addresses MEDs utilization for chronic conditions and medication information seeking.

Primary Care Office Visits For Acute Care Dropped Sharply In 2002-15, While ED Visits Increased Modestly

The traditional model of primary care practices as the main provider of care for acute illnesses is rapidly changing. Over the past two decades the growth in emergency department (ED) visits has spurred efforts to reduce "inappropriate" ED use. We examined a nationally representative sample of office and ED visits in the period 2002-15. We found a 12 percent increase in ED use (from 385 to 430 visits per 1,000 population), which was dwarfed by a decrease of nearly one-third in the rate of acute care visits to primary care practices (from 938 to 637 visits per 1,000 population). The decrease in primary care acute visits was also present among two vulnerable populations: Medicaid beneficiaries and adults ages sixty-five and older, either in Medicare or privately insured. As acute care delivery shifts away from primary care practices, there is a growing need for integration and coordination across an increasingly diverse spectrum of venues where patients seek care for acute illnesses.

Caregiver and Adolescent Patient Perspectives on Comprehensive Care for Inflammatory Bowel Diseases: Building a Family-Centered Care Delivery Model

BACKGROUND

Children with inflammatory bowel diseases (IBDs) require primary and gastrointestinal (GI) care, but little is known about patient and family preferences for care receipt. We aimed to understand caregiver perceptions of current healthcare quality, describe barriers to receiving healthcare, and elicit caregiver and adolescent preferences for how comprehensive care ideally would be delivered.

METHODS

This was an anonymous survey of caregivers of 2- to 17-year olds with IBD and adolescents with IBD aged 13-17 years at a large, free-standing children's hospital. Surveys assessed patient medical history, family demographics, perceptions of health care quality and delivery, barriers to primary and GI care, and preferences for optimal care delivery.

RESULTS

Two hundred and seventeen caregivers and 140 adolescents were recruited, 214 caregivers and 133 adolescents consented/assented, and 160 caregivers and 84 adolescents completed the survey (75% and 60% response rate, respectively). Mean patient age was 14 years (SD = 3); 51% male; 79% Crohn's disease, 16% ulcerative colitis, and 4% indeterminate colitis. Caregivers were primarily female (86%), Caucasian (94%), and living in a 2-caregiver household (79%). Most caregivers reported that their child's primary care physician (PCP) and GI doctor oversaw their primary care (71%) and their IBD care (94%), respectively. Caregivers were satisfied with communication with their PCP and GI providers (>90%) but did not know how well they communicated with one another (54%). Barriers to primary and GI care varied, and few caregivers (6%) reported unmet healthcare needs. Caregivers and adolescents saw PCPs and GI doctors having important roles in comprehensive care, though specific preferences for care delivery differed.

CONCLUSION

Caregivers and adolescent perspectives are essential to developing family-centered care models for children with IBD.

Collaborative practice trends in US physician office visits: an analysis of the National Ambulatory Medical Care Survey (NAMCS), 2007-2016

OBJECTIVE

Practice arrangements in physician offices were characterised by examining the share of visits that involved physician assistants (PAs) and nurse practitioners (NPs). The hypothesis was that collaborative practice (ie, care delivered by a dyad of physician-PA and/or physician-NP) was increasing.

DESIGN

Temporal ecological study.

SETTING

Non-federal physician offices.

PARTICIPANTS

Patient visits to a physician, PA or NP, spanning years 2007-2016.

METHODS

A stratified random sample of visits to office-based physicians was pooled through the National Ambulatory Medical Care Survey public use linkage file. Among 317 674 visits to physicians, PAs or NPs, solo and collaborative practices were described and compared over two timespans of 2007-2011 and 2012-2016. Weighted patient visits were aggregated in bivariate analyses to achieve nationally representative estimates. Survey statistics assessed patient demographic characteristics, reason for visit and visit specialty by provider type.

RESULTS

Within years 2007-2011 and 2012-2016, there were 4.4 billion and 4.1 billion physician office visits (POVs), respectively. Comparing the two timespans, the rate of POVs with a solo PA (0.43% vs 0.21%) or NP (0.31% vs 0.17%) decreased. Rate of POVs with a collaborative physician-PA increased non-significantly. Rate of POVs with a collaborative physician-NP (0.49% vs 0.97%, p<0.01) increased. Overall, collaborative practice, in particular physician-NP, has increased in recent years (p<0.01), while visits handled by a solo PA or NP decreased (p<0.01). In models adjusted for patient age and chronic conditions, the odds of collaborative practice in years 2012-2016 compared with years 2007-2011 was 35% higher (95% CI 1.01 to 1.79). Furthermore, in 2012-2016, NPs provided more independent primary care, and PAs provided more independent care in a non-primary care medical specialty. Preventive visits declined among all providers.

CONCLUSIONS

In non-federal physician offices, collaborative care with a physician-PA or physician-NP appears to be a growing part of office-based healthcare delivery.

Greater patient-centered medical home implementation was associated with lower attrition from VHA primary care

BACKGROUND

Patient-centered medical home models such as the Veterans Health Administration (VHA) Patient Aligned Care Team (PACT) model aim to improve primary care through accessible, comprehensive, continuous team-based care. Practices that adhere to patient-centered medical home principles have been found to exhibit higher patient satisfaction, possibly leading to higher retention of patients longitudinally and reducing attrition from care. We examined whether greater PACT implementation was related to lower attrition from VHA primary care.

METHODS

A national cohort of 1.5 million nonelderly patients with chronic conditions and using VHA primary care in the baseline year (fiscal year 2015) was identified. Attrition was measured as not receiving primary care over two subsequent years. PACT implementation in 863 VHA primary care practices was measured by the PACT Implementation Progress Index (Pi2) across 8 domains.

RESULTS

Overall, the attrition rate was 4.4%. Predicted attrition was highest for patients treated in practices with the lowest PACT implementation scores (4.8%) compared to 4.0% among patients in practices with the highest PACT implementation scores (difference = -0.8 (95% CI: -1.3, -0.2)). Better performance on most PACT domains was significantly associated with lower attrition.

CONCLUSIONS

Primary care practices that facilitate easier access to providers as well as provide more seamless care coordination, better communication with providers, and support for self-management appear to positively affect patients' decisions to stay in VHA care.

IMPLICATIONS

Provision of accessible, comprehensive, team-based primary care, as measured in this study, is likely to be a determinant of patient retention in VHA care.

LEVEL OF EVIDENCE

3.

Patient engagement in the nonclinical setting: A concept analysis

OBJECTIVE

Redesigning of health care through patient engagement at policy levels has been declared as the 21st-century solution to improving health outcomes of patients, enhancing patient safety, and reducing climbing health care costs. Despite these optimistic claims, conceptual clarity regarding patient engagement is lacking, thereby limiting the potential for both taking up this engagement and evaluating its effectiveness. Of particular interest is patient engagement in nonclinical settings, meaning engagement at more strategic tables.

METHODOLOGY

A conceptual analysis, of patient engagement within nonclinical settings, using Walker and Avant's eight-step method.

RESULTS

Four key attributes are identified for patient engagement within the nonclinical setting: power, communication, collaboration, and information sharing. Patient engagement is defined as a process in which patients, caregivers, and health care professionals collaborate as equal partners, contributing unique skills while sharing information and perspectives toward innovative ideas that contribute to the overall improvement of health care.

CONCLUSION

The concept of patient engagement carries with it, a long journey of milestones and learning, yet continues to lack clarity. Obtaining conceptual clarity is a necessary step to developing reliable methods of measuring the actual contribution of patient engagement in health care system improvements.

Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration

BACKGROUND

The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization.

OBJECTIVE

To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs).

DESIGN

Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects.

PARTICIPANTS

A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module.

MAIN MEASURES

Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims.

KEY RESULTS

Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs.

CONCLUSIONS

Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.

Thriving in today's health care environment: strategies for social work leadership in population health

The current healthcare environment challenges social workers to balance multiple constituencies - organizational, payer-related, and professional - and convey the value-added nature of clinical work with patients and families. As healthcare systems move towards population health, leadership opportunities abound. This article provides an historical overview of healthcare transformation and its impact on social work practice, and describes strategies implemented to bolster the clinical focus and organizational responsiveness of Mount Sinai Health System care management staff. The training and supervisory approaches offered make possible relatable and synergistic connections between clinical practice and organizational imperatives to decrease unnecessary utilization and healthcare costs.

The medical home functions of primary care practices that care for adults with psychological distress: a cross-sectional study

BACKGROUND

Primary care practices are changing the way that they provide care by increasing their medical home functionality. Medical home functionality can improve access to care and increase patient-centeredness, which is essential for persons with mental health issues. This study aims to explore the degree to which medical home functions have been implemented by primary care practices that care for adults with psychological distress.

METHODS

Analysis of the 2015 Medical Expenditure Panel Survey Household Component and Medical Organizations Survey. This unique data set links data from a nationally representative sample of US households to the practices in which they receive primary care. This study focused on adults aged 18 and above.

RESULTS

As compared to adults without psychological distress, adults with psychological distress had significantly higher rates of chronic illness and poverty. Adults with psychological distress were more likely to receive care from practices that include advanced practitioners and are non-profit or hospital-based. Multivariate models that were adjusted for patient-level and practice-level characteristics indicated that adults with psychological distress are as likely to receive primary care from practices with medical home functionality, including case management, electronic health records, flexible scheduling, and PCMH certification, as adults without psychological distress.

CONCLUSIONS

Practices that care for adults with mental health issues have not been left behind in the transition towards medical home models of primary care. Policy makers should continue to prioritize adults with mental health issues to receive primary care through this model of delivery due to this population's great potential to benefit from improved access and care coordination.

TRIAL REGISTRATION

This study does not report the results of a health care intervention on human subject's participants.

Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach

Background

Health systems in the United States are increasingly required to become leaders in quality to compete successfully in a value-conscious purchasing market. Doing so involves developing effective clinical teams using approaches like the clinical microsystems framework. However, there has been limited assessment of this approach within United States primary care settings.

Methods

This paper describes the implementation, mixed-methods evaluation results, and lessons learned from instituting a Microsystems approach across 6 years with 58 primary care teams at a large Midwestern academic health care system. The evaluation consisted of a longitudinal survey augmented by interviews and focus groups. Structured facilitated longitudinal discussions with leadership captured ongoing lessons learned. Quantitative analysis employed ordinal logistic regression and compared aggregate responses at 6-months and 12-months to those at the baseline period. Qualitative analysis used an immersion/crystallization approach.

Results

Survey results (N = 204) indicated improved perceptions of: organizational support, team effectiveness and cohesion, meeting and quality improvement skills, and team communication. Thematic challenges from the qualitative data included: lack of time and coverage for participation, need for technical/technology support, perceived devaluation of improvement work, difficulty aggregating or spreading learnings, tensions between team and clinic level change, a part-time workforce, team instability and difficulties incorporating a data driven improvement approach.

Conclusions

These findings suggest that a microsystems approach is valuable for building team relationships and quality improvement skills but is challenged in a large, diverse academic primary care context. They additionally suggest that primary care transformation will require purposeful changes implemented across the micro to macro-level including but not only focused on quality improvement training for microsystem teams.

Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim

A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

The impact of patient-centered medical homes on medication adherence?

Accreditation of providers helps resolve the pervasive information asymmetries in health care markets. However, meeting accreditation standards typically involves flexibility in implementation, leading to heterogeneity in performance. For example, the patient-centered medical home (PCMH) is a leading model for recognizing high-performing primary care practices. Flexibility in PCMH implementation allows for varying degrees of emphasis on processes designed to enhance medication adherence. To assess the impact of the PCMH on adherence, we combine 6 years of detailed patient claims data with a novel dataset containing detailed practice-level PCMH attributes. We study the effects of the number and configuration of adherence-relevant capabilities, using variation in the timing of PCMH adoption to estimate its impact. While PCMH adoption improved overall medication adherence, when combining claims data with the unique recognition data detailing what PCMH capabilities were adopted, we find that these gains are concentrated among patients in practices that adopted more adherence-relevant capabilities. Despite mixed evidence in the literature concerning costs and utilization, our results indicate that PCMH recognition improves medication adherence.

The economics of patient-centered care

The Patient-Centered Medical Home (PCMH) is a widely-implemented model for improving primary care, emphasizing care coordination, information technology, and process improvements. However, its treatment as an undifferentiated intervention in policy evaluation obscures meaningful variation in implementation. This heterogeneity leads to contracting inefficiencies between insurers and practices and may account for mixed evidence on its success. Using a novel dataset we group practices into meaningful implementation clusters and then link these clusters with detailed patient claims data. We find implementation choice affects performance, suggesting that generally-unobserved features of primary care reorganization influence patient outcomes. Reporting these features may be valuable to insurers and their members.

Implementing the patient-centered medical home in complex adaptive systems: Becoming a relationship-centered patient-centered medical home

BACKGROUND

This study explores the implementation experience of nine primary care practices becoming patient-centered medical homes (PCMH) as part of the New Hampshire Citizens Health Initiative Multi-Stakeholder Medical Home Pilot.

PURPOSE

The purpose of this study is to apply complex adaptive systems theory and relationship-centered organizations theory to explore how nine diverse primary care practices in New Hampshire implemented the PCMH model and to offer insights for how primary care practices can move from a structural PCMH to a relationship-centered PCMH.

METHODOLOGY/APPROACH

Eighty-three interviews were conducted with administrative and clinical staff at the nine pilot practices, payers, and conveners of the pilot between November and December 2011. The interviews were transcribed, coded, and analyzed using both a priori and emergent themes.

FINDINGS

Although there is value in the structural components of the PCMH (e.g., disease registries), these structures are not enough. Becoming a relationship-centered PCMH requires attention to reflection, sensemaking, learning, and collaboration. This can be facilitated by settings aside time for communication and relationship building through structured meetings about PCMH components as well as the implementation process itself. Moreover, team-based care offers a robust opportunity to move beyond the structures to focus on relationships and collaboration.

PRACTICE IMPLICATIONS

(a) Recognize that PCMH implementation is not a linear process. (b) Implementing the PCMH from a structural perspective is not enough. Although the National Committee for Quality Assurance or other guidelines can offer guidance on the structural components of PCMH implementation, this should serve only as a starting point. (c) During implementation, set aside structured time for reflection and sensemaking. (d) Use team-based care as a cornerstone of transformation. Reflect on team structures and also interactions of the team members. Taking the time to reflect will facilitate greater sensemaking and learning and will ultimately help foster a relationship-centered PCMH.

Improving Adherence to Care Recommendations Using a Community Health Worker (CHW) Intervention with the Pediatric Medical Home

While CHW interventions improve health outcomes, evidence identifying specific domains of CHW-delivered support resulting in positive outcomes is limited. Our goals were to identify domains of CHW-delivered support that assist families with adhering to recommended pediatric care; and, to identify predictors of successful completion of an enriched medical home intervention (EMHI) using trained CHWs making home visits to provide health education and support positive health behaviors. We performed a prospective descriptive study of 88 families participating in a protocol-based EMHI. Completers (N = 46) finished the program with mutual agreement that the family can independently adhere to recommended clinical care. Non-completers (N = 42) were lost to follow-up or dropped out of the program before reaching this milestone. Using Grounded Theory, two trained coders evaluated CHW tasks recorded in an electronic database and classified these tasks across 17 domains. We assessed predictors of EMHI completion using logistic regression. The 88 EMHI participants were primarily <24 months of age (80 %), Hispanic (56 %), and Medicaid enrollees (67 %). Hispanic families (OR = 2.76, p = 0.04) and those with self-reported program goals to 'facilitate family's creation of a system to keep track of child's medical information' (OR = 3.11, p = 0.02) or a 'newborn-specific goal' (OR = 3.21, p = 0.04), such as feeding and safety tips, were more likely to complete the EMHI compared to their counterparts. The most consistent CHW tasks were supporting medical appointments, medication maintenance, and providing health education. CHW interventions designed to improve health behavior outcomes of 'at-risk' families, including Medicaid enrollees, may benefit from support in goal-setting and strategies to systematically manage their child's medical care.

Psychometric evaluation and design of patient-centered communication measures for cancer care settings

OBJECTIVE

To evaluate the psychometric properties of questions that assess patient perceptions of patient-provider communication and design measures of patient-centered communication (PCC).

METHODS

Participants (adults with colon or rectal cancer living in North Carolina) completed a survey at 2 to 3 months post-diagnosis. The survey included 87 questions in six PCC Functions: Exchanging Information, Fostering Health Relationships, Making Decisions, Responding to Emotions, Enabling Patient Self-Management, and Managing Uncertainty. For each Function we conducted factor analyses, item response theory modeling, and tests for differential item functioning, and assessed reliability and construct validity.

RESULTS

Participants included 501 respondents; 46% had a high school education or less. Reliability within each Function ranged from 0.90 to 0.96. The PCC-Ca-36 (36-question survey; reliability=0.94) and PCC-Ca-6 (6-question survey; reliability=0.92) measures differentiated between individuals with poor and good health (i.e., known-groups validity) and were highly correlated with the HINTS communication scale (i.e., convergent validity).

CONCLUSION

This study provides theory-grounded PCC measures found to be reliable and valid in colorectal cancer patients in North Carolina. Future work should evaluate measure validity over time and in other cancer populations.

PRACTICE IMPLICATIONS

The PCC-Ca-36 and PCC-Ca-6 measures may be used for surveillance, intervention research, and quality improvement initiatives.

The Impact of Patient-Centered Medical Homes on Quality of Care and Medication Adherence in Patients with Diabetes Mellitus

BACKGROUND

Current evidence suggests that patient-centered medical homes (PCMHs) potentially increase overall quality of disease management, including preventive care. However, there are mixed findings regarding quality of diabetes care, and little evidence exists with respect to the effect of PCMHs on medication adherence in patients with diabetes.

OBJECTIVE

To investigate associations between PCMHs and process measures of diabetes care, as well as adherence to oral hypoglycemic agents (OHAs) in patients with diabetes in a nationally representative U.S.

SAMPLE

METHODS

Using the 2009-2013 longitudinal data files from the Medical Expenditure Panel Survey, adult diabetes patients were identified. Patients whose usual sources of care have all PCMH features at baseline (i.e., enhanced access after hours and online, shared decision making, and enhanced patient engagement) were categorized as the PCMH group, which was compared with patients without PCMH features. Process measures of diabetes care included ≥ 2 hemoglobin A1c tests and ≥ 1 cholesterol test, foot examination, dilated eye examination, and flu vaccination during 1 year of follow-up. Medication possession ratio (MPR) during follow-up was calculated for patients with OHAs without any insulin use, with MPR ≥ 80% considered to be adherent to OHAs. Univariate and multivariate regression models considering sampling strata and weights were used to examine the association between the PCMH and study outcomes.

RESULTS

A total of 3,334 patients with diabetes was identified, representing 61 million U.S. lives. The mean (SE) age was 61.6 (0.3) years, and 52.4% of patients were female. The mean (SE) years of having diabetes was 12.0 (0.2) years. Approximately 11.4% of the patients were categorized as the PCMH group at baseline, and only 3.6% of those patients remained in the PCMH group for 2 years. Of the diabetic patients identified, only 26.9% met all of the diabetes care process measure criteria defined in this study. A higher proportion of patients met process measure criteria in the PCMH group compared with the non-PCMH group (33.8% vs. 26.0%, respectively, P = 0.015). The weighted mean MPR (95% CI) of OHAs from the 2 groups were not statistically different (0.68, 95% CI = 0.63-0.74 for the PCMH group; 0.77, 95% CI = 0.72-0.82 for the non-PCMH group, P = 0.675), resulting in 47.4% of adherent patients in the study population. Overall, the PCMH group was associated with improvement in the process measures of diabetes care (adjusted odds ratios [OR] = 1.42, 95% CI = 1.06-1.91). The effect was greater among the patients who stayed in the PCMH group for 2 years (OR = 2.09, 95% CI = 1.27-3.45); were aged < 65 years (OR = 2.19, 95% CI = 1.47-3.28); or had less than 3 comorbid conditions (OR = 2.38, 95% CI = 1.46-3.88). However, the PCMH group was not associated with an increased adherence to OHAs (P = 0.495) or an increase in MPR (P = 0.570).

CONCLUSIONS

Patients with all PCMH features were associated with improvement in the process measures of diabetes care, but not in adherence to OHAs. Future studies should investigate the mechanism of PCMHs in overall quality of care, as well as medication adherence.

DISCLOSURES

No outside funding supported this study. The author reports no conflicts of interests.

'Who is on your health-care team?' Asking individuals with heart failure about care team membership and roles

BACKGROUND

Complex, chronically ill patients require interprofessional teams to address their multiple health needs; heart failure (HF) is an iconic example of this growing problem. While patients are the common denominator in interprofessional care teams, patients have not explicitly informed our understanding of team composition and function. Their perspectives are crucial for improving quality, patient-centred care.

OBJECTIVES

To explore how individuals with HF conceptualize their care team, and perceive team members' roles.

SETTING AND PARTICIPANTS

Individuals with advanced HF were recruited from five cities in three Canadian provinces.

DESIGN

Individuals were asked to identify their HF care team during semi-structured interviews. Team members' titles and roles, quotes pertaining to team composition and function, and frailty criteria were extracted and analysed using descriptive statistics and content analysis.

RESULTS

A total of 62 individuals with HF identified 2-19 team members. Caregivers, nurses, family physicians and cardiologists were frequently identified; teams also included dentists, foot care specialists, drivers, housekeepers and spiritual advisors. Most individuals met frailty criteria and described participating in self-management.

DISCUSSION

Individuals with HF perceived being active participants, not passive recipients, of care. They identified teams that were larger and more diverse than traditional biomedical conceptualizations. However, the nature and importance of team members' roles varied according to needs, relationships and context. Patients' degree of agency was negotiated within this context, causing multiple, sometimes conflicting, responses.

CONCLUSION

Ignoring the patient's role on the care team may contribute to fragmented care. However, understanding the team through the patient's lens - and collaborating meaningfully among identified team members - may improve health-care delivery.

HIV Provider Experiences Engaging and Retaining Patients in HIV Care and Treatment: "A Soft Place to Fall"

Engaging and retaining persons with HIV in care and treatment is key to reducing new HIV infections in the United States. Understanding the experiences, barriers, and facilitators to engaging and retaining persons in HIV care from the perspective of HIV care providers could help provide insight into how best to achieve this goal. We present qualitative data from 30 HIV care providers in three cities. We identified three facilitators to HIV care: providing a medical home, team-based care and strategies for engaging and retaining patients in HIV care, and focus on provider-patient relationships. We identified two main barriers to care: facility-level policies and patient-level challenges. Our findings suggest that providers embrace the medical home model for engaging patients but need support to identify aspects of the model that promote engagement in long-term HIV care, improve the quality of the provider-patient relationship, and address persistent logistical barriers, such as transportation.

Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis

The expansion of primary care and community-based service delivery systems is intended to meet emerging needs, reduce the costs of hospital-based ambulatory care and prevent avoidable hospital use by the provision of more appropriate care. Great emphasis has been placed on the role of self-management in the complex process of care of patient with long-term conditions. Several studies have determined that nurses, among the health professionals, are more recommended to promote health and deliver preventive programs within the primary care context. The aim of this systematic review and meta-analysis is to assess the efficacy of the nurse-led self-management support versus usual care evaluating patient outcomes in chronic care community programs. Systematic review was carried out in MEDLINE, CINAHL, Scopus and Web of Science including RCTs of nurse-led self-management support interventions performed to improve observer reported outcomes (OROs) and patients reported outcomes (PROs), with any method of communication exchange or education in a community setting on patients >18 years of age with a diagnosis of chronic diseases or multi-morbidity. Of the 7,279 papers initially retrieved, 29 met the inclusion criteria. Meta-analyses on systolic (SBP) and diastolic (DBP) blood pressure reduction (10 studies-3,881 patients) and HbA1c reduction (7 studies-2,669 patients) were carried-out. The pooled MD were: SBP -3.04 (95% CI -5.01--1.06), DBP -1.42 (95% CI -1.42--0.49) and HbA1c -0.15 (95% CI -0.32-0.01) in favor of the experimental groups. Meta-analyses of subgroups showed, among others, a statistically significant effect if the interventions were delivered to patients with diabetes (SBP) or CVD (DBP), if the nurses were specifically trained, if the studies had a sample size higher than 200 patients and if the allocation concealment was not clearly defined. Effects on other OROs and PROs as well as quality of life remain inconclusive.

Factors Influencing Communication with Doctors via the Internet: A Cross-Sectional Analysis of 2014 HINTS Survey

Based on Street's (2003) ecological framework of communication in medical encounters, this study examined personal, interpersonal, and media factors that could influence patients' use of the Internet to communicate with doctors. Results from data analysis of responses from the 2014 Health Information National Trends Survey showed that patient activation and ease of Internet access were two positive predictors of online doctor-patient communication. In addition, patients' trust in doctors positively moderated the relationships between patient activation and online doctor-patient communication, and between perceived health status and online doctor-patient communication. Finally, the quality of patients' past experiences communicating with doctors had a positive moderation effect on the association between health information seeking behavior and online doctor-patient communication. Implications and limitations are discussed.

Patient-centered medical homes in Louisiana had minimal impact on Medicaid population's use of acute care and costs

The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward.

Psychologists' Contributions to Patient-Centered Medical Homes

Mounting evidence supports the value of integrated healthcare and the need for interprofessional practice within patient-centered medical homes (PCMH). Incorporating behavioral health services is key to fully implementing the PCMH concept. Unfortunately, psychologists have not been front and center in this integrative and interprofessional care movement nor have they typically received adequate training or experience to work effectively in these integrated care programs. This article builds the case for the value of PCMHs, particularly those that incorporate behavioral health services. Attention is paid to the diverse roles psychologists play in these settings, including as direct service providers, consultants, teachers/supervisors, scholars/program evaluators, and leaders. There is a discussion of the competencies psychologists must possess to play these roles effectively. Future directions are discussed, with a focus on ways psychologists can bolster the PCMH model by engaging in interprofessional partnerships related to education and training, practice, research, and leadership.

Redesign of chronic illness care in children and adolescents: evidence for the chronic care model

PURPOSE OF REVIEW

This article provides an overview of the chronic care model (CCM), examines the evidence for its utility in pediatric and adolescent chronic illness, and discusses practical steps for improving chronic illness care in the pediatric medical home.

RECENT FINDINGS

Few studies have used the CCM as an improvement framework in pediatrics. However, in recent years, several quality improvement efforts based on the CCM have demonstrated improvement in important process measures or clinical outcomes in pediatric or adolescent obesity, inflammatory bowel disease, attention-deficit/hyperactivity disorder, depression, and asthma.

SUMMARY

The CCM is an improvement framework that has demonstrated success in improving the care of children and adolescents with chronic disease. More research is needed to identify priority conditions for improvement efforts, to better understand the mediators of health outcomes in pediatric chronic disease, and to rigorously demonstrate the effectiveness of new models of chronic illness care. The evidence to date suggests that the CCM may be useful in guiding the redesign of care delivery systems to improve the health outcomes of young people with chronic disease.

Patient-Centered Homes and Integrated Behavioral Health Care: Reclaiming the Role of "Consultant" for Psychiatric-Mental Health Nurse Practitioner

The notion of patient-centered care has long been linked with nursing practice since Florence Nightingale. The discipline of nursing is focused on the holistic care of individuals, families, and communities in times of sickness and/or health. However, in psychiatric-mental health nursing, the concepts of mental health and psychiatric illness still remain marginalized in our health care delivery systems, as well as in nursing education, knowledge development, and practice. Even with the concept of patient-centered homes, acute and primary care providers are reluctant to embrace care of those with psychiatric illness in their respective settings. Psychiatric illness was and continues to be in the shadows, hidden and often ignored by the larger community as well as by health care providers. This paper describes a Health Resources Services Administration (HRSA) Advanced Nursing Education (ANE) training grant's objective of reintegrating psychiatric-mental health practice into ALL health care delivery systems using the concept of patient-centered nursing care as a foundation for, and promotion of, the Psychiatric-Mental Health Nurse Practitioner (PMH-NP) as the "navigator" for not only the patients and their families, but also for their acute and primary care colleagues using an Interprofessional Education Model. The major barriers and lessons learned from this project as well as the need for psychiatric-mental health nurses to reclaim their role as a consultant/liaison in acute, primary, and long-term care settings will be discussed. The PMHNP as a consultant/liaison is being revitalized as an innovative advanced practice nursing health care model in North Carolina.

Future Directions for the Implementation and Dissemination of Statewide Developmental-Behavioral Pediatric Integrated Health Care

The integration of mental health and pediatric health care services has long been a goal for both research and practice. With the advent of federal policies developed to mandate clinical efficiency across the health care spectrum, this issue is becoming more salient. Applied literature on this topic is only recently emerging, however, and there are limited contextual examples to guide program development, research, and refinement. This article presents background information relevant to the development of such a program (the Center for Advancement of Youth). The cultural and organizational contexts for the project are discussed, with particular emphasis on models for cooperation among several institutions of varying size and scope. The implications for the future of tangible research in this area are also discussed, with attention to extending lessons learned to diverse settings motivated to integrate various aspects of health care service provision.

Physician Perspectives on Medical Home Recognition for Practice Transformation for Children

OBJECTIVE

To examine child-serving physicians' perspectives on motivations for and support for practices in seeking patient-centered medical home (PCMH) recognition, changes in practice infrastructure, and care processes before and after recognition, and perceived benefits and challenges of functioning as a PCMH for the children they serve, especially children with special health care needs.

METHODS

Semistructured interviews with 20 pediatricians and family physicians at practices that achieved National Committee for Quality Assurance level 3 PCMH recognition before 2011. We coded notes and identified themes using an iterative process and pattern recognition analysis.

RESULTS

Physicians reported being motivated to seek PCMH recognition by a combination of altruistic and practical goals. Most said recognition acknowledged existing practice characteristics, but encouraged ongoing, and in some cases substantial, transformation. Although many physicians said recognition helped practices improve financial arrangements with payers and participate in quality initiatives, most physicians could not assess the specific benefits of recognition on patients' use of services or health outcomes. Challenges for practices in providing care for children included managing additional physician responsibilities, communicating with other providers and health systems, and building sustainable care coordination procedures.

CONCLUSIONS

PCMH recognition can be valuable to practices as a public acknowledgement to payers and patients that certain processes are in place, and can also catalyze new and continued transformation. Programs and policies seeking to transform primary care for children should leverage physicians' motivations and find mechanisms to build practices' capacity for care management systems and linkages with the medical neighborhood.

Improving management of resistant hypertension: Rationale and protocol for a cluster randomized trial addressing physician managers in primary care

BACKGROUND

Resistant hypertension (RH) is defined as uncontrolled blood pressure (BP) despite ≥3 antihypertensive agents. It is estimated to account for 12-28% of all hypertensive patients. Despite a higher risk of cardiovascular events, hypertension therapy in these patients is often insufficient. In a previous study we successfully tested an evidence-based, physician manager-centered hypertension management.

METHODS

For this cluster randomized trial (CRT), a random sample of 102 German primary care practices will be randomized into two study arms (1:1). Physician managers and practice assistants of the intervention arm will participate in three-session medical education on hypertension management to implement 1) standardized diagnostic and therapeutic procedures for RH patients, 2) structured recall of patients with uncontrolled BP, and 3) teaching and supervision of RH patients on BP self-measurements. Practice tools are provided to facilitate implementation, e.g., how to distinguish true from pseudo RH and guideline-based medication selection. Physicians will specify guideline-algorithms for their practice to manage RH. A secured web-based peer-group exchange with hypertension specialists is offered to both professional groups. Physicians of both study arms will consecutively recruit patients with RH. BP will be measured by ambulatory BP monitoring at baseline and after 12 months. The primary endpoint is defined as treatment success with either normalized BP (24h<130/80 mmHg) and/or a reduction by ≥20 mmHg systolic and/or ≥10 mmHg diastolic. Secondary analyses will focus on changes in physicians' knowledge and practice routines.

DISCUSSION

This CRT will determine the effectiveness of a physician manager-centered intervention on treatment success in high-risk patients.

Using Digital Technology to Engage and Communicate with Patients: A Survey of Patient Attitudes

BACKGROUND

As primary care moves toward a system of population health management, providers will need to engage patients outside traditional office-based interactions.

OBJECTIVE

We assessed patient attitudes regarding technology use to communicate with their primary care team or to engage with other patients outside typical office settings. Design/Participants/Main Measures We conducted a national survey using GfK KnowledgePanel(®) to examine attitudes on the use of digital technology (email, text messaging, and social media such as Facebook and Twitter) to communicate with primary care teams about health behavior goals and test results. We also assessed attitudes toward the use of digital technologies to engage with other patients in activities such as peer coaching.

KEY RESULTS

Of the 5119 panel members invited to participate, 3336 completed the survey (response rate, 65.2 %). Among respondents, more than half (58 %) reported using Facebook, and nearly two-thirds (64.1 %) used text messaging. Overall, few participants were willing to communicate about health goals via social media (3.1 %) or text messaging (13.3 %), compared to email (48.8 %) or phone (75.5 %) (results were similar for communication about test results). Among those that used text messaging, race/ethnicity was the only factor independently associated with greater support for text messaging [African American (OR 1.44; 95 % CI, 1.01-2.06) and Hispanic (OR 1.8; 95 % CI, 1.25-2.59)] in multivariate models. Participants interested in engaging in peer coaching through Facebook (11.7 %) were more likely to be younger (p < 0.0001), female (p < 0.001), and a racial/ethnic minority (African American, non-Hispanic or Hispanic, p < 0.0004).

CONCLUSIONS

Despite regular use of new digital technology such as text messaging and social media, few participants supported using these tools for communicating with their physicians' practice. Participants were most supportive of using email for communication. Contrary to previous studies, among users of technology, low socioeconomic status and racial/ethnic minorities were equally or more likely to support use.

Affordable Care Act and Diabetes Mellitus

The Affordable Care Act (ACA) has the potential for great impact on U.S. health care, especially for chronic disease patients requiring long-term care and management. The act was designed to improve insurance coverage, health care access, and quality of care for all Americans, which will assist patients with diabetes mellitus in acquiring routine monitoring and diabetes-related complication screening for better health management and outcomes. There is great potential for patients with diabetes to benefit from the new policy mandating health insurance coverage and plan improvement, Medicaid expansion, minimum coverage guarantees, and free preventative care. However, policy variability among states and ACA implementation present challenges to people with diabetes in understanding and optimizing ACA impact. This paper aims to select the most influential components of the ACA as relates to people with diabetes and discuss how the ACA may improve health care for this vulnerable population.

Patient perceptions and expectations of an anticoagulation service: a quantitative comparison study of clinic-based testers and patient self-testers

BACKGROUND

Government initiatives see the provision of technology-assisted self-care as one of the key areas in which there is capacity for improving quality of care whilst reducing costs. However, levels of patient engagement in self-testing and management (STM) remain low. Little emphasis has been placed on understanding the patients' perspectives of the reasons for this limited engagement. Typically, patient engagement in STM is achieved via the provision of patient education programmes, which aim to enable patients to make the changes necessary to become competent self-carers. However, placing the onus to change on the individual patient is unrealistic. If levels of patient engagement are to be improved, patient needs and expectations of clinical services must be better understood and service provision must be adapted accordingly.

OBJECTIVE

Explore patient perceptions and expectations of clinical service provision and their views of having and making choices about care.

METHODS

Participants [N = 191, 103 patient self-tester managers (PSTMs) and 87 clinic-based testers (CBTs)] completed the SERVQUAL and ChQ instruments to capture perspectives on service quality and choice, respectively. A comparative statistical analysis explored the similarities and differences between PSTMs' and CBTs' responses.

RESULTS

Clinic-based testers' perceptions of service quality were significantly more positive than PSTMs', as were their expectations of the 'tangible' aspects of service delivery. PSTMs' expectations of service quality were significantly higher than their perceptions. PSTMs attributed significantly more value to making choices compared with CBTs.

CONCLUSIONS AND RECOMMENDATIONS

To close the gap between PSTMs expectations and perceptions of service quality and better cater for their choice preferences, service providers may benefit from taking into account the following practice considerations: maintain frequent, timely, personalised and direct interactions with PSTMs; prioritise investment in resources to facilitate patient/practitioner interaction over tangible facilities; ensure that PSTMs are given the opportunity to make choices about their care.

Mental health service use types among Asian Americans with a psychiatric disorder: considerations of culture and need

Despite levels of need that are comparable with other groups, relatively few Asian Americans receive mental health care. While studies have described the tendency for Asian Americans to delay care until mental health symptoms are severe, relatively little research has examined how the severity of symptoms impact mental health service use. This study uses publicly available data from the National Latino and Asian American Study (NLAAS) and focuses solely on Asian American respondents with a psychiatric disorder (n = 230). Unexpectedly, few Asian Americans with a psychiatric disorder received care in a medical setting. The perception of mental health needs increased the likelihood of using mental health specialist care. Social and systemic barriers together hinder mental health service use. Implications for addressing Asian American mental health service use within a changing health care environment are discussed.

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities

The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA.

Effects of depression on the subsequent year's healthcare expenditures among older adults: two-year panel study

This study investigated changes in depression status over 2 years and examined whether having depression in Year 1 is associated with greater healthcare expenditures in Year 2 among community-dwelling older adults. This study analyzed the Medical Expenditure Panel Survey (Panel 13, 2008-2009) for a nationally representative sample of 1,740 older adults (65+). The two self-reported depression measures used were the ICD-9-CM (depression) and Patient Health Questionnaire-2 (potential depression, scores 3 or higher). Using the combined two-part models, additional healthcare costs at Year 2 associated with the Year 1 depression status were calculated by the service type after adjusting for predisposing, enabling, and need covariates assessed at Year 2. Over 7.9% of older adults reported depression and an additional 6.5% presented with potential depression. The ICD-9 depression status was relatively stable; 84% continued reporting depression during Year 2. Those with depression at Year 1 spent $3,855 more on total healthcare, $1,053 more on office-based visits, and $929 more on prescription drugs during Year 2 compared with non-depressed people after controlling for other covariates, including healthcare needs (p < .05). While potential depression was less persistent (31.1% remained potentially depressed at Year 2), potential depression was associated with lower socio-economic status and greater healthcare expenditures from home health services and emergency department visits during Year 2. These results indicate the importance of monitoring depression in older adults, considering its impacts on the increases in healthcare expenditures in the following year even after controlling for co-occurring health conditions.

Cost-effectiveness of a Barcelona home care program for individuals with multimorbidity

To improve the efficiency and effectiveness of care and optimize healthcare resources, a home healthcare program was created for individuals with multiple chronic conditions. Demographic and clinical characteristics of the 261 individuals (mean age 84) included in the program from its inception in 2011 through 2013 (mean stay in the program 203±192 days) were prospectively analyzed. The number of hospital admissions, length of stay, and costs for individuals admitted to the program were compared for two time periods: the 6 months before admission to the program and their stay in the program. After admission to the program, the number of hospital admissions and the hospital length of stay per person per month decreased from 0.36±0.21 to 0.19±0.52 (P<.001) and from 3.5 to 1 day (P<.001), respectively. Surveys of randomly selected patients and caregivers showed high satisfaction with the program. Costs per person per day decreased from €54.65 (US$73.12) to €17.91 (US$23.96), a reduction of 67.1%. Fewer admissions and shorter hospital stays enabled the hospital to eliminate one acute bed for every 50 individuals admitted to the program. In conclusion, home care for individuals with chronic illness with multimorbidity reduced the number of hospital admissions and length of stay, resulting in good patient satisfaction and lower costs.

The most used and most helpful facilitators for patient-centered medical home implementation

Background

Like other transformative healthcare initiatives, patient-centered medical home (PCMH) implementation requires substantial investments of time and resources. Even though PCMH and PCMH-like models are being implemented by multiple provider practices and health systems, little is known about what facilitates their implementation. The purpose of this study was to assess which PCMH-implementation resources are most widely used, by whom, and which resources primary care personnel find most helpful.

Methods

This study is an analysis of data from a cross-sectional survey of primary care personnel in the Veterans Health Administration in 2012, in which respondents were asked to rate whether they were aware of and accessed PCMH-implementation resources, and to rate their helpfulness. Logistic regression was used to produce odds ratios for the outcomes (1) resource use and (2) resource helpfulness. Respondents were nested within clinics, nested, in turn, within 135 parent hospitals.

Results

Teamlet huddles were the most widely accessed (80.4% accessed) and most helpful (90.4% rated helpful) resource; quality-improvement methods to conduct small tests of change were the least frequently accessed (42.4% accessed) resource though two-thirds (66.7%) of users reported as helpful. Supervisors were significantly more likely (ORs, 1.46 to 1.86) to use resources than non-supervisors but were less likely to rate the majority (8 out of 10) of resources as “somewhat/very helpful” than non-supervisors (ORs, 0.72 to 0.84). Longer-tenured employees tended to rate resources as more helpful.

Conclusions

These findings are the first in the PCMH literature that we are aware of that systematically assesses primary care staff’s access to and the helpfulness of PCMH implementation resources. Supervisors generally reported greater access to resources, relative to non-supervisors, but rated resources as less helpful, suggesting that information about them may not have been optimally disseminated. Knowing what resources primary care staff use and find helpful can inform administrators’ and policymakers’ investments in PCMH-implementation resources. The implications of our model extend beyond just PCMH implementation but also to considerations when providing implementation resources for other complex quality-improvement initiatives.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0246-9) contains supplementary material, which is available to authorized users.

Hypertension management in primary care: study protocol for a cluster randomized controlled trial

BACKGROUND

Studies worldwide show insufficient blood pressure control rates, and effective management of hypertension remains a challenge in general practice. Although structured forms of care improved blood pressure in randomized controlled trials, little is known about their effects under routine primary care. This cluster randomized trial (CRT) evaluates the effects of a modern interactive medical education series for general practitioners on hypertension management, including practice redesign strategies.

METHODS/DESIGN

For this CRT, 24 primary care academic teaching practices of the University of Duisburg-Essen, Germany, are randomized into two study arms. With the objective of improving hypertension control, general practitioners of the intervention group participate in a three-session medical education program on structured hypertension management. The program aims at changing physician awareness and practice design. Various practice tools are provided: for example, checklists on valid blood pressure readings, medication selection, detection of secondary hypertension, and patient education. General practitioners of both study groups include hypertensive patients with and without hypertension-related diseases such as angiographically proven coronary disease, and peripheral or cerebral vascular disease. Blood pressure is measured by 24-hour readings. Analyses will focus on differences in blood pressure control and changes of practice management between intervention and control group.

DISCUSSION

The study will determine the effectiveness of our practice redesign intervention on hypertension control. The intervention addresses general practitioners and practice assistants, while aiming at benefits on the patient level. Therefore, the cluster design is used to evaluate the effects.

TRIAL REGISTRATION

DRKS00006315 (date of registration: 14 July 2014).

Subjective experience or objective process: understanding the gap between values and practice for involving patients in designing patient-centred care

PURPOSE

Patient-centred care and patient involvement are increasingly central concepts in health policy in the UK and elsewhere. However, there is little consensus regarding their definition or how to achieve "patient-centred" care in everyday practice or how to involve patients in service redesign initiatives. The purpose of this paper is to explore these issues from the perspective of key stakeholders within National Health Service (NHS) hospitals in the UK.

DESIGN/METHODOLOGY/APPROACH

Semi-structured interviews, covering a range of topics related to service redesign, were conducted with 77 key stakeholders across three NHS Trusts in the West Midlands. In total, 20 of these stakeholders were re-interviewed 18 months later. Data were managed and analysed using the Framework Method.

FINDINGS

While patient-centred care and patient involvement were regularly cited as important to the stakeholders, a gap persisted between values and reported practice. This gap is explained through close examination of the ways in which the concepts were used by stakeholders, and identifying the way in which they were adapted to fit other organizational priorities. The value placed on positive subjective experience changed to concerns about objective measurement of the patients as they move through the system.

RESEARCH LIMITATIONS/IMPLICATIONS

Increased awareness and reflection on the conceptual tensions between objective processes and subjective experiences could highlight reasons why patient-centred values fail to translate into improved practice.

ORIGINALITY/VALUE

The paper describes and explains a previously unarticulated tension in health organisations between values and practice in patient centred care and patient involvement in service redesign.

Healthcare system supports for young adult patients with pediatric onset chronic conditions: a qualitative study

Over 90% of children with chronic conditions survive into adulthood necessitating primary care teams to care for adults with pediatric-onset chronic conditions. This study explores practice supports and barriers to care for this population via qualitative techniques. Using in depth interviews with twenty-two healthcare providers practice supports identified include: formalizing intake processes, interoperable electronic medical records, and leveraging care coordination. Barriers identified included: definition of the medical team, lack of appropriate medical records, time and administrative burden, lack of training, and financial constraints. Themes may be utilized to design interventions and improve care coordination for patients with pediatric-onset chronic conditions.

Association between medical home characteristics and staff professional experiences in pediatric practices

BACKGROUND

The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature.

METHODS

Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware's seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice's medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%.

RESULTS

Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout.

CONCLUSIONS

Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.

Do patient-centered medical homes reduce emergency department visits?

OBJECTIVE

To assess whether adoption of the patient-centered medical home (PCMH) reduces emergency department (ED) utilization among patients with and without chronic illness.

DATA SOURCES

Data from approximately 460,000 Independence Blue Cross patients enrolled in 280 primary care practices, all converting to PCMH status between 2008 and 2012.

RESEARCH DESIGN

We estimate the effect of a practice becoming PCMH-certified on ED visits and costs using a difference-in-differences approach which exploits variation in the timing of PCMH certification, employing either practice or patient fixed effects. We analyzed patients with and without chronic illness across six chronic illness categories.

PRINCIPAL FINDINGS

Among chronically ill patients, transition to PCMH status was associated with 5-8 percent reductions in ED utilization. This finding was robust to a number of specifications, including analyzing avoidable and weekend ED visits alone. The largest reductions in ED visits are concentrated among chronic patients with diabetes and hypertension.

CONCLUSIONS

Adoption of the PCMH model was associated with lower ED utilization for chronically ill patients, but not for those without chronic illness. The effectiveness of the PCMH model varies by chronic condition. Analysis of weekend and avoidable ED visits suggests that reductions in ED utilization stem from better management of chronic illness rather than expanding access to primary care clinics.