The Community Primary Care Champions Fellowship: a mixed methods evaluation of an interprofessional fellowship for physician assistants and physicians

BACKGROUND

Primary care in the US faces challenges with clinician recruitment, retention, and burnout, with further workforce shortages predicted in the next decade. Team-based care can be protective against clinician burnout, and opportunities for interprofessional education (IPE) on professional development and leadership could encourage primary care transformation. Despite an increasingly important role in the primary care workforce, IPE initiatives training physician assistants (PAs) alongside physicians are rare. We describe the design, curriculum, and outcomes from an interprofessional primary care transformation fellowship for community-based primary care physicians and PAs.

METHODS

The Community Primary Care Champions (CPCC) Fellowship was a one-year, part-time fellowship which trained nine PAs, fourteen physicians, and a behavioralist with at least two years of post-graduate clinical experience in six content pillars: quality improvement (QI), wellness and burnout, mental health, social determinants of health, medical education, and substance use disorders. The fellowship included a recurring schedule of monthly activities in self-study, lectures, mentoring, and community expert evening discussions. Evaluation of the fellowship included pre, post, and one-year follow-up self-assessments of knowledge, attitudes, and confidence in the six content areas, pre- and post- wellness surveys, lecture and discussion evaluations, and midpoint and exit focus groups.

RESULTS

Fellows showed significant improvement in 24 of 28 self-assessment items across all content areas post-fellowship, and in 16 of 18 items one-year post-fellowship. They demonstrated reductions in emotional exhaustion and depersonalization post-fellowship and increased confidence in working in interprofessional teams post-fellowship which persisted on one-year follow-up assessments. All fellows completed QI projects and four presented their work at national conferences. Focus group data showed that fellows experienced collaborative, meaningful professional development that was relevant to their clinical work. They appreciated the flexible format and inclusion of interprofessional community experts in evening discussions.

CONCLUSIONS

The CPCC fellowship fostered an interprofessional community of practice that provided an effective IPE experience for physicians and PAs. The learning activities, and particularly the community expert discussions, allowed for a flexible, relevant experience, resulting in personal and professional growth along with increased confidence working within interprofessional teams.

Perceptions and outcomes of an embedded Alzheimer Society First Link Coordinator in rural primary health care memory clinics

BACKGROUND

Primary health care has a central role in dementia detection, diagnosis, and management, especially in low-resource rural areas. Care navigation is a strategy to improve integration and access to care, but little is known about how navigators can collaborate with rural primary care teams to support dementia care. In Saskatchewan, Canada, the RaDAR (Rural Dementia Action Research) team partnered with rural primary health care teams to implement interprofessional memory clinics that included an Alzheimer Society First Link Coordinator (FLC) in a navigator role. Study objectives were to examine FLC and clinic team member perspectives of the impact of FLC involvement, and analysis of Alzheimer Society data comparing outcomes associated with three types of navigator-client contacts.

METHODS

This study used a mixed-method design. Individual semi-structured interviews were conducted with FLC (n = 3) and clinic team members (n = 6) involved in five clinics. Data were analyzed using thematic inductive analysis. A longitudinal retrospective analysis was conducted with previously collected Alzheimer Society First Link database records. Memory clinic clients were compared to self- and direct-referred clients in the geographic area of the clinics on time to first contact, duration, and number of contacts.

RESULTS

Three key themes were identified in both FLC and team interviews: perceived benefits to patients and families of FLC involvement, benefits to memory clinic team members, and impact of rural location. Whereas other team members assessed the patient, only FLC focused on caregivers, providing emotional and psychological support, connection to services, and symptom management. Face-to-face contact helped FLC establish a relationship with caregivers that facilitated future contacts. Team members were relieved knowing caregiver needs were addressed and learned about dementia subtypes and available services they could recommend to non-clinic clients with dementia. Although challenges of rural location included fewer available services and travel challenges in winter, the FLC role was even more important because it may be the only support available.

CONCLUSIONS

FLC and team members identified perceived benefits of an embedded FLC for patients, caregivers, and themselves, many of which were linked to the FLC being in person.

Interprofessional Education and Essential Approach to Health care

In today's changing landscape of the US health care system, it is imperative to have a health care delivery model that is patient-centered and delivered by a multidisciplinary collaborative team with an understanding of each other's roles and responsibilities as well as communicate effectively. Academic institutions must create partnerships with health systems and ambulatory care settings to provide health profession students with authentic and inclusive interprofessional learning opportunities which include practice-ready skills which are needed to enter the health care workforce. Nurses are well positioned to lead this effort and practice within interprofessional teams in health care organizations.

Enhancing Availability of Services to Control Hypertension Through a Team-based Care Approach That Includes Pharmacists

BACKGROUND

Primary care physician (PCP) shortages are expected to increase. The Michigan Medicine Hypertension Pharmacists' Program uses a team-based care (TBC) approach to redistribute some patient care responsibilities from PCPs to pharmacists for patients with diagnosed hypertension.

OBJECTIVES

This evaluation analyzed whether the Michigan Medicine Hypertension Pharmacists' Program increased the availability of hypertension management services and described facilitators that addressed barriers to program sustainability and replicability.

METHODS

We conducted a retrospective observational study that used a mixed methods approach. We examined the availability of hypertension management services using the number of pharmacists' referrals of patients to other services and the number of PCP appointments. We analyzed qualitative interviews with program staff and site-level quantitative data to examine the program's impact on the availability of services, the impact of TBC that engage pharmacists, and program barriers and facilitators.

RESULTS

Patients who visited a pharmacist had fewer PCP visits over 3- and 6-month periods compared to a matched comparison group that did not see a pharmacist and were 1.35 times more likely to receive a referral to a specialist within a 3-month period. Support from leaders and physicians, shared electronic health record access, and financial backing emerged as leading factors for program sustainability and replicability.

CONCLUSION

Adding pharmacists to the care team reduced the number of PCP appointments per patient while increasing the availability of hypertension management services; this may in turn improve PCPs' availability. Similar models may be sustainable and replicable by relying on organizational buy-in, accessible infrastructure, and financing.

Polypharmacy in the Cardiovascular Geriatric Critical Care Population: Improving Outcomes

The cardiovascular geriatric population requiring intensive or critical care is a group vulnerable to adverse outcomes because of age, the critical care environment, geriatric syndromes, and multiple chronic conditions. Polypharmacy increases the risk of adverse events in this group. Several tools and aids are available to guide the clinical practice of appropriate prescribing and deprescribing. To optimize the care of the cardiovascular geriatric population, evidence-based prescribing, and deprescribing tools can be implemented by the interprofessional team consisting of the patient, their support system, critical care nurses, advanced practice clinicians, physicians, and allied health professionals.

The impact of team-based primary care on medication-related outcomes in older adults: A comparative analysis of two Canadian provinces

Objective

To evaluate if access to team-based primary care is related to medication management outcomes for older adults.

Methods

We completed two retrospective cohort studies using administrative health data for older adults (66+) in Ontario (n = 428,852) and Québec (n = 310,198) who were rostered with a family physician (FP) between the 2001/02 and 2017/18 fiscal years. We generated matched comparison groups of older adults rostered to an FP practicing in a team-based model, and older adults rostered to an FP in a non-team model. We compared the following outcomes between these groups: any adverse drug reactions (ADRs), any potentially inappropriate prescription (PIP), and polypharmacy. Average treatment effects of access to team-based care were estimated using a difference-in-differences estimator.

Results

The risk of an ADR was 22 % higher (RR = 1.22, 95 % CI = 1.18, 1.26) for older adults rostered to a team-based FP in Québec and 6 % lower (RR = 0.943, 95 % CI = 0.907, 0.978) in Ontario. However, absolute risk differences were less than 0.5 %. Differences in the risk of polypharmacy were small in Québec (RR = 1.005, 95 % CI = 1.001, 1.009) and Ontario (RR = 1.004, 95 % CI = 1.001, 1.007) and had absolute risk differences of less than 1 % in both provinces. Effects on PIP were not statistically or clinically significant in adjusted models.

Interpretation

We did not find evidence that access to team-based primary care in Ontario or Québec meaningfully improved medication management outcomes for older adults.

Cost analysis of the WHO-HEARTS program for hypertension control and CVD prevention in primary health facilities in Ethiopia

Background

In 2020, Ethiopia launched the Ethiopia Hypertension Control Initiative (EHCI) program to improve hypertension care using the approach described in the WHO HEARTS technical package.

Objective

To estimate the costs of implementing the HEARTS program for hypertension control and cardiovascular disease (CVD) prevention in the primary care setting in Ethiopia for adult primary care users in the catchment area of five examined facilities.

Study design

This study entails a program cost analysis using cross-sectional primary and secondary data.

Methods

Micro-costing facility surveys were used to assess activity costs related to training, counselling, screening, lab diagnosis, medications, monitoring, and start-up costs at five selected health facilities. Cost data were obtained from primary and secondary sources, and expert opinion. Annual costs from the health system perspective were estimated using the Excel-based HEARTS costing tool under two intervention scenarios - hypertension-only control and a CVD risk management program, which addresses diabetes and hypercholesterolemia in addition to hypertension.

Results

The estimated cost per adult primary care user was USD 5.3 for hypertension control and USD 19.3 for integrated CVD risk management. The estimated medication cost per person treated for hypertension was USD 9.0, whereas treating diabetes and high cholesterol would cost USD 15.4 and USD 15.3 per person treated, respectively. Medications were the major cost driver, accounting for 37% of the total cost in the hypertension control program. In the CVD risk management scenario, the proportions of medication and lab diagnostics of total costs were 18% and 64%, respectively.

Conclusions

The results from this study can inform planning and budgeting for HEARTS scale-up to prevent CVD across Ethiopia.

One-Year All-Cause Mortality and Delivery of the Collaborative Chronic Care Model in General Mental Health Clinics

OBJECTIVE

This study aimed to determine whether the evidence-based collaborative chronic care model (CCM) is associated with reduced all-cause mortality among adult patients treated in general mental health clinics.

METHODS

Data came from a stepped-wedge, cluster-randomized CCM implementation trial across nine U.S. Department of Veterans Affairs medical centers. Survival analysis was used to estimate the relative effect of the treatment (N=5,570) compared with a control group (N=46,443) over 1 year.

RESULTS

After adjustment for site-level and individual-level acute care utilization factors, analyses indicated that patients treated with the CCM experienced a reduction in all-cause mortality relative to patients in the control cohort (hazard ratio=0.76, 95% CI=0.60-0.95).

CONCLUSIONS

This study is the first in which CCM has been shown to reduce all-cause mortality for patients treated in general mental health clinics. Care delivery models should be considered part of efforts to reduce the life expectancy gap between individuals with psychiatric conditions and those without such conditions.

A Mixed-Methods Approach for Evaluating Implementation Processes and Program Costs for a Hypertension Management Program Implemented in a Federally Qualified Health Center

Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension.

Facilitation of team-based care to improve HTN management and outcomes: a protocol for a randomized stepped wedge trial

BACKGROUND

There are well-established guidelines for treating hypertension (HTN), yet only half of patients with HTN meet the defined target of < 140/90. Team-based care (TBC) is an evidence-based strategy for improving blood pressure (BP) management and control. TBC is defined as the provision of health services by at least two health professionals "who work collaboratively with patients and their caregivers to accomplish shared goals to achieve coordinated, high-quality care". However, primary care practices experience challenges to implementing TBC principles and care processes; these are more pronounced in small independent practice settings (SIPs). Practice facilitation (PF) is an implementation strategy that may overcome barriers to adopting evidence-based TBC to improve HTN management in SIPs.

METHODS

Using a stepped wedge randomized controlled trial design, we will test the effect of PF on the adoption of TBC to improve HTN management in small practices (< 5 FTE clinicians) in New York City, and the impact on BP control compared with usual care. We will enroll 90 SIPs and randomize them into one of three 12-month intervention waves. Practice facilitators will support SIPs to adopt TBC principles to improve implementation of five HTN management strategies (i.e., panel management, population health, measuring BP, supporting medication adherence, self-management). The primary outcome is the adoption of TBC for HTN management measured at baseline and 12 months. Secondary outcomes include the rate of BP control and sustainability of TBC and BP outcomes at 18 months. Aggregated data on BP measures are collected every 6 months in all clusters so that each cluster provides data points in both the control and intervention conditions. Using a mixed methods approach, we will also explore factors that influence the effectiveness of PF at the organization and team level.

DISCUSSION

This study will provide much-needed guidance on how to optimize adoption and sustainability of TBC in independent primary care settings to reduce the burden of disease related to suboptimal BP control and advance understanding of how facilitation works to improve implementation of evidence-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05413252 .

Interdisciplinary Education and Health Care in Geriatric Dental Medicine

Geriatric patients are more likely to have multiple medical comorbidities, physical limitations, and mental impairments that warrant careful consideration while providing patient care. Dentistry, along with other health care professional programs, incorporate interprofessional education (IPE) experiences to provide students with skills they need to deliver collaborative care in their future practice. Health professional programs should consider geriatric training in simulated learning environments, adult day programs, nursing homes, long-term care facilities, and home care experiences to provide students valuable IPE experiences. Lastly, this article presents a call to action for professional organizations to consider offering continuing education courses in IPE.

Team-Based Diabetes Care in Ontario and Hong Kong: a Comparative Review

PURPOSE OF REVIEW

There are gaps in implementing and accessing team-based diabetes care. We reviewed and compared how team-based diabetes care was implemented in the primary care contexts of Ontario and Hong Kong.

RECENT FINDINGS

Ontario's Diabetes Education Programs (DEPs) were scaled-up incrementally. Hong Kong's Multidisciplinary Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) evolved from a research-driven quality improvement program. Each jurisdiction had a mixture of non-team and team-based primary care with variable accessibility. Referral procedures, follow-up processes, and financing models varied. DEPs used a flexible approach, while the RAMP-DM used structured assessment for quality assurance. Each approach depended on adequate infrastructure, processes, and staff. Diabetes care is most accessible and functional when integrated team-based services are automatically initiated upon diabetes diagnosis within a strong primary care system, ideally linked to a register with supports including specialist care. Structured assessment and risk stratification are the basis of a well-studied, evidence-based approach for achieving the standards of team-based diabetes care, although flexibility in care delivery may be needed to meet the unique needs of some individuals. Policymakers and funders should ensure investment in skilled health professionals, infrastructure, and processes to improve care quality.

The Team-Based Serious Illness Care Program, A Qualitative Evaluation of Implementation and Teaming

CONTEXT

Earlier and more frequent serious illness conversations with patients allow clinical teams to better align care with patients' goals and values. Nonphysician clinicians often have unique perspectives and understanding of patients' wishes and are thus well-positioned to support conversations with seriously ill patients. The Team-based Serious Illness Care Program (SICP) at Stanford aimed to involve all care team members to support and conduct serious illness conversations with patients and their caregivers and families.

OBJECTIVES

We conducted interviews with clinicians to understand how care teams implement team-based approaches to conduct serious illness conversations and navigate resulting team complexity.

METHODS

We used a rapid qualitative approach to analyze semistructured interviews of clinicians and administrative stakeholders in two team-based SICP implementation groups (i.e., inpatient oncology and hospital medicine) (n = 25). Analysis was informed by frameworks/theory: cross-disciplinary role agreement, team formation and functioning, and organizational theory.

RESULTS

Implementing team-based SICP was feasible. Theme 1 centered on how teams formed and managed to come to an agreement: teams with rapidly changing staffing/responsibilities prioritized communication, whereas teams with consistent staffing/responsibilities primarily relied on protocols. Theme 2 demonstrated that leaders and managers at multiple levels could support implementation. Theme 3 explored strengths and opportunities. Positively, team-based SICP distributed work burden, timed conversations in alignment with patient needs, and added unique value from nonphysician team members. Role ambiguity and conflict were attributed to miscommunication and ethical conflicts.

CONCLUSION

Team-based serious illness communication is viable and valuable, with a range of successful workflow and leadership approaches.

Team-based primary care reforms and older adults: a descriptive assessment of sociodemographic trends and prescribing endpoints in two Canadian provinces

BACKGROUND

Team-based primary care reforms aim to improve care coordination by involving multiple interdisciplinary health professionals in patient care. Team-based primary care may support improved medication management for older adults with polypharmacy and multiple points of contact with the healthcare system. However, little is known about this association. This study compares sociodemographic and prescribing trends among older adults in team-based vs. traditional primary care models in Ontario and Quebec.

METHODS

We constructed two provincial cohorts using population-level health administrative data from 2006-2018. Our primary exposure was enrollment in a team-based model of care. Key endpoints included adverse drug events (ADEs), potentially inappropriate prescriptions (PIPs), and polypharmacy. We plotted prescribing trends across the observation period (stratified by model of care) in each province. We used standardized mean differences to compare characteristics of older adults and providers, as well as prescribing endpoints.

RESULTS

Formal patient/physician enrollment increased in both provinces since the time of policy implementation; team-based enrollment among older adults was higher in Quebec (47%) than Ontario (33%) by the end of our observation period. The distribution of sociodemographic characteristics was reasonably comparable between team-based and non-team-based patients in both provinces, aside from a persistently higher share of rural patients in team-based care. Most PIPs assessed either declined or remained relatively steady over time, regardless of model of care and province. Several PIPs were more common among team-based patients than non-team-based patients, particularly in Quebec. We did not detect notable trends in ADEs or polypharmacy in either province.

CONCLUSIONS

Our findings offer encouraging evidence that many PIPs are declining over time in this population, regardless of patients' enrollment in team-based care. Rates of decline appear similar across models of care, suggesting these models may not meaningfully influence prescribing endpoints. Additional efforts are needed to understand the impact of team-based care among older adults and improve primary care prescribing practices.

Revisiting the Time Needed to Provide Adult Primary Care

BACKGROUND

Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care.

OBJECTIVE

To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model.

DESIGN

Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels.

PARTICIPANTS

Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017-2018 National Health and Nutrition Examination Survey.

MAIN MEASURES

The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care.

KEY RESULTS

PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management).

CONCLUSIONS

PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.

Letter to the Editor In Response to: "Referring Provider Opinions of Pediatric Cardiology Evaluations Performed by Nurse Practitioners" (Suh et al. 2022)

The authors present a Letter to the Editor in response to the recently published article: "Referring Provider Opinions of Pediatric Cardiology Evaluations Performed by Nurse Practitioners" by Suh et al. (Pediatr Cardiol, https://doi.org/10.1007/s00246-022-02959-0 , 2022).

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis

Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.

Implementing Multidisciplinary, Team-Based Care in an Academic Outpatient Psychiatry Department

This column describes the implementation of a multidisciplinary, team-based model of care within an outpatient psychiatry practice at a large urban academic medical center. The authors outline the process by which the innovative team-based care model was selected, funded, and implemented to address long patient wait times, lack of clinical supports, and dissatisfaction of clinical providers. This column also describes the organizational norms that had to be adjusted or sustained to achieve the intended outcomes of reduced intake wait times and financial sustainability, while ensuring that patients continued to receive high-quality care.

Trends in prognosis after hospitalization for acute heart failure in Kurashiki Central hospital 2015-2018: single-center prospective study

Recently, we have been working on enhancing the effectiveness of treatment for acute heart failure (HF) through team-based care. This study was designed to assess the benefits of this initiative by quantifying the prognostic impact on HF patients receiving treatment at our hospital. We identified 1977 consecutive HF patients (mean age 78.3 ± 11.9 years) being discharged from our hospital between February 2015 and December 2018, divided them by admission year, and tracked changes over time, with 2015 as a reference. The postdischarge clinical outcome measures were defined as a composite of all-cause death or rehospitalization for HF, all-cause death, and rehospitalization for HF. The risk of a composite of all-cause death or rehospitalization for HF was lower in 2017 (adjusted hazard ratio, 0.72; 95% confidence interval: 0.57 to 0.91; p = 0.005) and 2018 (adjusted hazard ratio, 0.78; 95% confidence interval: 0.61 to 0.99; p = 0.045) than in 2015, and that of all-cause death was lower in 2017 (adjusted hazard ratio, 0.72; 95% confidence interval: 0.53 to 0.98; p = 0.04) and 2018 (adjusted hazard ratio, 0.60; 95% confidence interval: 0.43 to 0.85; p = 0.004) than in 2015, but that of rehospitalization for HF was not significantly different through the study period. The mortality rate decreased at the end of the study period, but the rate of rehospitalization for HF did not. The benefits of team-based care were difficult to evaluate by quantification.

Deprescribing in type 2 diabetes and cardiovascular disease: Recommendations for safe and effective initiation of glucagon-like peptide-1 receptor agonists in patients on insulin therapy

Select glucagon-like peptide-1 (GLP-1) receptor agonists have demonstrated cardiovascular benefits in both primary and secondary prevention populations and are recommended in multiple guidelines for cardiovascular risk reduction in people with type 2 diabetes (T2D). Despite this, uptake of GLP-1 receptor agonists in clinical practice has been lagging. While the etiology of their underuse is multifactorial, lack of comfortability in adding a GLP-1 receptor agonist to established insulin regimens is a common barrier. Adjustments to basal and bolus insulin doses upon initiation of GLP-1 receptor agonists in trials have varied. When recommending empiric dose adjustments during initiation of GLP-1 receptors agonists, the most recent A1C and the current blood glucose levels, if available, should be taken into consideration. When initiating in a person being managed with basal-only insulin regimens, an empiric 20 % dose reduction is recommended if the baseline A1C is ≤8 %. For individuals using intensive insulin regimens, empiric dose reductions of up to 25 % in basal and 50 % in bolus therapy were implemented and summarized further in this review. Overall, initiation of GLP-1 receptor agonists can decrease insulin requirements and may permit deintensification of antihyperglycemic therapy through the reduction or discontinuation of bolus insulin therapy. As a result, this simplified regimen promotes increased adherence, reduces glycemic variability and hypoglycemia, and improves overall glycemic management and quality of life. This review aims to serve as a guide for clinicians to facilitate the initiation of GLP-1 receptor agonists and deintensification of insulin by providing suggested dose adjustments based on available literature.

Determining the frequency and level of task-sharing for hypertension management in LMICs: A systematic review and meta-analysis

BACKGROUND

Low- and middle-income countries (LMICs) bear a disproportionately higher burden of Cardiovascular Disease (CVD). Team-based care approach adds capacity to improve blood pressure (BP) control. This updated review aimed to test team-based care efficacy at different levels of hypertension team-based care complexity.

METHODS

We searched PubMed, Embase, Cochrane, and CINAHL for newer articles on task-sharing interventions to manage hypertension in LMICs. Levels of tasks complexity performed by healthcare workers added to the clinical team in hypertension control programs were categorized as administrative tasks (level 1), basic clinical tasks (level 2), and/or advanced clinical tasks (level 3). Meta-analysis using an inverse variance weighted random-effects model summarized trial-based evidence on the efficacy of team-based care on BP control, compared with usual care.

FINDINGS

Forty-three RCT articles were included in the meta-analysis: 31 studies from the previous systematic review, 12 articles from the updated search. The pooled mean effect for team-based care was a -4.6 mm Hg (95% CI: -5.8, -3.4, I²  = 80.2%) decrease in systolic BP compared with usual care. We found similar comparative reduction among different levels of team-based care complexity, i.e., administrative and basic clinical tasks (-4.7 mm Hg, 95% CI: -6.8, -2.2; I²  = 79.8%); and advanced clinical tasks (-4.5 mmHg, 95%CI: -6.1, -3.3; I²  = 81%). Systolic BP was reduced most by team-based care involving pharmacists (-7.3 mm Hg, 95% CI: -9.2, -5.4; I²  = 67.2%); followed by nurses (-5.1 mm Hg, 95% CI: -8.0, -2.2; I²  = 72.7%), dieticians (-4.7 mmHg, 95%CI: -7.1, -2.3; I²  = 0.0%), then community health workers (-3.3 mm Hg, 95% CI: -4.8, -1.8; I²  = 77.3%).

INTERPRETATION

Overall, team-based hypertension care interventions consistently contributed to lower systolic BP compared to usual care; the effect size varies by the clinical training of the healthcare team members.

FUNDING

Resolve To Save Lives (RTSL) Vital Strategies, Danielle Cazabon, Andrew E. Moran, Yvonne Commodore-Mensah receive salary support from Resolve to Save Lives, an initiative of Vital Strategies. Resolve to Save Lives is jointly supported by grants from Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation.

Team-Based Care in Patients with Chronic Limb-Threatening Ischemia

PURPOSE OF REVIEW

Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach.

RECENT FINDINGS

Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.

Interprofessional student hotspotting: preparing future health professionals to deliver team-based care for complex patients

BACKGROUND

Interprofessional student hotspotting involves experiential and longitudinal learning about team-based care for patients with complex medical and social needs. As an emerging strategy for interprofessional education, there have been few research studies to examine student perspectives.

PURPOSE

This study used a descriptive qualitative approach to examine the experiences and perspectives of health professions students who participated in a six-month interprofessional student hotspotting program.

METHODS

At the end of the program, focus group interviews were conducted with 24 health professions students from medicine, social work, pharmacy, nursing, and health psychology.

RESULTS

Thematic analysis revealed four themes: Observed benefits of interprofessional collaboration; Gained skills for collaborative care; Experienced difficulty managing group dynamics; and Learned approaches to caring for complex patients.

CONCLUSION

The hotspotting program helped deepen students' appreciation for interprofessional team-based care. Repeated practice of teamwork skills during the six-month clinical learning experience resulted in students feeling more prepared to provide collaborative care for complex patients.

All Politics Are Local: A Single Institution Investigation of the Educational Impact of Residents and Fellows Working Together

BACKGROUND

Most general surgery residents pursue fellowship; there is limited understanding of the impact residents and fellows have on each other's education. The goal of this exploratory survey was to identify these impacts.

MATERIALS AND METHODS

Surgical residents and fellows at a single academic institution were surveyed regarding areas (OR assignments, the educational focus of the team, roles and responsibilities on the team, interpersonal communication, call, "other") hypothesized to be impacted by other learners. Impact was defined as "something that persistently affects the clinical learning environment and a trainee's education or ability to perform their job". Narrative responses were reviewed until dominant themes were identified.

RESULTS

Twenty-three residents (23/45, 51%) and 12 fellows (12/21, 57%) responded. Responses were well distributed among resident year (PGY-1:17% [4/23], PGY-2, 35% [8/23], PGY-3 26% [6/23], PGY-4 9% [2/23%], PGY-5 13% [3/23]). Most residents reported OR assignment (14/23, 61%) as the area of primary impact, fellows broadly reported organizational categories (Roles and responsibilities 33%, educational focus 16%, interpersonal communication 16%). Senior residents reported missing out on operations to fellows while junior residents reported positive impacts of operating directly with fellows. Residents of all levels reported that fellows positively contributed to their education. Fellows, senior residents, and junior residents reported positive experiences when residents and fellows operated together as primary surgeon and assistant.

CONCLUSIONS

Residents and fellows impact one another's education both positively and negatively. Case allocation concerns senior residents, operating together may alleviate this, providing a positive experience for all trainees. Defining a unique educational role for fellows and delineating team expectations may maximize the positive impacts in this relationship.

Facilitating Integration Through Team-Based Primary Healthcare: A Cross-Case Policy Analysis of Four Canadian Provinces

Introduction:

Team-based care can improve integrated health services by increasing comprehensiveness and continuity of care in primary healthcare (PHC) settings. Collaborative models involving providers from different professions can help to achieve coordinated, high-quality person-centred care. In Canada, there has been variation in both the timing/pace of adoption and approach to interprofessional PHC (IPHC) policy. Provinces are at different stages in the development, implementation, and evaluation of team-based PHC models. This paper describes how different policies, contexts, and innovations across four Canadian provinces (British Columbia, Alberta, Ontario, Quebec) facilitate or limit integrated health services through IPHC teams.

Methods:

Systematic searches identified 100 policy documents across the four provinces. Analysis was informed by Walt and Gilson’s Policy Triangle (2008) and Suter et al.’s (2009) health system integration principles. Provincial policy case studies were constructed and used to complete a cross-case comparison.

Results:

Each province implemented variations of an IPHC based model. Five key components were found that influenced IPHC and integrated health services: patient-centred care; team structures; information systems; financial management; and performance measurement.

Conclusion:

Heterogeneity of the implementation of PHC teams across Canadian provinces provides an opportunity to learn and improve interprofessional care and integrated health services across jurisdictions.

Multidisciplinary Care of Neurosurgical Patients with Genetic Syndromes

Neurosurgical patients with genetic syndromes often receive care from multidisciplinary teams. Successful models range from multiple providers in one clinic space seeing a patient together to specialists located at different institutions working together. Collaboration and bidirectional communication are key. Multidisciplinary care improves outcomes and patient satisfaction. Choosing the goal of the clinic, using ancillary staff, and obtaining institutional buy-in are important initial first steps to establishing a multidisciplinary team clinic. Multidisciplinary teams can leverage technology to expand care via telehealth in multidisciplinary clinics and more vitally communication between providers on the team.

Clinical decision support systems with team-based care on type 2 diabetes improvement for Medicaid patients: A quality improvement project

BACKGROUND

The prevalence of clinical inertia, the failure of appropriate treatment intensification in diabetes treatment, is a well-documented worldwide phenomenon. This project addresses the problem of clinical inertia through three interrelated activities, clinical decision support (CDSS), team-based care, and patient engagement in diabetes management.

OBJECTIVES

The purpose of this research is to provide analysis under the State-University Partnership Learning Network regarding the impact of an electronic decision support tool combined with team-based care workflow on provider decision-making and patient outcomes for the treatment of poorly controlled diabetes mellitus (diabetes) among patients receiving Kentucky Medicaid. The objectives of this study are to 1) assess clinical outcomes of type 2 diabetes in the Medicaid population with team-based care using CDSS, 2) evaluate physicians' and pharmacists' experience on CDSS.

METHODS

This is a quality improvement project using a mixed-method - longitudinal and control group comparison of outcomes based upon clinical measures and online surveys of providers and pharmacists involved in this project.

RESULTS

Patients treated by providers who changed the treatment regimen to one that either fully or partially followed the recommendation of the CDSS tool had a statistically significant reduction in HbA1c with an average initial HbA1c of 10.1 and the final HbA1c of 8. The online survey of physicians shows that more than 80% of physicians agree the use of CDSS will support improved patient outcomes. The use of a team-based care approach that includes pharmacists in implementing treatment changes was broadly supported by both physicians and pharmacists.

CONCLUSION

CDSS combined with team-based care can be effective in reducing HbA1c to targeted therapeutic levels. The use of CDSS provides a way to efficiently assess more than 160 potential frontline drugs and properly accelerate treatment. Consistent with the research literature, the inclusion of pharmacists can play a key role in team-based care to assess treatment alternatives and provide for improvement in outcomes and patient adherence for diabetes. The user surveys show both physicians and pharmacists have a positive attitude toward CDSS.

Incentives for physician teams: Effectiveness of performance feedback and payment distribution methods

Best practices in team-based incentive design remain underexplored. This study examines under group-based pay-for-performance, how managers incentivize physicians for teamwork through internal feedback and payment distribution methods. In collaboration with Taiwan Association of Family Medicine, authors conducted a national survey of physician groups, with a response rate of 48.3%. Multilevel linear regression was applied to 134 groups, collectively consisting of 1,245 physicians in Taiwan. The outcome variables were two manager-rated scores for group performance on achieving (a) comprehensive, coordinated, continuous care, and (b) patient health improvement. The results indicate that providing each physician feedback on peer performance is superior to not providing it; when providing peer information within a group, concealing identities is superior to revealing them. These findings imply that application of the principle of social comparison can be effective; however, caution should be taken when disclosure of identifiable peer performance may intensify peer competition and undermine care coordination in team-based models. Further, groups that distribute payments equally among physicians perform better than groups that distributed payment proportionally to physicians' patient shares. The findings are germane to small teams, where physicians do not have full control over care processes and outcomes, and need to work cooperatively to maximize group-based payment.

The impact of an accountable care unit on mortality: an observational study

Background: Despite enthusiasm for inpatient ward redesign, coordinated models require high effort with uncertain return on investment.

Objective: We aimed to reduce mortality and achieve a benchmark of zero preventable deaths by committing to an interprofessional model, including partnered nurse-physician unit leadership, geographic localization, and structured interdisciplinary bedside rounds (SIBR).

Methods: An observational pre-post design with 5-year follow-up studied the transition of a medical unit to an Accountable Care Unit (ACU). This geographic model enables partnered nurse-physician leadership and patient-centered workflows, including daily interdisciplinary bedside rounds. Potentially additive or confounding hospital-wide safety initiatives were tracked. Yearly mortality was compared using multivariable logistic regression and reported as odds ratio (OR). For the pre-specified goal of no preventable deaths, we report unexpected deaths, defined as those occurring without documentation of comfort as the goal of care.

Results: 12,158 inpatients (55.1% female, mean [sd] age 62.2 [19.7]) were observed over 6 years. Reduction in the risk-adjusted mortality was observed following ACU implementation, with Year 2 significantly lower than the pre-implementation year (adjusted odds ratio [aOR] = 0.58 [0.35–0.94]). Risk-adjusted mortality was similar in Year 3 (aOR = 0.64 [0.39–1.0]) but returned to baseline for Years 4 and 5. Unexpected deaths reached zero in Year 3 and plateaued in Years 4 and 5 at a rate below pre-implementation year (~0.1% vs. 0.38%).

Conclusions: A geographic ACU with nurse-physician partnered leadership and daily structured interdisciplinary bedside rounds can reduce total and unexpected mortality. However, maintenance requires constant effort and, in the real world, multiple confounders complicate study.

Interprofessional education on opioid use and pain identifies team-based learning needs

BACKGROUND

An interprofessional education (IPE) activity was designed for health professional students in pharmacy, medicine, nursing, social work, and addiction studies. The goals were to practice team-based collaboration for patients who are prescribed opioids for chronic pain and to evaluate student responses to the activity.

INTERPROFESSIONAL EDUCATION ACTIVITY

Student teams were guided through an unfolding patient case that included evaluating the patient's history, screening tool results, morphine equivalent dose, prescription monitoring program report, and videos of a patient-provider interaction. The two-hour, in-person IPE activity culminated in creation of a patient-centered treatment plan. Surveys were administered to compare pre- and post-course opioid knowledge and post-course IPE attitudes among the healthcare professions.

DISCUSSION

Pharmacy students' baseline opioid knowledge scores were similar to nursing students, significantly lower than medical students, and significantly higher than social work students. Pharmacy students reported significantly higher gains in opioid knowledge than medical students. Nursing and social work students showed significantly higher levels of agreement that the course enhanced attitudes toward interprofessional collaboration compared to medicine and pharmacy students. Students most frequently noted working with other professions as the most valuable aspect of the IPE activity.

IMPLICATIONS

Training gaps can be met using novel IPE activities specific to chronic pain and opioid use. Depending on profession, students demonstrated varied baseline knowledge regarding opioid use for chronic pain. Comparing knowledge gains and attitudes on IPE collaboration among professions can detect areas for program refinement to address each professions' unique needs.

A mixed methods evaluation of the implementation of pharmacy services within a team-based at-home care program

BACKGROUND

Sub-optimal medication use results in significant avoidable morbidity, mortality, and costs. Programs, such as comprehensive medication management (CMM), can help to optimize medication use, improve outcomes, and reduce costs. However, implementing programs like CMM can be challenging and differences in how CMM has been implemented may be responsible for observed heterogeneity in the outcomes associated with CMM.

OBJECTIVE(S)

Describe the implementation strategies utilized in implementing CMM telephonically within a team-based at-home care program and evaluate the implementation process.

METHODS

The implementation of CMM was facilitated using various implementation strategies including: develop educational material and conduct training, change record system, audit and feedback, learning collaborative, quality monitoring, readiness assessment, and implementation team formation. The impact of these strategies as well as pharmacist and team member perspectives on the implementation of CMM were examined using mixed methods and guided by Proctor's conceptual model for implementation.

RESULTS

The pharmacists felt that most of the implementation strategies used to facilitate consistent delivery of CMM were useful, but were unable to successfully implement all of them. Despite this, significant increases in fidelity to steps of the patient care process was achieved. The pharmacists felt that CMM was acceptable, appropriate for patient population, and feasible, but barriers (e.g., the telephonic and remote nature of the practice, the evolving nature of the program, and the difficulty in coordinating care between the patients primary care team and the care team affiliated with the program) affected the feasibility and organizational fit of CMM within this team-based, at-home care program. General pharmacy services, however, were seen as acceptable, appropriate, and feasible.

CONCLUSION

Deliberately designing and utilizing a variety of implementation strategies can facilitate the implementation of CMM and significantly increase fidelity to the patient care process. To improve feasibility and organizational fit of CMM, additional barriers and challenges need to be addressed.

"It is you, me on the team together, and my child": Attending, resident, and patient family perspectives on patient ownership

INTRODUCTION

Patient ownership is an important element of physicians' professional responsibility, but important gaps remain in our understanding of this concept. We sought to develop a theory of patient ownership by studying it in continuity clinics from the perspective of residents, attending physicians, and patients.

METHODS

Using constructivist grounded theory, we conducted 27 semi-structured interviews of attending physicians, residents, and patient families within two pediatric continuity clinics to examine definitions, expectations, and experiences of patient ownership from March-August 2019. We constructed themes using constant comparative analysis and developed a theory describing patient ownership that takes into account a diversity of perspectives.

RESULTS

Patient ownership was described as a bi-directional, relational commitment between patient/family and physician that includes affective and behavioral components. The experience of patient ownership was promoted by continuity of care and constrained by logistical and other systems-based factors. The physician was seen as part of a medical care team that included clinic staff and patient families. Physicians adjusted expectations surrounding patient ownership for residents based on scheduling limitations.

DISCUSSION

Our theory of patient ownership portrays the patient/family as an active participant in the patient-physician relationship, rather than a passive recipient of care. While specific expectations and tasks will vary based on the practice setting, our findings reframe the way in which patient ownership can be viewed and studied in the future by attending to a diversity of perspectives.

A Perspective from the Neurocritical Care Society and the Society of Critical Care Medicine: Team-Based Care for Neurological Critical Illness

The Neurocritical Care Society and the Society of Critical Care Medicine have worked together to create a perspective regarding the Standards of Neurologic Critical Care Units (Moheet et al. in Neurocrit Care 29:145-160, 2018). The most neurologically ill or injured patients warrant the highest standard of care available; this supports the need for defining and establishing specialized neurological critical care units. Rather than interpreting the Standards as being exclusionary, it is most appropriate to embrace them in the setting of team-based care. Since there are many more patients than there are highly specialized beds, collaborative care and appropriate transfer agreements are essential in promoting excellent patient outcomes. This viewpoint addresses areas of clarification and emphasizes the need for collegiality and partnership in delivering the best specialty critical care to our patients.

Dissemination of a telehealth cardiovascular risk service: The CVRS live protocol

BACKGROUND

Medical clinics are increasingly hiring clinical pharmacists to improve management of cardiovascular disease (CVD). However, the limited number of clinical pharmacists employed in a clinic may not impact the large number of complex patients needing the services. We have developed a remote telehealth service provided by clinical pharmacists to complement CVD services provided by on-site clinical pharmacists and aid sites without a clinical pharmacist. This cardiovascular risk service (CVRS) has been studied in two NIH-funded trials, however, we identified barriers to optimal intervention implementation. The purpose of this study is to examine how to implement the CVRS into medical offices and see if the intervention will be sustained.

METHODS

This is a 5-year, pragmatic, cluster-randomized clinical trial in 13 primary care clinics across the US. We randomized clinics to receive CVRS or usual care and will enroll 325 patient subjects and 288 key stakeholder subjects. We have obtained access to the electronic medical records (EMRs) of all study clinics to recruit subjects and provide the pharmacist intervention. The intervention is staggered so that after 12 months, the usual care sites will receive the intervention for 12 months. Follow-up will be accomplished though medical record abstraction at baseline, 12 months, 24 months, and 36 months.

CONCLUSIONS

This study will enroll subjects through 2021 and results will be available in 2024. This study will provide unique information on how the CVRS provided by remote clinical pharmacists can be effectively implemented in medical offices, many of which already employ on-site clinical pharmacists.

CLINICAL TRIAL REGISTRATION INFORMATION

NCT03660631: http://clinicaltrials.gov/ct2/show/NCT03660631.

Interdisciplinary Education and Health Care in Geriatric Dental Medicine

Geriatric patients are more likely to have multiple medical comorbidities, physical limitations, and mental impairments that warrant careful consideration while providing patient care. Dentistry, along with other health care professional programs, incorporate interprofessional education (IPE) experiences to provide students with skills they need to deliver collaborative care in their future practice. Health professional programs should consider geriatric training in simulated learning environments, adult day programs, nursing homes, long-term care facilities, and home care experiences to provide students valuable IPE experiences. Lastly, this article presents a call to action for professional organizations to consider offering continuing education courses in IPE.

Evaluation of a clinical pharmacist team-based telehealth intervention in a rural clinic setting: a pilot study of feasibility, organizational perceptions, and return on investment

BACKGROUND

Remote, centralized clinical pharmacist services provided by board-certified clinical pharmacists have been shown to effectively assist in chronic disease management. We assess the feasibility of implementing a pharmacist-led, remote, centralized pharmacy service to improve A1c levels in patient with diabetes in a rural clinic setting.

METHODS

This was a non-randomized pilot and feasibility study. Participants were enrolled in a pharmacist-led telehealth intervention service, with data prior to enrollment used as baseline data for control. To be included, patients needed to have A1c readings of greater than 7% to be considered uncontrolled. A1c changes were reported for two groups based on A1c ranges: between 7 and 10% and ≥ 10%. Clinical pharmacists and clinical pharmacy interns initiated contact with patients via telephone communication and managed the patients remotely. The following outcomes were evaluated: organization perceptions (patients, providers, and clinic staff), changes in A1c, medication discrepancies, impact of an internally operated Patient Assistance Program, and potential return on investment (ROI).

RESULTS

Fifty-two patients were initially identified and referred to the service with 43 patients consenting to participate in the intervention. Patient and provider survey responses were recorded. In the initial analysis occurring during the first 3 to 5 months of the program, there was considerable improvement in diabetes control as measured by A1c. For patients with uncontrolled diabetes with a baseline A1c > 7% but less than < 10% and ≥ 10%, the intervention resulted in an A1c decrease of 0.57% and 2.55%, respectively. Clinical pharmacists and clinical pharmacy interns identified at least one medication discrepancy in 44% of patients, with number of discrepancies ranging from 1 to 5 per patient. At the conclusion of the study window, 42 potentially billable encounters were documented, which would have generated a net profit of $1140 USD, had they been submitted for reimbursement. Given the potential revenue generation, the service theoretically yields a ROI of 1.4 to 1.

CONCLUSIONS

Initial results suggest that a pharmacist-led telehealth intervention has potential to decrease A1c levels in patients with diabetes, assist in identification of medication discrepancies, provide a positive return on investment for rural clinics, and potentially increase reimbursement for providers and clinics tasked with managing patients with uncontrolled diabetes.

Implementation of interprofessional team-based care: A cross-case analysis

Two out of five Canadians have at least one chronic disease and four out of five are at risk of developing a chronic disease. Successful disease management relies on interprofessional team-based approaches, yet lack of purposeful cultivation and patient engagement has led to systematic inefficiencies. Two primary care teams in Southwestern Ontario implementing interprofessional chronic care programs for patients with chronic obstructive pulmonary disease were compared. A mixed-methods cross-case analysis was conducted including interviews, focus groups, observations and document analysis. Cases (n = 2) were chosen based on intrinsic and unique value. Participants (n = 46) were sampled using a combination of purposive and multi-level sampling. Data was analyzed using an iterative process; inductive coding was used to gain a sense of context followed by a deductive cross-case analysis to compare and contrast themes across sites. Kompier's five-step framework was used to assess factors contributing to successful implementation and to provide insight into interactions between teams, providers and patients. Both cases satisfied all five factors (systemic and gradual approach, identification of risk factors, theory-driven, participatory approach and sustained committed support). However, one case was more successful at fully implementing their model, attributed to a flexible implementation, plans to mitigate risks, theory use, a supportive team and continued buy-in from leadership. By better understanding key facilitators and barriers, we can support the implementation of chronic disease management programs, foster sustainability of high-performing interprofessional teams, and engage patients in the development and maintenance of team-based chronic disease management.

Enhancing healthcare efficiency to achieve the Quadruple Aim: an exploratory study

Objective

Healthcare is battling a conflict between the Quadruple Aims—reducing costs; improving population health, patient experience, and team well-being—and productivity. This quasi-experimental pilot study tested a 2 week intervention aimed to address the Quadruple Aims while improving productivity. Participants were 25 employees and their patients in a primary care clinic. One provider and their team implemented an efficiency-focused intervention that modified work roles and processes focused on utilizing all team members’ skills as allowable by applicable licensure restrictions. The five remaining providers and their teams comprised the reference group, who continued patient care as usual. Study outcomes were measured via provider/staff and patient surveys and administrative data.

Results

In total, 46 team surveys and 156 patient surveys were collected. Clinic output data were retrieved for 467 visits. Compared to the reference team, the intervention team performed better in all Quadruple Aims and productivity measures. The intervention group offered 48% more patient slots than the average reference team. These preliminary results support the feasibility of introducing substantial process changes that show promising improvement in both the Quadruple Aims and productivity. A larger-scale study over a longer time period is needed to confirm findings and examine feasibility and cost-effectiveness.

Physician group, physician and patient characteristics associated with joining interprofessional team-based primary care in Ontario, Canada

PURPOSE

Countries throughout the world have been experimenting with new models to deliver primary care. We investigated physician group, physician and patient characteristics associated with voluntarily joining team-based primary care in Ontario.

METHODS

This cross-sectional study linked provincial administrative datasets to form data extractions of interest over time with the earliest in 2005 and the latest in 2013. We generated mixed, generalized chi-square and multivariate models to compare the characteristics of teams and non-teams, both with blended capitation reimbursement, and to examine characteristics associated with joining a team.

RESULTS

Having more physicians per group, being a female physician, having more years under the blended capitation model, having more patients in the lowest income quintile and more patients residing in rural areas were positively associated with joining a team. Being a female physician and having more patients who are males, recent immigrants and living in rural areas were positively associated with the outcome of joining teams in the late phase.

CONCLUSIONS

Our study findings indicate that there are differences in physician group, physician and patient characteristics when comparing teams to non-teams. Other jurisdictions aiming to expand physician participation in interprofessional care should note those factors. Researchers looking to understand the impact of team-based care should be aware of pre-existing differences and the need to address selection bias associated with participation in team-based care.

Roles of Registered Nurses in Pediatric Preventive Care Delivery: A Pilot Study on Between-office Variation and Within-office Role Overlap

PURPOSE

Registered nurses (RN) participate in delivery of routine pediatric preventive care. This pilot study characterized variation in RN roles and overlap with other team roles.

METHODS

We conducted a pilot cross-sectional survey of RNs from an urban/suburban pediatric primary care network. RNs described tasks during preventive visits and other staff completing similar tasks. Health system data characterized office staffing, volume, and patient population. We assessed whether role overlap and time on key tasks was associated with office characteristics or staffing ratios.

RESULTS

Twenty-three offices reported a mean ratio of RNs to physicians and nurse practitioners of 0.99 (range 0.62-1.33). Of tasks RNs completed during preventive care, health education overlapped most with physician/nurse practitioner roles (17 sites with overlap) and rooming patients overlapped most with medical assistant roles (20 sites with overlap). Across sites, RNs spent 9% of time on health education and 26% on rooming. Offices with more role overlap between RNs and physicians/nurse practitioners had higher RN to physician/nurse practitioner ratios (1.13 versus 0.86, t-test p-value 0.002). There was no association between role overlap and other office characteristics, or between RN time on key tasks and staffing ratios.

CONCLUSIONS

RN staffing ratios varied twofold across offices. RNs spent more time on tasks that overlapped with medical assistant roles than tasks that overlapped with physician/nurse practitioner roles.

PRACTICE IMPLICATIONS

Opportunities exist to optimize RN pediatric primary care roles, for example by delegating certain tasks. Optimization may reduce costs, while improving quality, patient experience, and staff satisfaction.

Team-based suicide prevention: lessons learned from early adopters of collaborative care

Suicide prevention in clinical settings requires coordination among multiple clinicians with expertise in different disciplines. We aimed to understand the benefits and challenges of a team approach to suicide prevention in primary care, with a particular focus on Veterans. The Veterans Health Administration has both a vested interest in preventing suicide and it has rapidly and systematically adopted team-based approaches for primary care interventions, including suicide prevention. We conducted eight focus groups and eight in-depth interviews with primary care providers (PCPs), behavioral health providers and nurses located in six regions within one Veterans Administration Catchment Area in the northeast of the US. Transcripts were analyzed using simultaneous deductive and inductive content analysis. Findings revealed that different clinicians were thought to have particular expertise and roles. Nurses were recognized as being well positioned to identify subtle changes in patient behavior that could put patients at risk for suicide; behavioral health providers were recognized for their skill in suicide risk assessment; and PCPs were felt to be an integral conduit between needed services and treatment. Our findings suggest that clinician role-differentiation may be an important by-product of team-based suicide prevention efforts in VHA settings. We contextualize our findings within both a processual and relational interprofessional framework and discuss implications for the implementation of team-based suicide prevention.

Primary Care Transformation

Primary care transformation will usher in a new era of advanced team-based care with extensive roles beyond the physician to build authentic healing relationships with patients. Smart technology will support these relationships, empower and engage patients, and build confidence that their health care team will take excellent care of them. Investments need to shift from catastrophic hospital-based care to proactive prevention and wellness, pushing us to think of health beyond health care. Systems need to build a culture of continuous improvement, supported by data-driven improvement science, and keep a sharp focus on the patient experience of care.

Taking note: A qualitative study of implementing a scribing practice in team-based primary care clinics

BACKGROUND

Though much is known about the benefits attributed to medical scribes documenting patient visits (e.g., reducing documentation time for the provider, increasing patient-care time, expanding the roles of licensed and non-licensed personnel), little attention has been paid to how care workers enact scribing as a part of their existing practice. The purpose of this study was to perform an ethnographic process evaluation of an innovative medical scribing practice with primary care teams in Veterans Health Administration (VHA) clinics across the United States. The aim of our study was to understand barriers and facilitators to implementing a scribing practice in primary care.

METHODS

At three to six months after medical scribing was introduced, we used semi-structured interviews and direct observations during site visits to five sites to describe the intervention, understand if the intervention was implemented as planned, and to record the experience of the teams who implemented the intervention. This manuscript only reports on semi-structured interview data collected from providers and scribes. Initial matrix analysis based on categories outlined in the evaluation plan informed subsequent deductive coding using the social-shaping theory Normalization Process Theory.

RESULTS

Through illustrating the slow accumulation of interactions and knowledge that fostered cautious momentum of teams working to normalize scribing practice in VHA primary care clinics, we show how the practice had 1) an organizing effect, as it centered a shared goal (the creation of the note) between the provider, scribe, and patient, and 2) a generative effect, as it facilitated care workers developing relationships that were both interpersonally and inter-professionally valuable. Based on our findings, we suggest that a scribing practice emphasizes the complementarity of existing professional roles, which thus leverage the interactional possibilities already present in the primary care team. Scribing, as a skill, forged moments of interprofessional fit. Scribing, in practice, created opportunities for interpersonal connection.

CONCLUSIONS

Our research suggests that individuals will notice different benefits to scribing based on their professional expectations and organizational roles related to documenting patient visits.

Improving Provider Adherence to Guideline Recommendations in Heart Failure

PURPOSE OF REVIEW

Heart failure clinical practice guidelines are fundamental and serve as framework for providers to deliver evidence-based care that correlates with enhanced patient outcomes. However, adherence, particularly to guideline-directed medical therapy, remains suboptimal for a multitude of reasons.

RECENT FINDINGS

Despite robust clinical trials, updated guidelines and an expert consensus statement from American Heart Association, American College of Cardiology, and Heart Failure Society of America registry data signal that heart failure patients do not receive appropriate pharmacotherapy and may receive an intracardiac device without prior initiation or optimization of medical therapy. Strategies to improve provider adherence to heart failure guidelines include multidisciplinary models and appropriate referral and care standardization. These approaches can improve morbidity, mortality, and quality of life in HF patients.

Interprofessional team-based approach to patients with chronic hepatitis C and personality disorder: Three case studies

Hepatitis C virus is a blood borne pathogen that infects 130 million people worldwide. After a prolonged period of slowly progressive liver injury, those infected are at risk of advancing to end stage liver disease, with its associated complications, and hepatocellular carcinoma. Rates of past and/or current substance use and behavioral comorbidities are higher among those infected with hepatitis C compared to the general population. A number of patient, provider and system barriers to care and treatment have led to low rates of treatment initiation in this population despite pharmacologic advances that have made hepatitis C a curable disease. Innovation in care delivery is considered a key strategy that will help reach more patients. We present three case studies of patients with chronic hepatitis C and multiple psychiatric comorbidities who were successfully engaged in care and treated for their chronic hepatitis C in our multidisciplinary primary care-based program.

Best Practices in Tele-Teaming: Managing Virtual Teams in the Delivery of Care in Telepsychiatry

PURPOSE OF THE REVIEW

To review and organize best practices around management of virtual teams for psychiatrists working in team-based telepsychiatry services.

RECENT FINDINGS

An early but evolving literature in telepsychiatric team-based care is beginning to examine the importance of team function. Psychiatrists will increasingly have opportunities to engage in team-based telepsychiatry in evolving models that improve outcomes, enhance quality, and expand access to behavioral health treatments. While the literature is limited in psychiatry and medicine on virtual teams, there is a growing literature from applied psychology and business. This article synthesizes these findings along with lessons learned from the field to provide recommendations for psychiatrists involved in team-based telepsychiatry. Providing this type of care involves mastering the management of virtual teams. Psychiatrists are well positioned to play a distinctive and central leadership role for team-based telepsychiatry.

Care Coordination Using a Shared Plan of Care Approach: From Model to Practice

INTRODUCTION

Children and youth with special health care needs (CYSHCN) need, but do not have, adequate care coordination (CC); CC leads to better pediatric care, improved family/professional experience of care, and enhanced population health. Current CC initiatives are promising but lack adherence to emerging definitions/standards. A Lucile Packard Report provides guidelines for using a Shared Plan of Care (SPoC) as a CC approach; studied implementation is needed.

PURPOSE

The studied implementation of the Riley Care Coordination Program (RCCP) set out to: 1) illuminate components of family-centered, interdisciplinary, team-based care/coordination and SPoC, use 2) underscore family participation/engagement 3) reveal implementation processes/lessons learned.

METHODS

Children (ages 2-10) with neurodevelopmental disabilities were referred by subspecialists; families agreed to participate in RCCP from a children's hospital ambulatory care setting. RCCP team used a five-phase workflow to implement CC: (1) Family Outreach/Engagement 2) Family and Team Pre-Visit Work, 3) Population-Based Teamwork, 4) Planned-Care Visits/SPOC "Co-Production", 5) Ongoing Care Coordination and Community Transfer. Family surveys and SPoC goals informed an evaluation.

RESULTS

Children (268) with neurodevelopmental disabilities enrolled/completed the 6-month RCCP; it was a feasible endeavor. The co-produced SPoC supported families/care neighborhood partners to meet goals/unmet needs. Team plan-do-study-act improvement cycles informed RCCP enhancements.

DISCUSSION/CONCLUSION

Eliciting/using family goals to drive CC emphasized family priorities; children/families gained interventions, treatments, confidence and navigation skills. Going beyond episodic, reactive care, RCCP achieved better CC with care neighborhood learning partnerships. Investing in this quality care coordination with fidelity to national standards holds promise.

Optimizing huddle engagement through leadership and problem-solving within primary care: A study protocol for a cluster randomized trial

BACKGROUND

Team-based care has been identified as a key component in transforming primary care. An important factor in implementing team-based care is the requirement for teams to have daily huddles. During huddles, the care team, comprising physicians, nurses, and administrative staff, come together to discuss their daily schedules, track problems, and develop countermeasures to fix these problems. However, the impact of these huddles on staff burnout over time and patient outcomes are not clear. Further, there are challenges to implementing huddles in fast-paced primary care clinics. We will test whether the impact of a behavioral intervention of leadership training and problem-solving during the daily huddling process will result in higher consistent huddling in the intervention arm and result in higher team morale, reduced burnout, and improved patient outcomes.

METHODS/DESIGN

We will conduct a care-team-level cluster randomized trial within primary care practices in two Midwestern states. The intervention will comprise a 1-day training retreat for leaders of primary care teams, biweekly sessions between huddle optimization coaches and members of the primary care teams, as well as coaching site visits at 30 and 100 days post intervention. This behavioral intervention will be compared to standard care, in which care teams have huddles without any support or training. Surveys of primary care team members will be administered at baseline (prior to training), 100 days (for the intervention arm only), and 180 days to assess team dynamics. The primary outcome of this trial will be team morale. Secondary outcomes will assess the impact of this intervention on clinician burnout, patient satisfaction, and quality of care.

DISCUSSION

This trial will provide evidence on the impact of a behavioral intervention to implement huddles as a key component of team-based care models. Knowledge gained from this trial will be critical to broader deployment and successful implementation of team-based care models.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03062670 . Registered on 23 February 2017.

Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies

Background

Home-based primary care (HBPC) is a multidisciplinary, ongoing care strategy that can provide cost-effective, in-home treatment to meet the needs of the approximately four million homebound, medically complex seniors in the U.S. Because there is no single model of HBPC that can be adopted across all types of health organizations and U.S. geographic regions, we conducted a six-site HBPC practice assessment to better understand different operation structures, common challenges, and approaches to delivering HBPC.

Methods

Six practices varying in size, care team composition and location agreed to participate. At each site we conducted unstructured interviews with key informants and directly observed practices and procedures in the field and back office.

Results

The aggregated case studies revealed important issues focused on team composition, patient characteristics, use of technology and urgent care delivery. Common challenges across the practices included provider retention and unmet community demand for home-based care services. Most practices, regardless of size, faced challenges around using electronic medical records (EMRs) and scheduling systems not designed for use in a mobile practice. Although many practices offered urgent care, practices varied in the methods used to provide care including the use of community paramedics and telehealth technology.

Conclusions

Learnings compiled from these observations can inform other HBPC practices as to potential best practices that can be implemented in an effort to improve efficiency and scalability of HBPC so that seniors with multiple chronic conditions can receive comprehensive primary care services in their homes.

Advancing team-based primary health care: a comparative analysis of policies in western Canada

Background

We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta and Saskatchewan to understand how they inform the design and implementation of team-based primary health care service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada.

Methods

We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewed relevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We compared and contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narratives prepared from the comparative analysis by offering contextual information on potential policy imperatives. Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtable event guided prioritization of policy imperatives.

Results

The concept of team-based PHC varies widely across and within the three provinces. We noted policy gaps related to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policies speak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignment of goals and policies at different system levels; (2) investment of resources for system change; (3) compensation models for all members of the team; and (4) accountability through collaborative practice metrics.

Conclusions

Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinated approach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanisms and performance monitoring could accelerate systemic transformation by removing some well-known barriers to team-based care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2439-1) contains supplementary material, which is available to authorized users.