Rethinking Health and Health Care: How Clinicians and Practice Groups Can Better Promote Whole Health and Well-Being for People and Communities

A new National Academies of Sciences, Engineering, and Medicine report, "Achieving Whole Health: A New Approach for Veterans and the Nation," redefines what it means to be healthy and creates a roadmap for health systems, including the Veterans Health Administration and the nation, to scale and spread a whole health approach to care. The report identifies 5 foundational elements for whole health care and sets 6 national, state, and local policy goals for change. This article summarizes the report, emphasizes the importance of preventive medicine, and identifies concrete actions clinicians and practices can take now to deliver whole health care.

Towards practice change: a qualitative study examining the impact of a Child Psychiatric Access Program (Project TEACH) on Primary Care Provider practices in New York State during pandemic times

BACKGROUND

This study aims to explore the perceived impact of Project TEACH (Training and Education for the Advancement of Children's Health), a New York State Office of Mental Health funded Child Psychiatric Access Program (CPAP), on pediatric Primary Care Providers (PCPs) and their practice. Practice change over time was assessed in the context of rising mental health needs and in the context of COVID19 pandemic.

METHODS

Focus groups utilizing a semi-structured format were conducted with pediatric PCPs who have been high utilizers of Project TEACH over the past 5-10 years and PCPs in similar regions who have been low or non-utilizers of the program. The semi-structured interview focused on practice change, asking about pediatric mental health, practice setting and flow, professional development, and changes over time in the context of COVID-19 pandemic and Project TEACH.

RESULTS

Themes identified include increasing confidence of PCPs, particularly those who are high utilizers of the phone consultation line, increased routine use of screening and comfort bridging pediatric patients with mental health needs. Challenges include rising mental health needs, inadequate mental health services, difficulties with family follow through and high emotional burden on PCPs caring for these patients. In this context, participants noted that collaboration with Project TEACH provided needed emotional support.

CONCLUSIONS

Integrated care and CPAPs such as Project TEACH are vital to helping PCPs handle rising mental health needs particularly in current crisis times. Ongoing systemic challenges accessing care remain and contribute to emotional burden placed on pediatric PCPs.

Strengths and limitations of a novel "Flip the Pharmacy" practice transformation coach advanced pharmacy practice experience

BACKGROUND AND PURPOSE

Flip the Pharmacy (FtP) helps community pharmacies "flip" from dispensing- to patient-centered care models with assistance from practice transformation coaches ("coaches"). Purdue University College of Pharmacy created a novel advanced pharmacy practice experience (APPE) positioning students to serve as FtP coaches with oversight from four faculty coaches. This communication describes the APPE's design, characterizes preliminary student coaching outcomes, and identifies the APPE's strengths and limitations.

EDUCATIONAL ACTIVITY AND SETTING

Twelve pharmacies were coached by APPE students. The APPE was designed to enhance student knowledge and skills in the scaled implementation of advanced patient care services through structured weekly activities: Week 1, student orientation and training; Week 2, preparing for pharmacy visits; and Weeks 3 and 4, conducting pharmacy visits. Students also performed recurring tasks each week, including managing social media accounts.

FINDINGS

Twenty-eight students completed the APPE. Students conducted 81 in-person and 105 virtual visits. Faculty coaches were estimated to need 40 to 50  hours each month for coaching-related activities; involving student coaches reduced faculty coach time by approximately 50%, with faculty spending 20  hours on average per month vs. students spending 50.84  hours. APPE strengths included intentional weekly structuring and oversight and careful student transitions; limitations included minimal pharmacy vendor knowledge and limited rapport-building with pharmacies.

SUMMARY

Early experiences demonstrated several benefits, including optimized faculty coach time and student exposure to practice transformation. Future endeavors to implement similar APPEs should incorporate strategies to enhance pharmacy vendor knowledge and strengthen relationship-building with participating pharmacies.

Implementation and evaluation of a practice transformation advanced pharmacy practice experience

BACKGROUND AND PURPOSE

Advanced entrepreneurship opportunities are important to consider as entrepreneurial skills become increasingly important to develop in pharmacy students. This institution implemented a new practice transformation advanced pharmacy practice experience (APPE), pairing students with community partners to implement and/or evaluate pharmacy services, network with pharmacists, and receive mentorship. The purpose of this article is to describe the APPE and students' outcomes during this first pilot year.

EDUCATIONAL ACTIVITY AND SETTING

A faculty preceptor mentored and oversaw all APPE activities. Students were selected through an application process, and community partners were recruited based on alignment with students' goals and need for student assistance. Community partners prepared a list of practice transformation activities needed at their sites, and progress was tracked during weekly virtual meetings. APPE students completed a pre-APPE questionnaire, collecting background information and predictors of entrepreneurship: proactive personality, entrepreneurial self-efficacy, and individual entrepreneurial orientation (IEO). At the end of the APPE, IEO was measured again, and students reflected on what skills were developed.

FINDINGS

Three students participated in the first year and were paired with various community partners. IEO baseline scores ranged from 24 to 28 (mean = 25.3, SD = 2.3), and follow-up scores increased to 28 to 30 (mean = 29.0, SD = 1.0). Students reported development in both soft and technical skills.

SUMMARY

The practice transformation APPE offered students a unique opportunity to develop a diverse set of skills during a focused five-week experience. Based on positive feedback from students, this institution plans to continue to expand this APPE.

Implementation and Qualitative Evaluation of a Primary Care Redesign Model with Expanded Scope of Work for Medical Assistants

BACKGROUND

Implementation of primary care models involving expanded scope of work and redesigned workflows for medical assistants (MAs) as primary care team members can be challenging. Implementation strategies and participatory evaluation informed by implementation science frameworks may inform organizational decisions about model scale-up and sustainment.

OBJECTIVE

This paper reports implementation strategies and qualitative evaluation of a primary care redesign (PCR) model implementation that included an expanded scope of work for MAs.

DESIGN

Qualitative evaluation of implementation strategies and clinician and staff experience with implementation of PCR using semi-structured key informant interviews. The evaluation was guided by the RE-AIM framework and the Consolidated Framework for Implementation Research.

PARTICIPANTS

Sixty-nine clinicians, staff, practice leaders, and administrators from 7 primary care practices (4 general internal medicine, 3 family medicine) implementing PCR.

INTERVENTIONS

The PCR model included enhanced rooming and documentation support. The health system used multiple strategies to implement PCR, including rapid improvement events, changing clinic space configurations, developing electronic health record templates and performance dashboards, and practice coaching.

APPROACH

The Consolidated Framework for Implementation Research and the RE-AIM evaluation and planning framework guided development of semi-structured interview guides. A deductive, structural coding approach was used for analysis.

KEY RESULTS

PCR implementation was facilitated by clear communication about the intervention source, mechanisms for feedback about model goals, and physical environments and electronic health record (EHR) systems that supported the added staff and modified clinic workflow. Clinicians and staff benefited from the ability to see the model in action prior to go-live and opportunities for consistent provider-MA pairings.

CONCLUSIONS

The PCR model can support achieving the Quadruple Aim when fully implemented with paired MAs and clinicians who are well prepared to follow redesigned workflows and function as a team. Implementation can be effectively supported by a participatory evaluation guided by implementation science frameworks.

Child Psychiatrists and Psychologists: Enhanced Collaboration in Primary Care

Psychiatry and psychology have a long history of competition that too often interferes with the collaboration that can characterize complementary contributions to our common missions. We hope this article will inspire our disciplines to expand on this collaboration, for the sake of our children and families, our communities, our colleagues, and honestly, ourselves. We are better together than apart. This text is a blueprint for the assumptions, attitudes, skills, and advocacy that can make this partnership healthy and successful.

Adapting Well-Being into Outpatient Child Psychiatry

Traditional child psychiatry practices focus on children's symptoms and families' deficits. Focusing on goals and strengths can prepare patients and families for what they can do to enhance their health. The evidence-base for well-being practices supports integration into contemporary practice. Practical guidelines are described for using the initial assessment to address well-being practices, and to plan treatment with psychoeducation, motivational interviewing, and ongoing monitoring. Engaging and effective clinical strategies can further support and build patient and family well-being.

Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation

Background

Much research does not address the practical needs of stakeholders responsible for introducing health care delivery interventions into organizations working to achieve better outcomes. In this article, we present an approach to using the Consolidated Framework for Implementation Research (CFIR) to guide systematic research that supports rapid-cycle evaluation of the implementation of health care delivery interventions and produces actionable evaluation findings intended to improve implementation in a timely manner.

Methods

To present our approach, we describe a formative cross-case qualitative investigation of 21 primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a multi-payer supported primary care practice transformation intervention led by the Centers for Medicare and Medicaid Services. Qualitative data include observational field notes and semi-structured interviews with primary care practice leadership, clinicians, and administrative and medical support staff. We use intervention-specific codes, and CFIR constructs to reduce and organize the data to support cross-case analysis of patterns of barriers and facilitators relating to different CPC components.

Results

Using the CFIR to guide data collection, coding, analysis, and reporting of findings supported a systematic, comprehensive, and timely understanding of barriers and facilitators to practice transformation. Our approach to using the CFIR produced actionable findings for improving implementation effectiveness during this initiative and for identifying improvements to implementation strategies for future practice transformation efforts.

Conclusions

The CFIR is a useful tool for guiding rapid-cycle evaluation of the implementation of practice transformation initiatives. Using the approach described here, we systematically identified where adjustments and refinements to the intervention could be made in the second year of the 4-year intervention. We think the approach we describe has broad application and encourage others to use the CFIR, along with intervention-specific codes, to guide the efficient and rigorous analysis of rich qualitative data.

Trial registration

NCT02318108

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0550-7) contains supplementary material, which is available to authorized users.

Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation

OBJECTIVE

To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived.

DATA SOURCE/STUDY SETTING

An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home.

STUDY DESIGN

Convergent case study mixed methods design.

DATA COLLECTION/EXTRACTION METHODS

Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database.

PRINCIPAL FINDINGS

Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change.

CONCLUSIONS

Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.