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Cogan AM, Haltom TM, Shimada SL, Davila JA, McGinn BP, Fix GM. Understanding patients' experiences during transitions from one electronic health record to another: A scoping review. PEC Innov 2024; 4:100258. [PMID: 38327990 PMCID: PMC10847675 DOI: 10.1016/j.pecinn.2024.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/09/2023] [Accepted: 01/21/2024] [Indexed: 02/09/2024]
Abstract
Objectives Identify existing research on impacts of transitions between electronic health record (EHR) systems on patients' healthcare experiences. Methods Scoping review. We searched MedLine, OVID, Embase, CINAHL, and PsycInfo databases for articles on patient experiences with EHR-to-EHR transitions. Results Three studies met inclusion criteria. All three used validated surveys to compare patient satisfaction with care pre- and post-transition. The surveys did not include specific questions about the EHR transition; one study focused on patient perceptions of provider computer use. Satisfaction levels initially decreased following EHR implementation, then returned to baseline between six and 15 months later in two of three studies. Factors associated with changes in observed satisfaction are unknown. Conclusions Patient experience has been given limited attention in studies of EHR-to-EHR transitions. Future research should look beyond satisfaction, and examine how an EHR-to-EHR transition can impact the quality of patients' care, including safety, effectiveness, timeliness, efficiency, and equity. Innovation To our knowledge, this is the first literature review on EHR transitions that specifically focused on patient experiences. In preparation for a transition from one EHR to another, healthcare system leaders should consider the multiple ways patients' experiences with care may be impacted and develop strategies to minimize disruptions in care.
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Affiliation(s)
- Alison M. Cogan
- Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
- Center for the Study of Health Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Trenton M. Haltom
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine-Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie L. Shimada
- Center for Healthcare Organization and Implementation Research (CHOIR) at the Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jessica A. Davila
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine-Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Bryan P. McGinn
- Department of Health Policy and Management, Providence College, Providence, RI, USA
| | - Gemmae M. Fix
- Center for Healthcare Organization and Implementation Research (CHOIR) at the Bedford VA Medical Center, Bedford, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
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Zogas A, Sitter KE, Barker AM, Fix GM, Khanna A, Herbst AN, Vimalananda VG. Strategies for engaging patients in co-design of an intervention. Patient Educ Couns 2024; 123:108191. [PMID: 38367306 DOI: 10.1016/j.pec.2024.108191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVE We provide practical guidance about using co-design methods to collaborate with patients to create patient-facing interventions, which others can use when undertaking similar projects. METHODS This is a narrative review synthesizing co-design principles and published literature with our experience working alongside five Veteran patients of the U.S. Department of Veterans Affairs in New England to co-design a portfolio of patient-facing materials to improve patient-centered care coordination. Our process took 12 weeks (April - June 2022) and was conducted entirely via video conference. RESULTS Co-design is a participatory research method. Its principles include sharing power over the research process and products, agency for all participants, embracing a plurality of forms of knowledge, and mutual and reciprocal benefit. We describe three stages of the co-design process (preparatory work; design and development; feedback and closure), strategies and techniques we used at each stage, challenges we faced, and considerations for addressing them. CONCLUSION Co-designing patient-facing interventions blends different forms of knowledge to produce practical, contextually specific interventions with ownership by the people who will use them. PRACTICE IMPLICATIONS Co-design is a feasible methodology for most health services research teams whose goal is to intensify patient engagement in research.
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Affiliation(s)
- Anna Zogas
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA; Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Kailyn E Sitter
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Anna M Barker
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Gemmae M Fix
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA; Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Aishwarya Khanna
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA; University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Abigail N Herbst
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA; Section of Endocrinology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Foster M, Fix GM, Hyde J, Dunlap S, Byrne TH, Sugie NF, Kuhn R, Gabrielian S, Roncarati JS, Zhao S, McInnes DK. Capturing the Dynamics of Homelessness Through Ethnography and Mobile Technology: Protocol for the Development and Testing of a Smartphone Technology-Supported Intervention. JMIR Res Protoc 2024; 13:e53022. [PMID: 38648101 DOI: 10.2196/53022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/23/2024] [Accepted: 02/22/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND US military veterans who have experienced homelessness often have high rates of housing transition. Disruptions caused by these transitions likely exacerbate this population's health problems and interfere with access to care and treatment engagement. Individuals experiencing homelessness increasingly use smartphones, contributing to improved access to medical and social services. Few studies have used smartphones as a data collection tool to systematically collect information about the daily life events that precede and contribute to housing transitions, in-the-moment emotions, behaviors, geographic movements, and perceived social support. OBJECTIVE The study aims to develop and test a smartphone app to collect longitudinal data from veterans experiencing homelessness (VEH) and to evaluate the feasibility and acceptability of using the app in a population that is unstably housed or homeless. METHODS This study's design had 3 phases. Phase 1 used ethnographic methods to capture detailed data on day-to-day lived experiences of up to 30 VEH on topics such as housing stability, health, and health behaviors. Phase 2 involved focus groups and usability testing to develop and refine mobile phone data collection methods. Phase 3 piloted the smartphone mobile data collection with 30 VEH. We included mobile ethnography, real-time surveys through an app, and the collection of GPS data in phase 3. RESULTS The project was launched in June 2020, and at this point, some data collection and analysis for phases 1 and 2 are complete. This project is currently in progress. CONCLUSIONS This multiphase study will provide rich data on the context and immediate events leading to housing transitions among VEH. This study will ensure the development of a smartphone app that will match the actual needs of VEH by involving them in the design process from the beginning. Finally, this study will offer important insights into how best to develop a smartphone app that can help intervene among VEH to reduce housing transitions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/53022.
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Affiliation(s)
- Marva Foster
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, United States
- Department of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Gemmae M Fix
- Department of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Justeen Hyde
- Department of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Thomas H Byrne
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Department of Social Welfare Policy, Boston University School of Social Work, Boston, MA, United States
| | - Naomi F Sugie
- Department of Criminology, Law and Society, University of California Irvine, Irvine, CA, United States
| | - Randall Kuhn
- Department of Community Health Services, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, United States
| | - Sonya Gabrielian
- Department of Mental Health, VA Greater Los Angeles, Los Angeles, CA, United States
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Jill S Roncarati
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, United States
- Boston Health Care for the Homeless Program, Boston, MA, United States
| | - Shibei Zhao
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
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Kaitz J, Vimalananda VG, Charns MP, Fix GM. Multidisciplinary providers' perceptions of care delivery for sleep disorders: A qualitative case study. Sleep Health 2024:S2352-7218(24)00009-3. [PMID: 38519364 DOI: 10.1016/j.sleh.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVES Sleep disorders are wide-ranging in their causes and impacts on other physical and mental health conditions. Thus, sleep disorders could benefit from a multidisciplinary approach to assessment and treatment. An integrated care model is often recommended but is costly to implement. We sought to understand how, in the absence of an established organizational structure for integrated sleep care, providers from different clinics work together to provide care for sleep disorders. METHODS A qualitative case study at one U.S. Department of Veterans Affairs (VA) medical center. We used a purposeful nested sampling strategy, combining maximum variation sampling and snowball sampling to recruit key staff involved in sleep care. RESULTS We interviewed providers (N = 10) from sleep medicine, primary care, and mental health services. Providers identified the ubiquity of sleep disorders and a concomitant need for multidisciplinary care. However, they described limited opportunities for multidisciplinary interactions and consequently a negative impact on clinical care. Providers described fragmentation in two areas: among sleep specialists and between sleep specialists and other referring and managing providers. CONCLUSIONS A range of interventions, based on setting and resources, could improve care coordination both among sleep specialists and between sleep and nonsleep providers. While integrated sleep specialist clinics could reduce care fragmentation, they may not directly impact coordination with referring providers, like primary care and general mental health, who are essential in managing chronic conditions. Future work should continue to explore improving care coordination for sleep problems to ensure patients receive high-quality, timely, patient-centered care.
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Affiliation(s)
- Jenesse Kaitz
- Sleep Medicine, VA Puget Sound Healthcare System, Seattle, Washington, USA.
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA; Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Martin P Charns
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA; Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, Massachusetts, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA; Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA; Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, Massachusetts, USA
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Wolfe HL, Fix GM, Hughto JMW, Hughes LD, Operario D, Hadland SE, Siegel J, Drainoni ML. Understanding how primary care providers report discussing substance use with transgender and gender diverse patients. Patient Educ Couns 2024; 120:108101. [PMID: 38103396 PMCID: PMC10842839 DOI: 10.1016/j.pec.2023.108101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/28/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES To explore how primary care providers report discussing substance use with transgender and gender diverse (TGD) adult patients within the context of discussing gender-affirming interventions. METHODS Between March and April 2022, in-depth, semi-structured qualitative interviews were conducted with 15 primary care providers who care for TGD patients in the Northeastern US. Thematic analysis was used to analyze interview data and identify themes. RESULTS Two primary themes emerged among providers: 1) placing a focus on harm reduction, emphasizing reducing negative consequences of substance use, and 2) using access to gender-affirming interventions as an incentive for patients to change their substance use patterns. CONCLUSIONS Focusing on harm reduction can emphasize reducing potential adverse outcomes while working with TGD patients towards their gender-affirmation goals. Future research should explore varying approaches to how substance use is discussed with TGD patients, as well as the interpretation of gender-affirming clinical guidelines. PRACTICE IMPLICATIONS Findings from this study indicate a need for enhancing provider knowledge around the appropriate application of gender-affirming care guidelines. Investing in training efforts to improve gender-affirming care is critical for encouraging approaches that prioritize harm reduction and do not unnecessarily prevent access to gender-affirming interventions.
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Affiliation(s)
- Hill L Wolfe
- Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, USA; Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, USA.
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, USA; Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, USA
| | - Jaclyn M W Hughto
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, USA; Department of Epidemiology, Brown University School of Public Health, Providence, USA; The Fenway Institute, Fenway Health, Boston, USA
| | - Landon D Hughes
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Scott E Hadland
- Division of Adolescent and Young Adult Medicine, Mass General for Children, Boston, USA; Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Jennifer Siegel
- Division of General Internal Medicine, Transgender Health Program, Massachusetts General Hospital, Boston, USA; Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, USA; Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA; Evans Center for Implementation and Improvement Sciences, Boston University, Boston, USA
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Jackson GL, Fix GM, White BS, Cutrona SL, Reardon CM, Damschroder LJ, Burns M, DeLaughter K, Opra Widerquist MA, Arasim M, Lindquist J, Gifford AL, King HA, Kaitz J, Jasuja GK, Hogan TP, Lopez JCF, Henderson B, Fitzgerald BA, Goetschius A, Hagan D, McCoy C, Seelig A, Nevedal A. Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration. Front Health Serv 2024; 3:1223277. [PMID: 38420338 PMCID: PMC10900518 DOI: 10.3389/frhs.2023.1223277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/20/2023] [Indexed: 03/02/2024]
Abstract
Introduction The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA. Methods Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators. Results In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank. Conclusion DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.
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Affiliation(s)
- George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Gemmae M. Fix
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Brandolyn S. White
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Caitlin M. Reardon
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Laura J. Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Madison Burns
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | | | - Maria Arasim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Jennifer Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
- Division of General Internal Medicine, Duke University, Durham, NC, United States
| | - Jenesse Kaitz
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Guneet K. Jasuja
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Timothy P. Hogan
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Jaifred Christian F. Lopez
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
| | - Blake Henderson
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Blaine A. Fitzgerald
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Amber Goetschius
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Danielle Hagan
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Carl McCoy
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Alex Seelig
- Agile Six Applications, Inc., San Diego, CA, United States
| | - Andrea Nevedal
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
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Faro EZ, Taber P, Seaman AT, Rubinstein EB, Fix GM, Healy H, Reisinger HS. Implicit and explicit: a scoping review exploring the contribution of anthropological practice in implementation science. Implement Sci 2024; 19:12. [PMID: 38347574 PMCID: PMC10863116 DOI: 10.1186/s13012-024-01344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/20/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND This study's goal is to identify the existing variation in how, why, and by whom anthropological practice is conducted as part of implementation science projects. As doctorally trained anthropologists, we sought to characterize how and why the term "ethnography" was variously applied in the implementation science literature and characterize the practice of anthropology within and across the field. METHODS While we follow the PRISMA-ScR checklist, we present the work with a narrative approach to accurately reflect our review process. A health services librarian developed a search strategy using subject headings and keywords for the following databases: PubMed, Embase (Elsevier), Cochrane CENTRAL (Wiley), CIHAHL (EBSCO), PsycINFO (EBSCO), Web of Science Core Collection, and Anthropology Plus (EBSCO). We focused on the practice of anthropology in implementation research conducted in a healthcare setting, in English, with no date restrictions. Studies were included if they applied one or several elements of anthropological methods in terms of study design, data collection, and/or analysis. RESULTS The database searches produced 3450 results combined after duplicates were removed, which were added to Rayyan for two rounds of screening by title and abstract. A total of 487 articles were included in the full-text screening. Of these, 227 were included and received data extraction that we recorded and analyzed with descriptive statistics in three main domains: (1) anthropological methods; (2) implementation science methods; and (3) study context. We found the use of characteristic tools of anthropology like ethnography and field notes are usually not systematically described but often mentioned. Further, we found that research design decisions and compromises (e.g., length of time in the field, logistics of stakeholder involvement, reconciling diverse firsthand experiences) that often impact anthropological approaches are not systematically described. CONCLUSIONS Anthropological work often supports larger, mixed-methods implementation projects without being thoroughly reported. Context is essential to anthropological practice and implicitly fundamental to implementation research, yet the goals of anthropology and how its practice informs larger research projects are often not explicitly stated.
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Affiliation(s)
- Elissa Z Faro
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Peter Taber
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Aaron T Seaman
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, ND, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford and VA Boston Healthcare System, Bedford, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Heather Healy
- Hardin Library for the Health Sciences, University of Iowa, Iowa City, IA, USA
| | - Heather Schacht Reisinger
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
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Murray GF, Lakin JR, Paasche-Orlow MK, Tulsky JA, Volandes A, Davis AD, Zupanc SN, Carney MT, Burns E, Martins-Welch D, LaVine N, Itty JE, Fix GM. Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial. J Gen Intern Med 2023; 38:3558-3565. [PMID: 37488368 PMCID: PMC10713958 DOI: 10.1007/s11606-023-08320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN Qualitative interview study. PARTICIPANTS Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Genevra F Murray
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Tufts University School of Medicine, Division of General Internal Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - James A Tulsky
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Section of General Internal Medicine, Boston, MA, USA
- ACP Decisions, Waban, MA, USA
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria T Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Edith Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Diana Martins-Welch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Nancy LaVine
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jennifer E Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Gemmae M Fix
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA, USA
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Herbst AN, McCullough MB, Wiener RS, Barker AM, Maguire EM, Fix GM. Proactively tailoring implementation: the case of shared decision-making for lung cancer screening across the VA New England Healthcare Network. BMC Health Serv Res 2023; 23:1282. [PMID: 37993840 PMCID: PMC10664378 DOI: 10.1186/s12913-023-10245-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/30/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Shared Decision-Making to discuss how the benefits and harms of lung cancer screening align with patient values is required by the US Centers for Medicare and Medicaid and recommended by multiple organizations. Barriers at organizational, clinician, clinical encounter, and patient levels prevent SDM from meeting quality standards in routine practice. We developed an implementation plan, using the socio-ecological model, for Shared Decision-Making for lung cancer screening for the Department of Veterans Affairs (VA) New England Healthcare System. Because understanding the local context is critical to implementation success, we sought to proactively tailor our original implementation plan, to address barriers to achieving guideline-concordant lung cancer screening. METHODS We conducted a formative evaluation using an ethnographic approach to proactively identify barriers to Shared Decision-Making and tailor our implementation plan. Data consisted of qualitative interviews with leadership and clinicians from seven VA New England medical centers, regional meeting notes, and Shared Decision-Making scripts and documents used by providers. Tailoring was guided by the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). RESULTS We tailored the original implementation plan to address barriers we identified at the organizational, clinician, clinical encounter, and patient levels. Overall, we removed two implementation strategies, added five strategies, and modified the content of two strategies. For example, at the clinician level, we learned that past personal and clinical experiences predisposed clinicians to focus on the benefits of lung cancer screening. To address this barrier, we modified the content of our original implementation strategy Make Training Dynamic to prompt providers to self-reflect about their screening beliefs and values, encouraging them to discuss both the benefits and potential harms of lung cancer screening. CONCLUSIONS Formative evaluations can be used to proactively tailor implementation strategies to fit local contexts. We tailored our implementation plan to address unique barriers we identified, with the goal of improving implementation success. The FRAME-IS aided our team in thoughtfully addressing and modifying our original implementation plan. Others seeking to maximize the effectiveness of complex interventions may consider using a similar approach.
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Affiliation(s)
- Abigail N Herbst
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
| | - Megan B McCullough
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
- Department of Public Health, Zuckerberg School of Health Sciences, University of Massachusetts, Lowell, MA, USA
| | - Renda Soylemez Wiener
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, DC, US, USA
- The Pulmonary Center, Boston University Chobanian &, Avedisian School of Medicine, Boston, MA, USA
| | - Anna M Barker
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
| | - Elizabeth M Maguire
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
| | - Gemmae M Fix
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA.
- General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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10
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Etingen B, Smith BM, Zeliadt SB, Kaitz JE, Barker AM, Hyde JK, Fix GM, Reed DE, Anderson E, Hogan TP, Bokhour BG. VHA Whole Health Services and Complementary and Integrative Health Therapies: a Gateway to Evidence-Based Mental Health Treatment. J Gen Intern Med 2023; 38:3144-3151. [PMID: 37442899 PMCID: PMC10651564 DOI: 10.1007/s11606-023-08296-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 06/16/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Engagement in evidence-based psychotherapy (EBP) among veterans with behavioral health conditions is often low. The Veterans Health Administration (VHA) is implementing a "Whole Health (WH)" system of care, to identify veteran personal health goals, align care with those goals, and offer services designed to engage and empower veterans to achieve well-being. OBJECTIVE To examine the relationship between veteran WH utilization and subsequent engagement in EBP. DESIGN Retrospective analysis of VHA administrative records from 18 facilities implementing WH. SUBJECTS Veterans (n = 265,364) with a diagnosis of depression, post-traumatic stress disorder (PTSD), and/or anxiety who had a mental healthcare encounter but no EBP use in fiscal year (FY) 2018. Among this cohort, 33,146 (12.5%) began using WH in FY2019. MAIN MEASURES We examined use of an EBP for depression, anxiety, and/or PTSD within 1 year of the index date of WH use compared to use of an EBP anytime during FY2019 for veterans not identified as using WH. We used multiple logistic regression to examine the association between veteran WH use and EBP engagement. KEY RESULTS Approximately 3.0% (n = 7,860) of the veterans in our overall cohort engaged in an EBP in the year following their index date. Controlling for key demographic, health, and utilization variables, WH users had 2.4 (95% CI: 2.2-2.5) times higher odds of engaging in an EBP the following year than those with no WH utilization. Associations between utilization of specific WH services (vs. no utilization of that service) and engagement in an EBP in the subsequent year ranged from 1.6 (95% CI: 1.0-2.6) to 3.5 (95% CI: 3.2-3.9) across the different types of WH services used. CONCLUSIONS WH use was associated with increased engagement in EBPs among veterans with depression, anxiety, and/or PTSD. Future interventions intended to promote veteran engagement in EBPs may benefit from leveraging WH services and therapies.
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Affiliation(s)
- Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA.
| | - Bridget M Smith
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Steven B Zeliadt
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
- University of Washington School of Public Health, Seattle, WA, USA
| | - Jenesse E Kaitz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Anna M Barker
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Justeen K Hyde
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - David E Reed
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Ekaterina Anderson
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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11
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Cordasco KM, Gable AR, Ganz DA, Brunner JW, Smith AJ, Hertz B, Post EP, Fix GM. Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements. J Gen Intern Med 2023; 38:1007-1014. [PMID: 37798582 PMCID: PMC10593700 DOI: 10.1007/s11606-023-08285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/13/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.
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Affiliation(s)
- Kristina M Cordasco
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Alicia R Gable
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - David A Ganz
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Julian W Brunner
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Brian Hertz
- Edward Hines Jr. VA Hospital, Hines, IL, USA
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- VA Central Office, Washington, DC, USA
| | - Edward P Post
- VA Central Office, Washington, DC, USA
- Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gemmae M Fix
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law Policy & Management, Boston University School of Public Health, Boston, MA, USA
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12
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Fix GM, Haltom TM, Cogan AM, Shimada SL, Davila JA. Understanding Patients' Preferences and Experiences During an Electronic Health Record Transition. J Gen Intern Med 2023:10.1007/s11606-023-08338-6. [PMID: 37580637 DOI: 10.1007/s11606-023-08338-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 07/13/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The Department of Veterans Affairs (VA) has embarked on the largest system-wide electronic health record (EHR) transition in history. To date, most research on EHR-to-EHR transitions has focused on employee and system transition-related needs, with limited focus on how patients experience transitions. OBJECTIVE (1) Understand patients' preferences for information and support prior to an EHR transition, and (2) examine actual patient experiences that occurred at facilities that implemented a new EHR. DESIGN We used a two-step approach. We had discussions with geographically diverse patient advisory groups. Discussions informed semi-structured, qualitative interviews with patients. PARTICIPANTS Patients affected by the EHR transition. MAIN MEASURES We met with four patient advisory groups at sites that had not transitioned their EHR. Interviews were conducted with patients who received care at one of two facilities that recently transitioned to the new EHR. KEY RESULTS Patient advisors identified key areas important to patients during an EHR transition. 1) Use a range of communication strategies to reach diverse populations, especially older, rural patients. 2) Information about the EHR transition should be clear and reinforce trustworthiness. 3) Patients will need guidance using the new patient portal. From the patient interviews, we learned if and how these key areas mapped onto patients' experiences. Patients at the sites that had transitioned learned about the new EHR through a variety of modalities, including letters and banners on the patient portal. However, their experiences varied in terms of information quality, leading to frustrations during and between healthcare encounters. Patient portal issues exacerbated frustrations. These raised concerns about the accuracy and security of the overall EHR. CONCLUSIONS Maintaining clear communication across patients, local leadership, and providers throughout an EHR transition is essential for successful implementation. Patient-facing communications can set expectations, and help patients receive adequate support, particularly related to the patient portal.
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Bedford Healthcare System, 200 Springs Rd., Bedford, MA, USA.
- Chobanian & Avedisian School of Medicine, Boston University, 72 E Concord St, Boston, MA, USA.
- Boston University School of Public Health, 715 Albany St., Boston, MA, USA.
| | - Trenton M Haltom
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey VA Medical Center, 2450 Holcombe Blvd Houston, Houston, TX, USA
- Department of Medicine-Health Services Research, Baylor College of Medicine, One Baylor Plaza Houston, Houston, TX, USA
| | - Alison M Cogan
- Center for the Study of Health Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, USA
- Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, Herman Ostrow School of Dentistry, University of Southern California, 1540 Alcazar St, Los Angeles, CA, USA
| | - Stephanie L Shimada
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Bedford Healthcare System, 200 Springs Rd., Bedford, MA, USA
- Boston University School of Public Health, 715 Albany St., Boston, MA, USA
- UMass Chan Medical School, 55 N Lake Ave, Worcester, MA, USA
| | - Jessica A Davila
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey VA Medical Center, 2450 Holcombe Blvd Houston, Houston, TX, USA
- Department of Medicine-Health Services Research, Baylor College of Medicine, One Baylor Plaza Houston, Houston, TX, USA
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Conti J, Fix GM, Javier SJ, Cheng H, Perez T, Dunlap S, McInnes DK, Midboe AM. Patient and provider perspectives of personal health record use: a multisite qualitative study in HIV care settings. Transl Behav Med 2023; 13:475-485. [PMID: 37084300 DOI: 10.1093/tbm/ibac118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
Use of tethered personal health records (PHRs) can streamline care, reduce unnecessary care utilization, and improve health outcomes for people living with human immunodeficiency virus (HIV). Providers play a role in influencing patients' decision to adopt and use PHRs. To explore patient and provider acceptance and use of PHRs in an HIV care setting. We used a qualitative study design guided by the Unified Theory of Acceptance and Use of Technology. Participants included providers of HIV care, patients living with HIV, and PHR coordinating and support staff in the Veterans Health Administration (VA). Interviews were analyzed using directed content analysis. We interviewed providers (n = 41), patients living with HIV (n = 60), and PHR coordinating and support staff (n = 16) at six VA Medical Centers between June and December 2019. Providers perceived PHR use could enhance care continuity, appointment efficiency, and patient engagement. Yet, some expressed concerns that patient PHR use would increase provider workload and detract from clinical care. Concerns about poor PHR interoperability with existing clinical tools further eroded acceptance and use of PHRs. PHR use can enhance care for patients with HIV and other complex, chronic conditions. Negative provider attitudes toward PHRs may impact providers' encouragement of use among patients, consequently limiting patient uptake. Multipronged interventions at the individual, institutional, and system level are needed to enhance PHR engagement among both providers and patients.
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Affiliation(s)
- Jennifer Conti
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Hannah Cheng
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Taryn Perez
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Donald Keith McInnes
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
- Division of Health Policy and Management, University of California Davis-School of Medicine, Davis, CA, USA
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Wolfe HL, Drainoni ML, Klasko-Foster L, Fix GM, Siegel J, Mimiaga MJ, Reisner SL, Hughto JM. Structural Equation Modeling of Stigma and HIV Prevention Clinical Services Among Transgender and Gender Diverse Adults: The Mediating Role of Substance Use and HIV Sexual Risk. J Acquir Immune Defic Syndr 2023; 92:300-309. [PMID: 36515898 PMCID: PMC9974738 DOI: 10.1097/qai.0000000000003144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Transgender and gender diverse (TGD) adults experience high levels of stigma that contributes to elevated substance use and HIV sexual risk behaviors. Despite higher burdens of substance use and HIV compared to cisgender adults, TGD individuals may be less likely to engage in health care to avoid further discrimination. SETTING This analysis included 529 TGD adults in Massachusetts and Rhode Island who were HIV negative or had an unknown HIV serostatus and were purposively sampled between March and August 2019. METHODS We used structural equation modeling to test whether substance use, HIV sexual risk behaviors (ie, condom use, sex work, and multiple partners), and receiving gender-affirming hormone therapy mediate any observed association between TGD-related stigma and utilization of HIV prevention clinical services (ie, HIV prevention programs, PrEP use, and HIV testing). RESULTS Substance use and HIV sexual risk mediated the relationship between TGD-related stigma and utilization of HIV prevention clinical services (β = 0.08; 95% CI = 0.05, 0.17; P = 0.03 and β = 0.26; 95% CI = 0.14 to 0.37; P < 0.001). Having a hormone therapy prescription was not a mediator between TGD-related stigma and HIV prevention clinical services. CONCLUSIONS Future interventions that aim to improve HIV prevention clinical services among TGD adults should consider the impact of TGD-related stigma on participants' substance use and sexual risk behaviors. These efforts require that health care organizations and community organizations make a deliberate investment in the reach and success of interventions and programs.
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Affiliation(s)
- Hill L. Wolfe
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA
- Evans Center for Implementation and Improvement Sciences, Boston University, Boston, MA
| | - Lynne Klasko-Foster
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
| | - Gemmae M. Fix
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Jennifer Siegel
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
- Transgender Health Program, Massachusetts General Hospital, Boston, MA
| | - Matthew J. Mimiaga
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
- The Fenway Institute, Fenway Health, Boston, MA
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA
- Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- University of California Los Angeles Center for LGBTQ Advocacy, Research & Health, Los Angeles, CA
| | - Sari L. Reisner
- The Fenway Institute, Fenway Health, Boston, MA
- General Medicine, Harvard Medical School, Boston, MA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Jaclyn M.W. Hughto
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, Rhode Island
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
- The Fenway Institute, Fenway Health, Boston, MA
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Kaitz J, DeLaughter K, Deeney C, Cutrona SL, Hogan TP, Gifford AL, Jackson GL, White B, King H, Reardon C, Nevedal A, Henderson B, Fix GM. Leveraging Organizational Conditions for Innovation: A Typology of Facility Engagement in the Veterans Health Administration Shark Tank-Style Competition. Perm J 2023:1-8. [PMID: 36946078 DOI: 10.7812/tpp/22.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Introduction The development and spread of innovation are known challenges in health care. The US Veterans Health Administration (VHA) created a "Shark Tank"-style competition directed at frontline employees. In this annual, systemwide competition, employees submit innovations to the competition, and winning innovations receive support for implementation in other facilities. Method A multiple case study design was used to understand facility engagement in the competition, and the relationship between engagement and organizational conditions. The authors created a typology to describe the relationship between facility engagement in the competition and organizational conditions for innovation. Results Overall, there was high participation in the VHA's competition across all 130 facilities. The authors identified 7 mutually exclusive types of facility engagement. Discussion As expected, facilities with the most established conditions for innovation were the most engaged in the competition. Additionally, other facilities had various ways to be involved. Consequently, there may be benefit to the VHA tailoring how they work with facilities, based on organizational conditions. Larger facilities with ongoing research and more resources may be more suited to develop innovations, whereas smaller facilities could benefit from a focus on adoption. Conclusion These insights are valuable to the VHA and can be used by other health care systems to tailor innovation programs and allocate resources based on diverse needs across a vast health care system.
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Affiliation(s)
- Jenesse Kaitz
- Center for Healthcare Organization and Implementation Research, VA Bedford and Boston Healthcare Systems, Bedford and Boston, MA, USA
| | - Kathryn DeLaughter
- Center for Healthcare Organization and Implementation Research, VA Bedford and Boston Healthcare Systems, Bedford and Boston, MA, USA
| | - Christine Deeney
- Center for Healthcare Organization and Implementation Research, VA Bedford and Boston Healthcare Systems, Bedford and Boston, MA, USA
| | - Sarah L Cutrona
- Center for Healthcare Organization and Implementation Research, VA Bedford and Boston Healthcare Systems, Bedford and Boston, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research, VA Bedford and Boston Healthcare Systems, Bedford and Boston, MA, USA
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research, VA Bedford and Boston Healthcare Systems, Bedford and Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Section of General Internal Medicine, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Brandolyn White
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Heather King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Caitlin Reardon
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Andrea Nevedal
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Blake Henderson
- Department of Veterans Affairs, VHA Innovation Ecosystem/Diffusion of Excellence, Washington, DC, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, VA Bedford and Boston Healthcare Systems, Bedford and Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Section of General Internal Medicine, Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
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16
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Spitzer EG, Kaitz J, Fix GM, Harvey KLL, Stadnick NA, Sullivan JL, Williamson AK, Miller CJ. Developing Relational Coordination: A Qualitative Study of Outpatient Mental Health Teams. Adm Policy Ment Health 2023:10.1007/s10488-023-01261-2. [PMID: 36892721 PMCID: PMC9996570 DOI: 10.1007/s10488-023-01261-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/10/2023]
Abstract
Previous studies have shown Relational Coordination improves team functioning in healthcare settings. The aim of this study was to examine the relational factors needed to support team functioning in outpatient mental health care teams with low staffing ratios. We interviewed interdisciplinary mental health teams that had achieved high team functioning despite low staffing ratios in U.S. Department of Veterans Affairs medical centers. We conducted qualitative interviews with 21 interdisciplinary team members across three teams within two medical centers. We used directed content analysis to code the transcripts with a priori codes based on the Relational Coordination dimensions, while also being attentive to emergent themes. We found that all seven dimensions of Relational Coordination were relevant to improved team functioning: frequent communication, timely communication, accurate communication, problem-solving communication, shared goals, shared knowledge, and mutual respect. Participants also described these dimensions as reciprocal processes that influenced each other. In conclusion, relational Coordination dimensions can play pivotal roles in improving team functioning both individually and in combination. Communication dimensions were a catalyst for developing relationship dimensions; once relationships were developed, there was a mutually reinforcing cycle between communication and relationship dimensions. Our results suggest that establishing high-functioning mental health care teams, even in low-staffed settings, requires encouraging frequent communication within teams. Moreover, attention should be given to ensuring appropriate representation of disciplines among leadership and defining roles of team members when teams are formed.
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Affiliation(s)
- Elizabeth G Spitzer
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research, Boston, Massachusetts and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States.
| | - Jenesse Kaitz
- VA Bedford Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, United States
| | - Gemmae M Fix
- VA Bedford Healthcare System Center for Healthcare Organization and Implementation Research and Boston University School of Public Health Boston, Bedford, Massachusetts, United States
| | - Kimberly L L Harvey
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research, Boston, Massachusetts and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Nicole A Stadnick
- Department of Psychiatry, University of California, San Diego; UC San Diego, Altman Clinical and Translational Research, Institute, Dissemination and Implementation Science Center, La Jolla, California; and Child and Adolescent Services Research Center, San Diego, California, United States
| | - Jennifer L Sullivan
- A Medical Center, Center of Innovation in Long Term Services and Supports and Brown University School of Public Health, Providence, Providence, Rhode Island, United States
| | | | - Christopher J Miller
- VA Boston Healthcare System Center for Healthcare Organization and Implementation Research and Department of Psychiatry, Harvard Medical School, Bedford, Massachusetts, United States
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Elwy AR, Maguire EM, McInnes DK, Fix GM. Creating Connections during COVID-19. Health Commun 2023; 38:424-431. [PMID: 34445899 DOI: 10.1080/10410236.2021.1969836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Our research group created a public communication strategy of expressive writing, to use within our research center over the Massachusetts COVID-19 stay at home advisories. Our goals were to 1) build community, 2) recognize the unique experiences, needs, concerns and coping strategies of our colleagues, and 3) create a mechanism to creatively share those experiences. We conceptualized a weekly e-newsletter, "Creativity in the Time of COVID-19," a collective effort for expressing and documenting the extraordinary, lived experiences of our colleagues during this unique time of a coronavirus pandemic. Through 23 online issues, we have captured 72 colleagues' perspectives on social isolation, the challenges of working from home, and hope in finding connection through virtual platforms. We have organized the themes of these submissions, in the forms of photos, essays, poetry, original artwork, and more, according to three components of the Social Connection Framework: structural, functional and quality approaches to creating social connectedness.
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Affiliation(s)
- A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University
- Department of Health Law, Policy and Management, Boston University School of Public Health
| | - Elizabeth M Maguire
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
- Department of Health Law, Policy and Management, Boston University School of Public Health
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System
- Department of Health Law, Policy and Management, Boston University School of Public Health
- Section of General Internal Medicine, Boston University School of Medicine
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18
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Reardon CM, Damschroder L, Opra Widerquist MA, Arasim M, Jackson GL, White B, Cutrona SL, Fix GM, Gifford AL, DeLaughter K, King HA, Henderson B, Vega R, Nevedal AL. Sustainment of diverse evidence-informed practices disseminated in the Veterans Health Administration (VHA): initial development and piloting of a pragmatic survey tool. Implement Sci Commun 2023; 4:6. [PMID: 36647162 PMCID: PMC9842210 DOI: 10.1186/s43058-022-00386-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/18/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND There are challenges associated with measuring sustainment of evidence-informed practices (EIPs). First, the terms sustainability and sustainment are often falsely conflated: sustainability assesses the likelihood of an EIP being in use in the future while sustainment assesses the extent to which an EIP is (or is not) in use. Second, grant funding often ends before sustainment can be assessed. The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program is one of few large-scale models of diffusion; it seeks to identify and disseminate practices across the VHA system. The DoE sponsors "Shark Tank" competitions, in which leaders bid on the opportunity to implement a practice with approximately 6 months of implementation support. As part of an ongoing evaluation of the DoE, we sought to develop and pilot a pragmatic survey tool to assess sustainment of DoE practices. METHODS In June 2020, surveys were sent to 64 facilities that were part of the DoE evaluation. We began analysis by comparing alignment of quantitative and qualitative responses; some facility representatives reported in the open-text box of the survey that their practice was on a temporary hold due to COVID-19 but answered the primary outcome question differently. As a result, the team reclassified the primary outcome of these facilities to Sustained: Temporary COVID-Hold. Following this reclassification, the number and percent of facilities in each category was calculated. We used directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), to analyze open-text box responses. RESULTS A representative from forty-one facilities (64%) completed the survey. Among responding facilities, 29/41 sustained their practice, 1/41 partially sustained their practice, 8/41 had not sustained their practice, and 3/41 had never implemented their practice. Sustainment rates increased between Cohorts 1-4. CONCLUSIONS The initial development and piloting of our pragmatic survey allowed us to assess sustainment of DoE practices. Planned updates to the survey will enable flexibility in assessing sustainment and its determinants at any phase after adoption. This assessment approach can flex with the longitudinal and dynamic nature of sustainment, including capturing nuances in outcomes when practices are on a temporary hold. If additional piloting illustrates the survey is useful, we plan to assess the reliability and validity of this measure for broader use in the field.
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Affiliation(s)
- Caitlin M. Reardon
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Laura Damschroder
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Marilla A. Opra Widerquist
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Maria Arasim
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - George L. Jackson
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Division of General Internal Medicine, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Family Medicine & Community Health, Duke University, Durham, USA
| | - Brandolyn White
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, USA ,grid.168645.80000 0001 0742 0364Division of General Internal Medicine, University of Massachusetts Medical School, Worcester, USA
| | - Gemmae M. Fix
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,grid.189504.10000 0004 1936 7558Section of General Internal Medicine, Boston University School of Medicine, Boston, USA
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,grid.189504.10000 0004 1936 7558Section of General Internal Medicine, Boston University School of Medicine, Boston, USA ,grid.189504.10000 0004 1936 7558Department of Health Law, Policy & Management, Boston University, Boston, USA
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research (CHOIR), Bedford & Boston VA Medical Centers, Bedford, USA ,Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, USA
| | - Heather A. King
- grid.512153.1Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, USA ,grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University, Durham, USA ,grid.26009.3d0000 0004 1936 7961Division of General Internal Medicine, Duke University, Durham, USA
| | - Blake Henderson
- grid.239186.70000 0004 0481 9574Innovation Ecosystem, United States Veterans Health Administration, Washington, D.C., USA
| | - Ryan Vega
- grid.239186.70000 0004 0481 9574Innovation Ecosystem, United States Veterans Health Administration, Washington, D.C., USA
| | - Andrea L. Nevedal
- grid.413800.e0000 0004 0419 7525Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, USA
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Abstract
OBJECTIVE To provide health research teams with a practical, methodologically rigorous guide on how to conduct direct observation. METHODS Synthesis of authors' observation-based teaching and research experiences in social sciences and health services research. RESULTS This article serves as a guide for making key decisions in studies involving direct observation. Study development begins with determining if observation methods are warranted or feasible. Deciding what and how to observe entails reviewing literature and defining what abstract, theoretically informed concepts look like in practice. Data collection tools help systematically record phenomena of interest. Interdisciplinary teams--that include relevant community members-- increase relevance, rigor and reliability, distribute work, and facilitate scheduling. Piloting systematizes data collection across the team and proactively addresses issues. CONCLUSION Observation can elucidate phenomena germane to healthcare research questions by adding unique insights. Careful selection and sampling are critical to rigor. Phenomena like taboo behaviors or rare events are difficult to capture. A thoughtful protocol can preempt Institutional Review Board concerns. INNOVATION This novel guide provides a practical adaptation of traditional approaches to observation to meet contemporary healthcare research teams' needs.
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Affiliation(s)
- Gemmae M. Fix
- VA Center for Healthcare Organization and Implementation Research, Boston and Bedford, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Bo Kim
- VA Center for Healthcare Organization and Implementation Research, Boston and Bedford, MA, USA
- Department of Psychiatry, Harvard Medical School, Cambridge, MA, USA
| | - Mollie Ruben
- Department of Psychology, University of Maine, Orono, ME, USA
| | - Megan B. McCullough
- VA Center for Healthcare Organization and Implementation Research, Boston and Bedford, MA, USA
- Department of Public Health, University of Massachusetts Lowell, Lowell, MA, USA
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20
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Khanna A, Fix GM, Anderson E, Bolton RE, Bokhour BG, Foster M, Smith JG, Vimalananda VG. Towards a framework for patient-centred care coordination: a scoping review protocol. BMJ Open 2022; 12:e066808. [PMID: 36456025 PMCID: PMC9716881 DOI: 10.1136/bmjopen-2022-066808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/31/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Patient-centred care and care coordination are each key priority areas for delivering high quality healthcare. However, the intersection between these two concepts is poorly characterised. We theorise that greater advancements in healthcare quality could be realised when care is organised in a way that aligns with patients' preferences, needs and values across every level of the healthcare system. There is currently no published review that describes the intersection of patient-centred care and care coordination. We will undertake a scoping review that will be foundational to the development of a conceptual framework for patient-centred care coordination that integrates and synthesises the overlap between these two concepts and describe how it manifests across levels of the healthcare system. METHODS AND ANALYSIS A multidisciplinary team of reviewers will conduct a scoping review of published and grey literature to identify and synthesise key concepts at the intersection of patient-centred care and care coordination, following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidance for scoping reviews. Databases we will use in our search include PubMed, CINAHL, Embase, Social Sciences Abstracts, Nursing and Allied Health Premium, Health and Medical Collection, and PsycINFO. Articles will be included that are English-language; published during or after 2001; describe a theory, conceptual model, theoretical framework or definition that addresses both patient-centred care and care coordination. Articles will be excluded if they do not address the intersection of patient-centred care and care coordination; discuss a patient-centred medical home without discussion on patient-centred care concepts; or discuss a paediatric, inpatient or palliative care setting. A data extraction template will facilitate qualitative thematic analysis and findings will be synthesised into a conceptual framework. ETHICS AND DISSEMINATION This work does not require ethics approval. A preliminary framework will be presented to a group of patient stakeholders for refinement before dissemination through a peer-reviewed journal and conference presentations.
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Affiliation(s)
- Aishwarya Khanna
- VA Bedford Healthcare System Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
- University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Gemmae M Fix
- VA Center for Healthcare Organization & Implementation Research Bedford Campus, Bedford, Massachusetts, USA
- Department of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ekaterina Anderson
- VA Bedford Healthcare System Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Rendelle E Bolton
- VA Bedford Healthcare System Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
- Brandeis University Heller School for Social Policy and Management, Waltham, Massachusetts, USA
| | - Barbara G Bokhour
- VA Center for Healthcare Organization & Implementation Research Bedford Campus, Bedford, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Marva Foster
- Department of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- VA Center for Healthcare Organization and Implementation Research Boston Campus, Boston, Massachusetts, USA
| | - Jason G Smith
- VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Varsha G Vimalananda
- VA Center for Healthcare Organization & Implementation Research Bedford Campus, Bedford, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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21
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Gurewich D, Kressin N, Bokhour BG, Linsky AM, Dichter ME, Hunt KJ, Fix GM, Niles BL. Randomised controlled trial evaluating the effects of screening and referral for social determinants of health on Veterans' outcomes: protocol. BMJ Open 2022; 12:e058972. [PMID: 36153033 PMCID: PMC9511545 DOI: 10.1136/bmjopen-2021-058972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 08/12/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Health policy leaders recommend screening and referral (S&R) for unmet social needs (eg, food) in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing cardiovascular disease (CVD) death and disability lie with addressing the social determinants of CVD outcomes. A limited but promising evidence base supports these recommendations, but more rigorous research is needed to guide health care-based S&R efforts. Funded by the Veteran Health Administration (VA), the study described in this paper will assess the efficacy of S&R on Veterans' connections to new resources to address social needs, reduction of unmet needs and health-related outcomes (adherence, utilisation and clinical outcomes). METHODS AND ANALYSIS We will conduct a 1-year mixed-methods randomised controlled trial at three VA sites, enrolling Veterans with CVD and CVD-risk. 880 Veterans experiencing one or more social needs will be randomised within each site (n=293 per site) to one of three study arms representing referral mechanisms of varying intensity (screening only, screening and provision of resource sheet(s), screening and provision of resource sheet(s) plus social work assistance). For each Veteran, we will examine associations of unmet social needs with health-related outcomes at baseline, and longitudinally compare the impact of each approach on connection to new resources (primary outcome) and follow-up outcomes over a 12-month period. We will additionally conduct qualitative interviews with key stakeholders, including Veterans to identify potential explanatory factors related to the relative success of the interventions. ETHICS AND DISSEMINATION Ethics approval was obtained from the VA Central Internal Review Board on 13 July 2021 (reference #: 20-07-Amendment No. 02). Findings will be disseminated through reports, lay summaries, policy briefs, academic publications, and conference presentations. TRIAL REGISTRATION NUMBER NCT04977583.
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Affiliation(s)
- Deborah Gurewich
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nancy Kressin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- School of Social Work, Temple University, Philadelphia, Pennsylvania, USA
| | - Kelly J Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H Johnson VAMC, Charleston, South Carolina, USA
| | - Gemmae M Fix
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Barbara L Niles
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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22
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McInnes DK, Dunlap S, Fix GM, Foster MV, Conti J, Roncarati JS, Hyde JK. Longitudinal high-frequency ethnographic interviewing to simulate and prepare for intensive smartphone data collection among veterans with homeless experience. Front Digit Health 2022; 4:897288. [PMID: 36033637 PMCID: PMC9411857 DOI: 10.3389/fdgth.2022.897288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/06/2022] [Indexed: 11/24/2022] Open
Abstract
Objective While Veteran homelessness has steadily declined over the last decade, those who continue to be unhoused have complex health and social concerns. Housing instability interferes with access to healthcare, social services, and treatment adherence. Preventing unwanted housing transitions is a public health priority. This study is the first phase of a larger research agenda that aims to test the acceptability and feasibility of smartphone-enabled data collection with veterans experiencing homelessness. In preparation for the development of the smartphone data collection application, we utilized ethnographic methods guided by user-centered design principles to inform survey content, approach to recruitment and enrollment, and design decisions. Methods We used a case study design, selecting a small sample (n = 10) of veterans representing a range of homelessness experiences based on risk and length of time. Participants were interviewed up to 14 times over a 4-week period, using a combination of qualitative methods. Additionally, 2 focus group discussions were conducted. Interviews were audio-recorded and transcribed. Data were synthesized and triangulated through use of rapid analysis techniques. Results All participants had experience using smartphones and all but one owned one at the time of enrollment. Participants described their smartphones as “lifelines” to social network members, healthcare, and social service providers. Social relationships, physical and mental health, substance use, income, and housing environment were identified as being directly and indirectly related to transitions in housing. Over the course of ~30 days of engagement with participants, the research team observed dynamic fluctuations in emotional states, relationships, and utilization of services. These fluctuations could set off a chain of events that were observed to both help participants transition into more stable housing or lead to setbacks and further increase vulnerability and instability. In addition to informing the content of survey questions that will be programmed into the smartphone app, participants also provided a broad range of recommendations for how to approach recruitment and enrollment in the future study and design features that are important to consider for veterans with a range of physical abilities, concerns with trust and privacy, and vulnerability to loss or damage of smartphones. Conclusion The ethnographic approach guided by a user-centered design framework provided valuable data to inform our future smartphone data collection effort. Data were critical to understanding aspects of day-to-day life that important to content development, app design, and approach to data collection.
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Affiliation(s)
- D. Keith McInnes
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Gemmae M. Fix
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Boston University School of Medicine, Section of General Internal Medicine, Boston, MA, United States
| | - Marva V. Foster
- Boston University School of Medicine, Section of General Internal Medicine, Boston, MA, United States
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States
- Department of Quality Management, VA Boston Healthcare System, Boston, MA, United States
| | - Jennifer Conti
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Jill S. Roncarati
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Boston Health Care for the Homeless Program, Boston, MA, United States
| | - Justeen K. Hyde
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Boston University School of Medicine, Section of General Internal Medicine, Boston, MA, United States
- *Correspondence: Justeen K. Hyde
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Wiener RS, Barker AM, Carter-Harris L, Caverly TJ, Crocker DA, Denietolis A, Doherty C, Fagerlin A, Gallagher-Seaman M, Gould MK, Han PKJ, Herbst AN, Ito Fukunaga M, McCullough MB, Miano DA, Quaife SL, Slatore CG, Fix GM. Stakeholder Research Priorities to Promote Implementation of Shared Decision-Making for Lung Cancer Screening: An American Thoracic Society and Veterans Affairs Health Services Research and Development Statement. Am J Respir Crit Care Med 2022; 205:619-630. [PMID: 35289730 DOI: 10.1164/rccm.202201-0126st] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Rationale: Shared decision-making (SDM) for lung cancer screening (LCS) is recommended in guidelines and required by Medicare, yet it is seldom achieved in practice. The best approach for implementing SDM for LCS remains unknown, and the 2021 U.S. Preventive Services Task Force calls for implementation research to increase uptake of SDM for LCS. Objectives: To develop a stakeholder-prioritized research agenda and recommended outcomes to advance implementation of SDM for LCS. Methods: The American Thoracic Society and VA Health Services Research and Development Service convened a multistakeholder committee with expertise in SDM, LCS, patient-centered care, and implementation science. During a virtual State of the Art conference, we reviewed evidence and identified research questions to address barriers to implementing SDM for LCS, as well as outcome constructs, which were refined by writing group members. Our committee (n = 34) then ranked research questions and SDM effectiveness outcomes by perceived importance in an online survey. Results: We present our committee's consensus on three topics important to implementing SDM for LCS: 1) foundational principles for the best practice of SDM for LCS; 2) stakeholder rankings of 22 implementation research questions; and 3) recommended outcomes, including Proctor's implementation outcomes and stakeholder rankings of SDM effectiveness outcomes for hybrid implementation-effectiveness studies. Our committee ranked questions that apply innovative implementation approaches to relieve primary care providers of the sole responsibility of SDM for LCS as highest priority. We rated effectiveness constructs that capture the patient experience of SDM as most important. Conclusions: This statement offers a stakeholder-prioritized research agenda and outcomes to advance implementation of SDM for LCS.
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Kearney L, Wiener RS, Dahodwala M, Fix GM, Hicks J, Little F, Howard J, Foreman AG, Wakeman C, O'Donnell C, Bulekova K, Drainoni ML, Kathuria H. A mixed methods study to inform and evaluate a longitudinal nurse practitioner/community health worker intervention to address social determinants of health and chronic obstructive pulmonary disease self-management. BMC Pulm Med 2022; 22:74. [PMID: 35232414 PMCID: PMC8889692 DOI: 10.1186/s12890-022-01863-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with low socioeconomic status experience higher prevalence and worse outcomes of chronic obstructive pulmonary disease (COPD). We undertook a quality improvement initiative at our safety net hospital in which a nurse practitioner (NP)/community health worker (CHW) team followed patients with COPD, frequent admissions, and unmet SDOH needs from hospitalization through one month post-discharge. We report our mixed methods approach to inform development and preliminary evaluation of this intervention. METHODS We first assessed characteristics of patients admitted with COPD in 2018 (n = 1811), performing multivariable logistic regression to identify factors associated with ≥ 2 admissions per year. We then tested a standardized tool to screen for unmet SDOH needs in a convenience sample of 51 frequently hospitalized patients with COPD. From January-July 2019, we pilot tested the NP/CHW intervention with 57 patients, reviewed NP/CHW logs, and conducted qualitative interviews with 16 patient participants to explore impressions of the intervention. RESULTS Patients with Medicaid insurance, mental health disorders, cardiac disease, and substance use disorder had increased odds of having ≥ 2 admissions. COPD severity, comorbidities, and unmet SDOH needs made COPD self-management challenging. Seventy-four percent of frequently admitted patients with COPD completing SDOH screening had unmet SDOH needs. Patients perceived that the NP/CHW intervention addressed these barriers by connecting them to resources and providing emotional support. CONCLUSIONS Many patients with COPD admitted at our safety-net hospital experience unmet SDOH needs that impede COPD self-management. A longitudinal NP/CHW intervention to address unmet SDOH needs following discharge appears feasible and acceptable.
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Affiliation(s)
- Lauren Kearney
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA
| | - Renda Soylemez Wiener
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA.,Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Mohsin Dahodwala
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA
| | - Gemmae M Fix
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,Department of Health Law Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Jacqueline Hicks
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Frederic Little
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA
| | - Jinesa Howard
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA
| | - Alexis Gallardo Foreman
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA
| | - Cornelia Wakeman
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA
| | - Charles O'Donnell
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA
| | - Katia Bulekova
- Research Computing Services (RCS) Group, Information Services & Technology, Boston University, Boston, MA, USA
| | - Mari-Lynn Drainoni
- 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.,Evans Center for Implementation and Improvement Sciences, Boston University, Boston, MA, USA
| | - Hasmeena Kathuria
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA, 02118, USA.
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25
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Volandes AE, Zupanc SN, Paasche-Orlow MK, Lakin JR, Chang Y, Burns EA, LaVine NA, Carney MT, Martins-Welch D, Emmert K, Itty JE, Moseley ET, Davis AD, El-Jawahri A, Gundersen DA, Fix GM, Yacoub AM, Schwartz P, Gabry-Kalikow S, Garde C, Fischer J, Henault L, Burgess L, Goldman J, Kwok A, Singh N, Alvarez Suarez AL, Gromova V, Jacome S, Tulsky JA, Lindvall C. Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial. JAMA Netw Open 2022; 5:e220354. [PMID: 35201306 PMCID: PMC8874350 DOI: 10.1001/jamanetworkopen.2022.0354] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. OBJECTIVE To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. DESIGN, SETTING, AND PARTICIPANTS The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included. MAIN OUTCOMES AND MEASURES The primary outcome was ACP documentation. RESULTS A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001). CONCLUSIONS AND RELEVANCE This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Boston, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edith A. Burns
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Nancy A. LaVine
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Diana Martins-Welch
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Kaitlin Emmert
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Jennifer E. Itty
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Edward T. Moseley
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Daniel A. Gundersen
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gemmae M. Fix
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
| | - Andrea M. Yacoub
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | | | | | | | - Jonathan Fischer
- Department of Community Health and Family Medicine, Hospice and Palliative Care, Duke University Health System, Durham, North Carolina
| | - Lori Henault
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leah Burgess
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Julie Goldman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anne Kwok
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nimisha Singh
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Armando L. Alvarez Suarez
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Valeria Gromova
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sonia Jacome
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A. Tulsky
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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DeLaughter KL, Fix GM, McDannold SE, Pope C, Bokhour BG, Shimada SL, Calloway R, Gordon HS, Long JA, Miano DA, Cutrona SL. Incorporating African American Veterans' Success Stories for Hypertension Management: Developing a Behavioral Support Texting Protocol. JMIR Res Protoc 2021; 10:e29423. [PMID: 34855617 PMCID: PMC8686408 DOI: 10.2196/29423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 08/24/2021] [Accepted: 09/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background Peer narratives engage listeners through personally relevant content and have been shown to promote lifestyle change and effective self-management among patients with hypertension. Incorporating key quotations from these stories into follow-up text messages is a novel way to continue the conversation, providing reinforcement of health behaviors in the patients’ daily lives. Objective In our previous work, we developed and tested videos in which African American Veterans shared stories of challenges and success strategies related to hypertension self-management. This study aims to describe our process for developing a text-messaging protocol intended for use after viewing videos that incorporate the voices of these Veterans. Methods We used a multistep process, transforming video-recorded story excerpts from 5 Veterans into 160-character texts. We then integrated these into comprehensive 6-month texting protocols. We began with an iterative review of story transcripts to identify vernacular features and key self-management concepts emphasized by each storyteller. We worked with 2 Veteran consultants who guided our narrative text message development in substantive ways, as we sought to craft culturally sensitive content for texts. Informed by Veteran input on timing and integration, supplementary educational and 2-way interactive assessment text messages were also developed. Results Within the Veterans Affairs texting system Annie, we programmed five 6-month text-messaging protocols that included cycles of 3 text message types: narrative messages, nonnarrative educational messages, and 2-way interactive messages assessing self-efficacy and behavior related to hypertension self-management. Each protocol corresponds to a single Veteran storyteller, allowing Veterans to choose the story that most resonates with their own life experiences. Conclusions We crafted a culturally sensitive text-messaging protocol using narrative content referenced in Veteran stories to support effective hypertension self-management. Integrating narrative content into a mobile health texting intervention provides a low-cost way to support longitudinal behavior change. A randomized trial is underway to test its impact on the lifestyle changes and blood pressure of African American Veterans. Trial Registration ClinicalTrials.gov NCT03970590; https://clinicaltrials.gov/ct2/show/NCT03970590 International Registered Report Identifier (IRRID) DERR1-10.2196/29423
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Affiliation(s)
- Kathryn L DeLaughter
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States.,Boston University School of Medicine, Boston, MA, United States
| | - Sarah E McDannold
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Charlene Pope
- Nursing, Ralph H Johnson VA Medical Center, Charleston, SC, United States.,College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States.,Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Stephanie L Shimada
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States.,Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Rodney Calloway
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Howard S Gordon
- Jesse Brown Veterans Affairs Medical Center and VA Center of Innovation for Complex Chronic Healthcare, Chicago, IL, United States.,Section of Academic Internal Medicine, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States.,Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, United States
| | - Judith A Long
- Corporal Michael J Crescenz VA Medical Center, VA Center for Health Equity Research and Promotion (CHERP), Philadelphia, PA, United States.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Danielle A Miano
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Sarah L Cutrona
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States.,Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
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27
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Wolfe HL, Fix GM, Bolton RE, Ruben MA, Bokhour BG. Development of observational rating scales for evaluating patient-centered communication within a whole health approach to care. Explore (NY) 2021; 17:491-497. [PMID: 32703684 PMCID: PMC7791595 DOI: 10.1016/j.explore.2020.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/19/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Teaching and evaluating patient-centered communication (PCC) skills that incorporate holistic approaches are increasingly relevant. OBJECTIVE This study describes the development of the Observational Whole Health Measure (OWHM) for evaluating the extent to which primary care providers in the Veterans Health Administration engaged in PCC in the context of a holistic approach to care known as "Whole Health." DESIGN AND SETTING Observational rating scales were created based on content from a national whole health clinical education program in the VA and refined from audio recordings of patient-provider interactions in primary care clinical encounters. Unpaired t-tests and Cohen's d were conducted to measure overall quality of what really matters and whole health goal setting and plan development. PARTICIPANTS 65 clinical encounters across 8 providers before and after participating in the training were included for analysis. INTERVENTION The intervention used for creating rating scales is a 2.5 day whole health clinical education program designed to teach providers PCC skills to identify what matters most for the patients and develop a patient-centered health plan that incorporates integrative health approaches to care. MAIN OUTCOME MEASURE Quality scores (0-4) were used to measure number of instances and extent to which providers explored what matters most to patients, dimensions of whole health, and development of a whole health plan tailored to patient's goals. RESULTS We developed the Observational Whole Health Measure (OWHM) that captures changes in provider communication. Significant differences in overall quality of whole health goal setting and plan development were detected between pre- and post-encounters, demonstrating a sensitivity to change. With the rise of integrative health approaches being adopted across clinical settings, the observational rating scales created in this study are likely to have increasing relevance.
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Affiliation(s)
- Hill L Wolfe
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, 200 Springs Road, Bedford, MA 01730, United States; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany Street, Boston, MA 02118, United States.
| | - Gemmae M Fix
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, 200 Springs Road, Bedford, MA 01730, United States; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany Street, Boston, MA 02118, United States
| | - Rendelle E Bolton
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, 200 Springs Road, Bedford, MA 01730, United States; Brandeis University, The Heller School for Social Policy and Management, 415 South Street, Waltham, MA 02453, United States
| | - Mollie A Ruben
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, Jamaica Plain Campus, Building 9, Boston, MA 02130, United States; University of Maine, Department of Psychology, 301 Little Hall, Orono, ME 04469, United States
| | - Barbara G Bokhour
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, 200 Springs Road, Bedford, MA 01730, United States; University of Massachusetts Medical School, Department of Population and Quantitative Health Sciences, 368 Plantation Street, Worcester, MA 01605, United States
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Bokhour BG, Bolton RE, Asch SM, Dvorin K, Fix GM, Gifford AL, Hyde JK, McInnes DK, Parker VA, Richardson K, Skolnik AA, Vaughan-Sarrazin MS, Wu J, Ohl ME. How Should We Organize Care for Patients With Human Immunodeficiency Virus and Comorbidities? A Multisite Qualitative Study of Human Immunodeficiency Virus Care in the United States Department of Veterans Affairs. Med Care 2021; 59:727-735. [PMID: 33900271 DOI: 10.1097/mlr.0000000000001563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With human immunodeficiency virus (HIV) now managed as a chronic disease, health care has had to change and expand to include management of other critical comorbidities. We sought to understand how variation in the organization, structure and processes of HIV and comorbidity care, based on patient-centered medical home (PCMH) principles, was related to care quality for Veterans with HIV. RESEARCH DESIGN Qualitative site visits were conducted at a purposive sample of 8 Department of Veterans Affairs Medical Centers, varying in care quality and outcomes for HIV and common comorbidities. Site visits entailed conduct of patient interviews (n=60); HIV care team interviews (n=60); direct observation of clinic processes and team interactions (n=22); and direct observations of patient-provider clinical encounters (n=45). Data were analyzed using a priori and emergent codes, construction of site syntheses and comparing sites with varying levels of quality. RESULTS Sites highest and lowest in both HIV and comorbidity care quality demonstrated clear differences in provision of PCMH-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs. Sites that had consistent processes for comorbidity care, whether in HIV or primary care clinics, had higher quality of comorbidity care. CONCLUSIONS Provision of high-quality HIV care and high-quality co-morbidity care require different care structures and processes. Provision of both requires a focus on providing care aligned with PCMH principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.
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Affiliation(s)
- Barbara G Bokhour
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester
| | - Rendelle E Bolton
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Steven M Asch
- Center for Innovation to Implementation (ci2i), VA Palo Alto HCS, Palo Alto
- Division of Primary Care and Population Health, Stanford University, Stanford, CA
| | - Kelly Dvorin
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
| | - Gemmae M Fix
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
- Department of Health Law, Policy and Management, Boston University School of Public Health
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Allen L Gifford
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
- Department of Health Law, Policy and Management, Boston University School of Public Health
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Justeen K Hyde
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - D Keith McInnes
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
- Department of Health Law, Policy and Management, Boston University School of Public Health
| | - Victoria A Parker
- Peter T. Paul College of Business & Economics, University of New Hampshire, Durham, NH
| | - Kelly Richardson
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA
| | - Avy A Skolnik
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
- University Health Services, University of Massachusetts, Amherst, Amherst, MA
| | - Mary S Vaughan-Sarrazin
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA
- Division of General Medicine
| | - Juliet Wu
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston
| | - Michael E Ohl
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), Department of Veteran Affairs, VA Bedford & VA Boston Healthcare Systems, Bedford & Boston, MA, USA.
- General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research (CHOIR), Department of Veteran Affairs, VA Bedford & VA Boston Healthcare Systems, Bedford & Boston, MA, USA
- General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
- General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA
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30
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Dryden EM, Hyde JK, Wormwood JB, Wu J, Calloway R, Cutrona SL, Elwyn G, Fix GM, Orner MB, Shimada SL, Bokhour BG. Assessing Patients' Perceptions of Clinician Communication: Acceptability of Brief Point-of-Care Surveys in Primary Care. J Gen Intern Med 2020; 35:2990-2999. [PMID: 32748346 PMCID: PMC7572926 DOI: 10.1007/s11606-020-06062-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Improving patient-centered (PC) communication is a priority in many healthcare organizations. Most PC communication metrics are distal to the care encounter and lack clear attribution, thereby reducing relevance for leaders and clinicians. OBJECTIVE We assessed the acceptability of measuring PC communication at the point-of-care. DESIGN A brief patient survey was conducted immediately post-primary care appointments at one Veterans Affairs Medical Center. Audit-feedback reports were created for clinicians and discussed in qualitative interviews. PARTICIPANTS A total of 485 patients completed the survey. Thirteen interviews were conducted with clinicians and hospital leaders. MAIN MEASURE(S) Measures included collaboRATE (a 3-item tool measuring PC communication), a question about how well needs were met, and overall visit satisfaction. Data were analyzed using descriptive statistics to characterize the mean and distribution of collaboRATE scores and determine the proportion of patients giving clinicians a "top score" on each item. Associations among responses were examined. Interviews focused on the value of measuring PC communication and were analyzed using a framework approach. KEY RESULTS The proportion of patients giving PC communication "top scores" ranged from 41 to 92% for 16 clinicians who had ≥ 25 completed surveys. Among patients who gave "top scores" for PC communication, the odds of reporting that needs were "completely met" were 10.8 times higher (p < .001) and the odds of reporting being "very satisfied" with their care were 13.3 times higher (p < .001) compared with patients who did not give "top scores." Interviewees found clinician-specific feedback useful; concerns included prioritizing this data when other measures are used to evaluate clinicians' performance. Difficulties improving PC communication given organizational structures were noted. Recommendations for interventions included peer-to-peer education and mentoring by top-scoring clinicians. CONCLUSIONS Assessing provider communication at the point-of-care is acceptable and useful to clinicians. Challenges remain to properly incentivize and support the use of this data for improving PC communication.
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Affiliation(s)
- Eileen M Dryden
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.
| | - Justeen K Hyde
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Boston University School of Medicine, Boston, MA, USA
| | - Jolie B Wormwood
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Psychology, University of New Hampshire, Durham, NH, USA
| | - Juliet Wu
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Rodney Calloway
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Sarah L Cutrona
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Gemmae M Fix
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Michelle B Orner
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Stephanie L Shimada
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Barbara G Bokhour
- US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Bolton RE, Fix GM, VanDeusen Lukas C, Elwy AR, Bokhour BG. Biopsychosocial benefits of movement-based complementary and integrative health therapies for patients with chronic conditions. Chronic Illn 2020; 16:41-54. [PMID: 29914264 DOI: 10.1177/1742395318782377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Complementary and integrative health practices are growing in popularity, including use of movement-based therapies such as yoga, tai-chi, and qigong. Movement-based therapies are beneficial for a range of health conditions and are used more frequently by individuals with chronic illness. Yet little is known about how patients with chronic conditions characterize the health benefits of movement-based therapies. Methods We conducted focus groups with 31 patients enrolled in yoga and qigong programs for chronic conditions at two VA medical centers. Transcripts were analyzed using conventional content analysis with codes developed inductively from the data. Participants’ descriptions of health benefits were then mapped to Engel’s biopsychosocial model. Results Participants described improvements in all biopsychosocial realms, including improved physical and mental health, reduced opiate and psychotropic use, enhanced emotional well-being, and better social relationships. Changes were attributed to physical improvements, development of coping skills, and increased self-awareness. Discussion Patients with chronic illnesses in our sample reported multiple benefits from participation in movement-based therapies, including in physical, mental, and social health realms. Providers treating patients with complex comorbidities may consider referrals to movement-based therapy programs to address multiple concerns simultaneously, particularly among patients seeking alternatives to medication or adjunctive to an opiate reduction strategy.
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Affiliation(s)
- Rendelle E Bolton
- U.S. Department of Veterans Affairs, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, USA
- Heller School for Social Policy and Management, Brandeis University, Waltham, USA
| | - Gemmae M Fix
- U.S. Department of Veterans Affairs, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, USA
| | - Carol VanDeusen Lukas
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, USA
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, Boston, USA
| | - A Rani Elwy
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, USA
- U.S. Department of Veterans Affairs, VA Boston Healthcare System, Boston, USA
| | - Barbara G Bokhour
- U.S. Department of Veterans Affairs, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, USA
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Koenders SL, Barnes LL, Laird LD, Ostrach B, Fix GM. APPLIED TRAINING IN A MEDICAL ANTHROPOLOGY MASTER'S PROGRAM. Pract Anthropol 2020; 42:43-47. [PMID: 35177878 PMCID: PMC8849477 DOI: 10.17730/0888-4552.42.1.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Learning practical skills is key to becoming an applied anthropologist. For my MS degree, I chose a program at Boston University School of Medicine that incorporates skills development into the curriculum through its Service-Learning Internship Program (SLIP). The SLIP facilitates students' familiarity with their field site throughout the first year, before they start summer fieldwork. My SLIP and thesis fieldwork took place in a VA hospital's pain clinic-a placement ideal for my interest in researching pain management during an opioid epidemic. This paper describes my training, developing a research question, meeting theoretical and logistical requirements, handling the unpredictable nature of research, data collection, analysis, and writing. I use getting Institutional Review Board (IRB) approval for my thesis project as an example of how these skills came together. Guided by my mentors, this experience afforded me hands-on training. I can now bring my anthropological approach into the work force.
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McElroy A, Cadzow R, Kahn LS, Fix GM. INTRODUCTION TO DIVERGENT PATHWAYS IN APPLIED ANTHROPOLOGY CAREERS. ACTA ACUST UNITED AC 2020; 42:2-10. [PMID: 33678951 DOI: 10.17730/0888-4552.42.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - Gemmae M Fix
- United States Department of Veteran Affairs, Center for Healthcare Organization and Implementation Research (CHOIR)
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Fix GM, McElroy A. DIVERGENT PATHS TO CAREER FULFILLMENT IN APPLIED ANTHROPOLOGY. ACTA ACUST UNITED AC 2020; 42:56-64. [PMID: 33678952 DOI: 10.17730/0888-4552.42.1.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite their academic training, most anthropologists do not work in tenure-track positions in departments of anthropology. While some systematic data indicate where these anthropologists are employed, we know less about their experiences or what led them to work outside the academy. This paper discusses examples of divergent career paths among the special issue contributors and analyzes key themes in their papers. While their histories vary generationally, our authors share commonalities. Many mastered cross-over skills that prepared them to work collaboratively and to apply anthropological insights and methods in research and community settings. Some perceived stigma and barriers to communicating with traditional academic colleagues. Others merged theory and practice to develop pedagogical reforms. Drawing on lessons as mentors in training programs and advocates in our own careers, we recommend that practitioners' narratives be used to re-imagine career options, revise training programs, and increase visibility for applied careers across the anthropological community.
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Affiliation(s)
- Gemmae M Fix
- United States Department of Veteran Affairs, Center for Healthcare Organization and Implementation Research (CHOIR) and Boston University's School of Public Health
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Kressin NR, Elwy AR, Glickman M, Orner MB, Fix GM, Borzecki AM, Katz LA, Cortés DE, Cohn ES, Barker A, Bokhour BG. Beyond Medication Adherence: The Role of Patients' Beliefs and Life Context in Blood Pressure Control. Ethn Dis 2019; 29:567-576. [PMID: 31641324 DOI: 10.18865/ed.29.4.567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective Despite numerous interventions to address adherence to antihypertensive medications, continued high rates of uncontrolled blood pressure (BP) suggest a need to better understand patient factors beyond adherence associated with BP control. We examined how patients' BP-related beliefs, and aspects of life context affect BP control, beyond medication adherence. Methods We conducted a cross-sectional telephone survey of primary care patients with hypertension between 2010 and 2011 (N=103; 93 had complete data on all variables and were included in the regression analyses). We assessed patient sociodemographics (including race/ethnicity), medication adherence, BP-related beliefs, aspects of life context, and used clinical BP assessments. Results Regression models including sociodemographics, medication adherence, and either beliefs or context consistently predicted BP control. Adding context after beliefs added no predictive value while adding beliefs after context significantly predicted BP control. Practical Implications Results suggest that when clinicians must choose a dimension on which to intervene, focusing on beliefs would be the most fruitful approach to effecting change in BP control.
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Affiliation(s)
- Nancy R Kressin
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA.,Section of General Internal Medicine, Boston University School of Medicine; Boston, MA
| | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA.,Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University; Providence, RI
| | - Mark Glickman
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA.,Department of Statistics, Harvard University; Boston, MA
| | - Michelle B Orner
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA.,Boston University School of Public Health; Boston, MA
| | - Ann M Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA.,Section of General Internal Medicine, Boston University School of Medicine; Boston, MA.,Boston University School of Public Health; Boston, MA
| | - Lois A Katz
- VA New York Harbor Healthcare System; New, York, NY.,New York University School of Medicine; New York, NY
| | - Dharma E Cortés
- Cambridge Health Alliance; Cambridge, MA.,Harvard Medical School; Cambridge, MA
| | - Ellen S Cohn
- Boston University, Sargent College of Health and Rehabilitation Sciences; Boston, MA
| | - Anna Barker
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), a VA HSR&D Center of Innovation, VA Boston Healthcare System and Edith Nourse Rogers Memorial Veterans Hospital; Bedford, MA.,Boston University School of Public Health; Boston, MA
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Fix GM, Reisinger HS, Etchin A, McDannold S, Eagan A, Findley K, Gifford AL, Gupta K, McInnes DK. Health care workers' perceptions and reported use of respiratory protective equipment: A qualitative analysis. Am J Infect Control 2019; 47:1162-1166. [PMID: 31182235 PMCID: PMC7115305 DOI: 10.1016/j.ajic.2019.04.174] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/21/2019] [Accepted: 04/22/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Little is known about health care workers' (HCW) perceptions of, or experiences using, respiratory protective equipment (RPE). We sought to characterize their perceptions and identify reasons underlying inappropriate use. METHODS We conducted 12 focus groups with nurses and nursing assistants at 4 medical centers. We analyzed the thematic content of 73 discrete "stories" told by focus group participants. RESULTS We identified 5 story types surrounding RPE use: 1) policies are known and seen during work routines; 2) during protocol lapses, use is reinforced through social norms; 3) clinical experiences sometimes supersede protocol adherence; 4) when risk perception is high, we found concern regarding accessing RPE; and 5) HCWs in emergency departments were viewed as not following protocol because risk was ever-present. DISCUSSION HCWs were aware of the importance of RPE and protocols for using it, and these supported use when protocol lapses occurred. However, protocol adherence was undermined by clinical experience, perceived risk, and the distinct context of the emergency department where patients continually arrive with incomplete or delayed diagnoses. CONCLUSIONS Protocols, visual cues, and social norms contribute to a culture of safety. This culture can be undermined when HCWs experience diagnostic uncertainty or they mistrust the protocol and instead rely on their clinical experiences.
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VA Hospital, Bedford, MA; Boston University School of Public Health, Boston, MA.
| | - Heather Schacht Reisinger
- Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA; University of Iowa Carver College of Medicine, Iowa City, IA
| | - Anna Etchin
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VA Hospital, Bedford, MA; Center for Healthcare Organization and Implementation Research (CHOIR), Boston University School of Medicine, VA Boston Healthcare System, Boston, MA
| | - Sarah McDannold
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VA Hospital, Bedford, MA
| | - Aaron Eagan
- VHA Office of Public Health, National Center for Occupational Health and Infection Control, Gainesville, FL
| | - Kimberly Findley
- VHA Office of Public Health, National Center for Occupational Health and Infection Control, Gainesville, FL
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston University School of Medicine, VA Boston Healthcare System, Boston, MA; Boston University School of Public Health, Boston, MA
| | - Kalpana Gupta
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston University School of Medicine, VA Boston Healthcare System, Boston, MA
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VA Hospital, Bedford, MA; Center for Healthcare Organization and Implementation Research (CHOIR), Boston University School of Medicine, VA Boston Healthcare System, Boston, MA; Boston University School of Public Health, Boston, MA
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Fix GM, Hyde JK, Bolton RE, Parker VA, Dvorin K, Wu J, Skolnik AA, McInnes DK, Midboe AM, Asch SM, Gifford AL, Bokhour BG. The moral discourse of HIV providers within their organizational context: An ethnographic case study. Patient Educ Couns 2018; 101:2226-2232. [PMID: 30131263 PMCID: PMC7819576 DOI: 10.1016/j.pec.2018.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts. METHODS Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes. RESULTS We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges. CONCLUSIONS AND PRACTICE IMPLICATIONS When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Justeen K Hyde
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Brandeis University, The Heller School for Social Policy and Management, Waltham, MA, USA
| | - Victoria A Parker
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Peter T. Paul College of Business & Economics, University of New Hampshire, Durham, NH, USA
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - Juliet Wu
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - Avy A Skolnik
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (ci2i), VA Palo Alto HCS, Palo Alto, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation (ci2i), VA Palo Alto HCS, Palo Alto, CA, USA; Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center and VA Boston Healthcare System, Bedford/Boston, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Hill JN, Locatelli SM, Bokhour BG, Fix GM, Solomon J, Mueller N, LaVela SL. Evaluating broad-scale system change using the Consolidated Framework for Implementation Research: challenges and strategies to overcome them. BMC Res Notes 2018; 11:560. [PMID: 30075807 PMCID: PMC6076417 DOI: 10.1186/s13104-018-3650-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 07/25/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient's circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation. RESULTS Application of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks.
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Affiliation(s)
- Jennifer N Hill
- Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Center of Innovation for, Complex Chronic Health Care (CINCCH), Edward Hines Jr. VA Hospital, 5000 S. 5th Ave (151H), Hines, IL, 60141, USA.
| | - Sara M Locatelli
- Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Center of Innovation for, Complex Chronic Health Care (CINCCH), Edward Hines Jr. VA Hospital, 5000 S. 5th Ave (151H), Hines, IL, 60141, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center, Center for Evaluating Patient-Centered Care (EPCC), Boston University School of Public Health, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Evaluating Patient-Centered Care (EPCC), Boston University School of Public Health, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Jeffrey Solomon
- Evaluating Patient-Centered Care (EPCC), Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Nora Mueller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center, Center for Evaluating Patient-Centered Care (EPCC), Boston University School of Public Health, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Sherri L LaVela
- Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Center of Innovation for Complex Chronic Health Care (CINCCH), Center for Healthcare Studies, Institute for Public Health and Medicine General Internal Medicine and Geriatrics, Edward Hines Jr. VA Hospital, Northwestern University, Feinberg School of Medicine, 5000 S. 5th Ave (151H), Hines, IL, 60141, USA
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Bokhour BG, Fix GM, Mueller NM, Barker AM, Lavela SL, Hill JN, Solomon JL, Lukas CV. How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation. BMC Health Serv Res 2018; 18:168. [PMID: 29514631 PMCID: PMC5842617 DOI: 10.1186/s12913-018-2949-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 02/19/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs. METHODS We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains. RESULTS Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges. CONCLUSIONS Transforming healthcare systems to focus on patient-centered care and better serve the "whole" patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.
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Affiliation(s)
- Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, Bedford, MA USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA
| | - Gemmae M. Fix
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, Bedford, MA USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA
| | - Nora M. Mueller
- Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, MD USA
| | - Anna M. Barker
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, Bedford, MA USA
| | - Sherri L. Lavela
- Center for Innovation for Complex Chronic Healthcare (CINNCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, IL USA
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Jennifer N. Hill
- Center for Innovation for Complex Chronic Healthcare (CINNCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, IL USA
| | | | - Carol VanDeusen Lukas
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, Bedford, MA USA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA USA
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Shimada SL, Petrakis BA, Rothendler JA, Zirkle M, Zhao S, Feng H, Fix GM, Ozkaynak M, Martin T, Johnson SA, Tulu B, Gordon HS, Simon SR, Woods SS. An analysis of patient-provider secure messaging at two Veterans Health Administration medical centers: message content and resolution through secure messaging. J Am Med Inform Assoc 2018; 24:942-949. [PMID: 28371896 DOI: 10.1093/jamia/ocx021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 02/24/2017] [Indexed: 11/14/2022] Open
Abstract
Objective We sought to understand how patients and primary care teams use secure messaging (SM) to communicate with one another by analyzing secure message threads from 2 Department of Veterans Affairs facilities. Methods We coded 1000 threads of SM communication sampled from 40 primary care teams. Results Most threads (94.5%) were initiated by patients (90.4%) or caregivers (4.1%); only 5.5% were initiated by primary care team members proactively reaching out to patients. Medication renewals and refills (47.2%), scheduling requests (17.6%), medication issues (12.9%), and health issues (12.7%) were the most common patient-initiated requests, followed by referrals (7.0%), administrative issues (6.5%), test results (5.4%), test issues (5.2%), informing messages (4.9%), comments about the patient portal or SM (4.1%), appreciation (3.9%), self-reported data (2.8%), life issues (1.5%), and complaints (1.5%). Very few messages were clinically urgent (0.7%) or contained other potentially challenging content. Message threads were mostly short (2.7 messages), comprising an average of 1.35 discrete content types. A substantial proportion of issues (24.2%) did not show any evidence of being resolved through SM. Time to response and extent of resolution via SM varied by message content. Proactive SM use by teams varied, but was most often for test results (32.7%), medication-related issues (21.8%), medication renewals (16.4%), or scheduling issues (18.2%). Conclusions The majority of messages were transactional and initiated by patients or caregivers. Not all content categories were fully addressed over SM. Further education and training for both patients and clinical teams could improve the quality and efficiency of SM communication.
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Affiliation(s)
- Stephanie L Shimada
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Department of Veterans Affairs, Bedford, MA, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.,Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Bedford, MA, USA
| | - Beth Ann Petrakis
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Department of Veterans Affairs, Bedford, MA, USA
| | - James A Rothendler
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Department of Veterans Affairs, Bedford, MA, USA
| | - Maryan Zirkle
- Portland VA Medical Center, Department of Veterans Affairs, Portland, OR, USA
| | - Shibei Zhao
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Department of Veterans Affairs, Bedford, MA, USA
| | - Hua Feng
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Department of Veterans Affairs, Bedford, MA, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Department of Veterans Affairs, Bedford, MA, USA
| | | | - Tracey Martin
- VISN1, Department of Veterans Affairs, Bedford, MA, USA
| | - Sharon A Johnson
- School of Business, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Bengisu Tulu
- School of Business, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Howard S Gordon
- Center for Innovation for Complex Chronic Healthcare, Jesse Brown VA Medical Center, Department of Veterans Affairs, Chicago, IL, USA.,Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Steven R Simon
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, Department of Veterans Affairs, Bedford, MA, USA
| | - Susan S Woods
- VA Maine Healthcare System, Connected Care Office, Veterans Health Administration, Augusta, ME, USA
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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McIntosh N, Fix GM, Allsup K, Charns M, McDannold S, Manning K, Forman DE. A Qualitative Study of Participation in Cardiac Rehabilitation Programs in an Integrated Health Care System. Mil Med 2017; 182:e1757-e1763. [DOI: 10.7205/milmed-d-17-00053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Nathalie McIntosh
- VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130
| | - Gemmae M. Fix
- Edith Nourse Rogers Memorial VA Hospital, 200 Springs Road, Bedford, MA 01730
- Boston University School of Public Health, 715 Albany Street, Boston, MA 02118
| | - Kelly Allsup
- VA Pittsburgh Healthcare System, 0 University Drive C, Pittsburgh, PA 15240
| | - Martin Charns
- VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130
- Boston University School of Public Health, 715 Albany Street, Boston, MA 02118
| | - Sarah McDannold
- Edith Nourse Rogers Memorial VA Hospital, 200 Springs Road, Bedford, MA 01730
- Boston University School of Public Health, 715 Albany Street, Boston, MA 02118
| | - Kenneth Manning
- Durham VA Medical Center, 508 Fulton Street, Durham, NC 27704
| | - Daniel E. Forman
- VA Pittsburgh Healthcare System, 0 University Drive C, Pittsburgh, PA 15240
- University of Pittsburgh, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15260
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Fix GM, VanDeusen Lukas C, Bolton RE, Hill JN, Mueller N, LaVela SL, Bokhour BG. Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care. Health Expect 2017; 21:300-307. [PMID: 28841264 PMCID: PMC5750758 DOI: 10.1111/hex.12615] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 12/30/2022] Open
Abstract
Background Patient‐centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient‐centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient‐centred care, conceptualize what they are implementing. Objective To examine how hospital employees conceptualize patient‐centred care. Research Design We conducted qualitative interviews about patient‐centred care during site four visits, from January to April 2013. Subjects We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient‐centred care transformation. Measures Data were analysed using grounded thematic analysis. Findings were then mapped to established patient‐centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient‐as‐person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor‐as‐person. Results We identified three distinct conceptualizations: (i) those that were well aligned with established patient‐centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient‐centred care into the organizational culture, encompassing the entire patient‐experience; and (iii) still others that were poorly aligned with patient‐centred care constructs, reflecting more traditional patient care practices. Conclusions Patient‐centred care ideals have permeated into healthcare systems. Additionally, patient‐centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient‐centred care so broadly, it encompasses on‐going hospital initiatives, while others consider patient‐centred care as inherent to specific positions. These latter conceptualizations risk undermining patient‐centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA.,Evaluating Patient-Centered Care, Bedford, MA, USA
| | - Carol VanDeusen Lukas
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA.,Evaluating Patient-Centered Care, Bedford, MA, USA
| | - Rendelle E Bolton
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Bedford, MA, USA.,Evaluating Patient-Centered Care, Bedford, MA, USA
| | - Jennifer N Hill
- Center for Evaluation of Practices and Experiences of Patient-Centered Care, Hines, IL, USA
| | - Nora Mueller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Bedford, MA, USA.,Evaluating Patient-Centered Care, Bedford, MA, USA
| | - Sherri L LaVela
- Center for Evaluation of Practices and Experiences of Patient-Centered Care, Hines, IL, USA.,Center for Healthcare Studies, Institute for Public Health and Medicine, General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA.,Evaluating Patient-Centered Care, Bedford, MA, USA
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Fix GM, Hogan TP, Amante DJ, McInnes DK, Nazi KM, Simon SR. Encouraging Patient Portal Use in the Patient-Centered Medical Home: Three Stakeholder Perspectives. J Med Internet Res 2016; 18:e308. [PMID: 27876686 PMCID: PMC5141333 DOI: 10.2196/jmir.6488] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/23/2016] [Accepted: 10/29/2016] [Indexed: 11/30/2022] Open
Abstract
Background Health care organizations are increasingly offering patients access to their electronic medical record and the ability to communicate with their providers through Web-based patient portals, thus playing a prominent role within the patient-centered medical home (PCMH). However, despite enthusiasm, adoption remains low. Objective We examined factors in the PCMH context that may affect efforts to improve enrollment in a patient portal. Methods Using a sociotechnical approach, we conducted qualitative, semistructured interviews with patients and providers from 3 primary care clinics and with national leaders from across a large integrated health care system. Results We gathered perspectives and analyzed data from 4 patient focus groups and one-on-one interviews with 1 provider from each of 3 primary care clinics and 10 program leaders. We found that leaders were focused on marketing in primary care, whereas patients and providers were often already aware of the portal. In contrast, both patients and providers cited administrative and logistical barriers impeding enrollment. Further, although leadership saw the PCMH as the logical place to focus enrollment efforts, providers and patients were more circumspect and expressed concern about how the patient portal would affect their practice and experience of care. Further, some providers expressed ambivalence about patients using the portal. Despite absence of consensus on how and where to encourage portal adoption, there was wide agreement that promoting enrollment was a worthwhile goal. Conclusions Patients, clinicians, and national leaders agreed that efforts were needed to increase enrollment in the patient portal. Opinions diverged regarding the suitability of the PCMH and, specifically, the primary care clinic for promoting patient portal enrollment. Policymakers should consider diverse stakeholder perspectives in advance of interventions to increase technology adoption.
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Affiliation(s)
- Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States.,Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Daniel J Amante
- Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - D Keith McInnes
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, United States
| | - Kim M Nazi
- Veterans Health Administration, Veterans and Consumers Health Informatics Office, Office of Connected Care, US Department of Veterans Affairs, Washington, DC, United States
| | - Steven R Simon
- Center for Healthcare Organization and Implementation Research, Bedford, MA, United States.,Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, United States
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Bokhour BG, Fix GM, Gordon HS, Long JA, DeLaughter K, Orner MB, Pope C, Houston TK. Can stories influence African-American patients' intentions to change hypertension management behaviors? A randomized control trial. Patient Educ Couns 2016; 99:1482-1488. [PMID: 27387121 DOI: 10.1016/j.pec.2016.06.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Information-only interventions for hypertension management have limited effectiveness, particularly among disadvantaged populations. We assessed the impact of viewing African-American patients' stories of successfully controlling hypertension on intention to change hypertension management behaviors and engagement with educational materials. METHODS In a three-site randomized trial, 618 African-American Veterans with uncontrolled hypertension viewed an information-only DVD about hypertension (control) or a DVD adding videos of African-American Veterans telling stories about successful hypertension management (intervention). After viewing, patients were asked about their engagement with the DVD, and their intentions to change behavior. Mean scores were compared with two-sided t-tests. RESULTS Results favored the Stories intervention, with significantly higher emotional engagement versus control (4.3 vs. 2.2 p<0.0001). Intervention patients reported significantly greater intentions to become more physically active (4.6 vs. 4.4, p=0.018), use salt substitutes (3.9 vs. 3.4, p=0.006), talk openly with their doctor about hypertension (4.6 vs. 4.5, p=0.049), and remember to take hypertension medication (4.8 vs. 4.6, p=0.04). CONCLUSION Patients were more emotionally engaged and reported intentions to change behavior when watching real patient hypertension management success stories. PRACTICE IMPLICATIONS Stories may be more influential than information alone, and represent a scalable approach to modifying behavioral intention.
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Affiliation(s)
- Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, United States; Department of Health Law Policy and Management, Boston University School of Public Health, United States.
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, United States; Department of Health Law Policy and Management, Boston University School of Public Health, United States.
| | - Howard S Gordon
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, United States; Section of Academic Internal Medicine, Department of Medicine, University of Illinois at Chicago College of Medicine, United States.
| | - Judith A Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz/Philadelphia VA Medical Center, United States; Division of General Internal Medicine, University of Pennsylvania School of Medicine, United States.
| | - Kathryn DeLaughter
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, United States.
| | - Michelle B Orner
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, United States.
| | - Charlene Pope
- Ralph H. Johnson VA Medical Center, United States; Medical University of South Carolina College of Nursing, United States.
| | - Thomas K Houston
- Center for Healthcare Organization and Implementation Research, ENRM Veterans Affairs Medical Center, United States; Division of Health Informatics and Implementation Science, Quantitative Health Sciences, University of Massachusetts Medical School, United States.
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Forman DE, Fix GM, McDannold S, McIntosh N, Schopfer DW, Whooley MA, Charns MP. Decisive Bearing of Organizational Dynamics on the Application and Success of Hospital-Based Cardiac Rehabilitation. Mayo Clin Proc 2016; 91:975-7. [PMID: 27378045 DOI: 10.1016/j.mayocp.2016.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/13/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Daniel E Forman
- VA Pittsburgh Healthcare System, Pittsburgh, PA; University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh, Pittsburgh, PA
| | - Gemmae M Fix
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; Boston University School of Public Health, Boston, MA
| | - Sarah McDannold
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; Boston University School of Public Health, Boston, MA
| | | | - David W Schopfer
- San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of California, San Francisco, CA
| | - Mary A Whooley
- San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of California, San Francisco, CA
| | - Martin P Charns
- VA Boston Healthcare System, Boston University School of Public Health, Boston, MA
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Locatelli SM, Hill JN, Bokhour BG, Krejci L, Fix GM, Nora Mueller, Solomon JL, Van Deusen Lukas C, LaVela SL. Provider perspectives on and experiences with engagement of patients and families in implementing patient-centered care. Healthcare (Basel) 2015; 3:209-14. [DOI: 10.1016/j.hjdsi.2015.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/11/2015] [Accepted: 04/29/2015] [Indexed: 11/27/2022] Open
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Klein DM, Fix GM, Hogan TP, Simon SR, Nazi KM, Turvey CL. Use of the Blue Button Online Tool for Sharing Health Information: Qualitative Interviews With Patients and Providers. J Med Internet Res 2015; 17:e199. [PMID: 26286139 PMCID: PMC4736289 DOI: 10.2196/jmir.4595] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/01/2015] [Accepted: 07/16/2015] [Indexed: 12/05/2022] Open
Abstract
Background Information sharing between providers is critical for care coordination, especially in health systems such as the United States Department of Veterans Affairs (VA), where many patients also receive care from other health care organizations. Patients can facilitate this sharing by using the Blue Button, an online tool that promotes patients’ ability to view, print, and download their health records. Objective The aim of this study was to characterize (1) patients’ use of Blue Button, an online information-sharing tool in VA’s patient portal, My HealtheVet, (2) information-sharing practices between VA and non-VA providers, and (3) how providers and patients use a printed Blue Button report during a clinical visit. Methods Semistructured qualitative interviews were conducted with 34 VA patients, 10 VA providers, and 9 non-VA providers. Interviews focused on patients’ use of Blue Button, information-sharing practices between VA and non-VA providers, and how patients and providers use a printed Blue Button report during a clinical visit. Qualitative themes were identified through iterative rounds of coding starting with an a priori schema based on technology adoption theory. Results Information sharing between VA and non-VA providers relied primarily on the patient. Patients most commonly used Blue Button to access and share VA laboratory results. Providers recognized the need for improved information sharing, valued the Blue Button printout, and expressed interest in a way to share information electronically across settings. Conclusions Consumer-oriented technologies such as Blue Button can facilitate patients sharing health information with providers in other health care systems; however, more education is needed to inform patients of this use to facilitate care coordination. Additional research is needed to explore how personal health record documents, such as Blue Button reports, can be easily shared and incorporated into the clinical workflow of providers.
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Affiliation(s)
- Dawn M Klein
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, IA, United States.
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McInnes DK, Fix GM, Solomon JL, Petrakis BA, Sawh L, Smelson DA. Preliminary needs assessment of mobile technology use for healthcare among homeless veterans. PeerJ 2015; 3:e1096. [PMID: 26246964 PMCID: PMC4525686 DOI: 10.7717/peerj.1096] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 06/19/2015] [Indexed: 12/19/2022] Open
Abstract
Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans' IT use. This study examines homeless veterans' access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used. Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.
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Affiliation(s)
- D. Keith McInnes
- Department of Veterans Affairs, Edith Nourse Rogers VA Hospital, Bedford, MA, USA
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Gemmae M. Fix
- Department of Veterans Affairs, Edith Nourse Rogers VA Hospital, Bedford, MA, USA
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Jeffrey L. Solomon
- Department of Veterans Affairs, Edith Nourse Rogers VA Hospital, Bedford, MA, USA
| | - Beth Ann Petrakis
- Department of Veterans Affairs, Edith Nourse Rogers VA Hospital, Bedford, MA, USA
| | - Leon Sawh
- VA National Center on Homelessness among Veterans, Philadelphia, PA and Bedford, MA, USA
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
- School of Criminology and Justice Studies, University of Massachusetts, Lowell, MA, USA
| | - David A. Smelson
- Department of Veterans Affairs, Edith Nourse Rogers VA Hospital, Bedford, MA, USA
- VA National Center on Homelessness among Veterans, Philadelphia, PA and Bedford, MA, USA
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
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Bokhour BG, Saifu H, Goetz MB, Fix GM, Burgess J, Fletcher MD, Knapp H, Asch SM. The role of evidence and context for implementing a multimodal intervention to increase HIV testing. Implement Sci 2015; 10:22. [PMID: 25889388 PMCID: PMC4333886 DOI: 10.1186/s13012-015-0214-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 01/26/2015] [Indexed: 11/10/2022] Open
Abstract
Background Increasing the use of routine preventive care such as HIV testing is important, yet implementation of such evidence-based clinical care is complex. The Promoting Action on Research Implementation in Health Services (PARiHS) model for implementation posits that implementation will be most successful when the evidence, context, and facilitation strategies are strong for the clinical practice. We evaluated the relative importance of perceived evidence, context, and facilitation of HIV testing during the implementation of a multimodal intervention in US Department of Veterans Affairs primary care clinics. Methods A multimodal intervention including clinical reminders (CRs), academic detailing—providing education sessions for providers—and social marketing to improve HIV testing was implemented in 15 VA primary care clinics in three regions. We conducted qualitative formative and process evaluations using semi-structured interviews with HIV lead clinicians, primary care lead clinicians, nurse managers, and social workers. Interviews were analyzed thematically to identify barriers and facilitators to implementation of HIV testing and how these were addressed by the intervention. Sites were then rated high, medium, or low on the dimensions of perceived evidence and the context for testing. We then assessed the relationship of these ratings to improvements in HIV testing rates found in earlier quantitative analyses. Results Sites that showed greatest improvements in HIV testing rates also rated high on evidence and context. Conversely, sites that demonstrated the poorest improvements in testing rates rated low on both dimensions. Perceptions of evidence and several contextual aspects resulted in both barriers and facilitators to implementing testing. Evidence barriers included provider perceptions of evidence for routine testing as irrelevant to their population. Contextual barriers included clinical reminder overload, insufficient resources, onerous consent processes, stigma, provider discomfort, and concerns about linking individuals who test positive to HIV treatment. While most barriers were ameliorated by the intervention, HIV stigma in particular regions and concerns about linkage to care persisted. Conclusions Interventions to implement evidence-based practices such as HIV testing can be successful when utilizing proven quality improvement techniques. However, it is critical to address providers’ perceptions of evidence and consider aspects of the local context in order to fully implement new routine clinical practices such as HIV testing.
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Affiliation(s)
- Barbara G Bokhour
- Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. .,Center for Healthcare Organization and Implementation Research, Bedford, MA, 01742, USA. .,Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Hemen Saifu
- Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. .,VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Matthew Bidwell Goetz
- Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. .,VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Gemmae M Fix
- Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. .,Center for Healthcare Organization and Implementation Research, Bedford, MA, 01742, USA. .,Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Jane Burgess
- Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. .,UCLA School of Nursing, Los Angeles, CA, USA.
| | - Michael D Fletcher
- Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. .,Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Herschel Knapp
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Steven M Asch
- Quality Enhancement Research Initiative for HIV and Hepatitis C, US Department of Veterans Affairs, Bedford, MA, USA. .,VA Palo Alto Health Care System, Menlo Park, CA, USA. .,Division of General Medical Disciplines, Stanford University Medical School, Palo Alto, CA, USA.
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