Sample records for additional primary care

  1. [Strengthening primary health care: a strategy to maximize coordination of care].

    PubMed

    de Almeida, Patty Fidelis; Fausto, Márcia Cristina Rodrigues; Giovanella, Lígia

    2011-02-01

    To describe and analyze the actions developed in four large cities to strengthen the family health strategy (FHS) in Brazil. Case studies were carried out in Aracaju, Belo Horizonte, Florianópolis, and Vitória based on semi-structured interviews with health care managers. In addition, a cross-sectional study was conducted with questionnaires administered to a sample of FHS workers and services users. Actions needed to strengthen primary health care services were identified in all four cities. These include increasing the number of services offered at the primary health care level, removing barriers to access, restructuring primary services as the entry point to the health care system, enhancing problem-solving capacity (diagnostic and therapeutic support and networking between health units to organize the work process, training, and supervision), as well as improving articulation between surveillance and care actions. The cities studied have gained solid experience in the reorganization of the health care model based on a strengthening of health primary care and of the capacity to undertake the role of health care coordinator. However, to make the primary care level the customary entry point and first choice for users, additional actions are required to balance supplier-induced and consumer-driven demands. Consumer driven demand is the biggest challenge for the organization of teamwork processes. Support for and recognition of FHS as a basis for primary health care is still an issue. Initiatives to make FHS better known to the population, health care professionals at all levels, and civil society organizations are still needed.

  2. Achieving Value in Primary Care: The Primary Care Value Model.

    PubMed

    Rollow, William; Cucchiara, Peter

    2016-03-01

    The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation. © 2016 Annals of Family Medicine, Inc.

  3. Diabetes care: model for the future of primary care.

    PubMed

    Posey, L Michael; Tanzi, Maria G

    2010-01-01

    To review relevant trends threatening primary care and the evidence supporting use of nonphysicians in primary and chronic care of patients with diabetes. Current medical and pharmacy literature as selected by authors. The care needed by patients with diabetes does not fit well into our current medical model for primary care, and an adequate supply of physicians is not likely to be available for primary care roles in coming years. Patients with diabetes who are placed on evidence-based regimens, are educated about their disease, are coached in ways that motivate them to lose weight and adopt other therapeutic lifestyle changes, and are adhering to and persisting with therapy will soon have improved clinical parameters. These quickly translate into fewer hospitalizations and emergency department visits. A growing body of literature supports the use of pharmacists and other nonphysicians in meeting the needs of patients with diabetes. Pharmacists should join nurse practitioners, specially trained nurses, and physician assistants as integral members of the health care team in providing care to patients with diabetes and, by logical extension, other chronic conditions. Demand for primary care is likely to outstrip the available supply of generalist physicians in the coming years. In addition to nurse practitioners and physician assistants, pharmacists should be considered for key roles in future interdisciplinary teams that triage and provide direct care to patients, including those with diabetes and other chronic conditions.

  4. Integrating Behavioral Health into Primary Care.

    PubMed

    McGough, Peter M; Bauer, Amy M; Collins, Laura; Dugdale, David C

    2016-04-01

    Depression is one of the more common diagnoses encountered in primary care, and primary care in turn provides the majority of care for patients with depression. Many approaches have been tried in efforts to improve the outcomes of depression management. This article outlines the partnership between the University of Washington (UW) Neighborhood Clinics and the UW Department of Psychiatry in implementing a collaborative care approach to integrating the management of anxiety and depression in the ambulatory primary care setting. This program was built on the chronic care model, which utilizes a team approach to caring for the patient. In addition to the patient and the primary care provider (PCP), the team included a medical social worker (MSW) as care manager and a psychiatrist as team consultant. The MSW would manage a registry of patients with depression at a clinic with several PCPs, contacting the patients on a regular basis to assess their status, and consulting with the psychiatrist on a weekly basis to discuss patients who were not achieving the goals of care. Any recommendation (eg, a change in medication dose or class) made by the psychiatrist was communicated to the PCP, who in turn would work with the patient on the new recommendation. This collaborative care approach resulted in a significant improvement in the number of patients who achieved care plan goals. The authors believe this is an effective method for health systems to integrate mental health services into primary care. (Population Health Management 2016;19:81-87).

  5. A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care.

    PubMed

    Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M; Wensing, Michel; Esmail, Aneez

    2015-09-01

    Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. To outline a research agenda for patient safety improvement in primary care in Europe and beyond. The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

  6. A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care

    PubMed Central

    Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M.; Wensing, Michel; Esmail, Aneez

    2015-01-01

    ABSTRACT Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement. PMID:26339841

  7. Monitoring quality in Israeli primary care: The primary care physicians' perspective

    PubMed Central

    2012-01-01

    among physicians who are young, board-certified in family medicine, and salaried. Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems. Conclusions The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified. PMID:22913311

  8. The ORIGINS of Primary Health Care and SELECTIVE Primary Health Care

    PubMed Central

    Cueto, Marcos

    2004-01-01

    I present a historical study of the role played by the World Health Organization and UNICEF in the emergence and diffusion of the concept of primary health care during the late 1970s and early 1980s. I have analyzed these organizations’ political context, their leaders, the methodologies and technologies associated with the primary health care perspective, and the debates on the meaning of primary health care. These debates led to the development of an alternative, more restricted approach, known as selective primary health care. My study examined library and archival sources; I cite examples from Latin America. PMID:15514221

  9. Primary care and care for older persons: position paper of the European Forum for Primary Care.

    PubMed

    Boeckxstaens, Pauline; De Graaf, Pim

    2011-01-01

    This article explores how to address the needs of the growing number of older patients in primary care practice. Primary care is not a fixed organisational structure but a combination of functional characteristics which has developed variably in European countries with differing responses to the emerging needs of older persons. Multimorbidity, frailty, disability and dependence play out differently in older persons; a key challenge for primary care is to provide a response that is adapted to the needs of individuals - as they see them and not as the professional defines them. Indeed, growing experience shows how to involve older persons in taking decisions. Contrary to popular opinion, older persons often rate their quality of life as high. Indeed, comprehensive primary care offers health promotion and prevention: also older people may benefit from measures that support their health and independence and some case descriptions show this potential. Although most people prefer to be in their own environment (home, community) during the last stage of life, providing end-of-life care in the community is a challenge for primary care because it requires continuity and coordination with specialist care. Successful models of care however do exist. Delivering seamless integrated care to older persons is a central theme in primary care. Rather than disease management, in primary care, case management is the preferred approach. Proactive geriatric assessment of individual medical, functional and social needs, including loneliness and isolation, has been shown to be useful and its place in primary care is the subject of further research. Clinical practice guidelines for multimorbidity are badly needed. Non-adherence to medication, linked to multiple and uncoordinated prescriptions, is a widespread and costly problem. Successful approaches in primary care are being developed, including the use of electronic patient files. With the general practitioner (GP) as the central care

  10. Smoking cessation in primary care clinics.

    PubMed

    Sippel, J M; Osborne, M L; Bjornson, W; Goldberg, B; Buist, A S

    1999-11-01

    To document smoking cessation rates achieved by applying the 1996 Agency for Health Care Policy and Research (AHCPR) smoking cessation guidelines for primary care clinics, compare these quit rates with historical results, and determine if quit rates improve with an additional motivational intervention that includes education as well as spirometry and carbon monoxide measurements. Randomized clinical trial. Two university-affiliated community primary care clinics. Two hundred five smokers with routinely scheduled appointments. All smokers were given advice and support according to AHCPR guidelines. Half of the subjects received additional education with spirometry and carbon monoxide measurements. Quit rate was evaluated at 9-month follow-up. Eleven percent of smokers were sustained quitters at follow-up. Sustained quit rate was no different for intervention and control groups (9% vs 14%; [OR] 0.6; 95% [CI] 0.2, 1.4). Nicotine replacement therapy was strongly associated with sustained cessation (OR 6.7; 95% CI 2.3, 19.6). Subjects without insurance were the least likely to use nicotine replacement therapy ( p =.05). Historical data from previously published studies showed that 2% of smokers quit following physician advice, and additional support similar to AHCPR guidelines increased the quit rate to 5%. The sustained smoking cessation rate achieved by following AHCPR guidelines was 11% at 9 months, which compares favorably with historical results. Additional education with spirometry did not improve the quit rate. Nicotine replacement therapy was the strongest predictor of cessation, yet was used infrequently owing to cost. These findings support the use of AHCPR guidelines in primary care clinics, but do not support routine spirometry for motivating patients similar to those studied here.

  11. [Mental disorders in primary care].

    PubMed

    Herzig, Lilli; Mühlemann, Nicole; Bischoff, Thomas

    2010-05-19

    Mental disorders (depression, anxiety and somatization) are frequent in Primary care and are often associated to physical complaints and to psychosocial stressors. Mental disorders have in this way a specific presentation and in addition patients may present different associations of them. Sometimes it is difficult to recognize them, but it is important to do so and to take rapidly care of these patients. Specific screening questions exist and have been used in a research of the Institute of General Medicine and the Department of Ambulatory Care and Community Medicine (PMU), University of Lausanne, Switzerland.

  12. Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care-Sensitive Conditions.

    PubMed

    Cecil, Elizabeth; Bottle, Alex; Sharland, Mike; Saxena, Sonia

    2015-01-01

    We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care-sensitive conditions. We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care-sensitive infectious and chronic conditions. There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care-referred admissions was falling before the reforms, and there were further sharp reductions in 2004. The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care-sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission. © 2015 Annals of Family Medicine, Inc.

  13. African Primary Care Research: qualitative interviewing in primary care.

    PubMed

    Reid, Steve; Mash, Bob

    2014-06-05

    This article is part of a series on African Primary Care Research and focuses on the topic of qualitative interviewing in primary care. In particular it looks at issues of study design, sample size, sampling and interviewing in relation to individual and focus group interviews.There is a particular focus on helping postgraduate students at a Masters level to write their research proposals.

  14. Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study.

    PubMed

    Long, Theodore; Chaiyachati, Krisda; Bosu, Olatunde; Sircar, Sohini; Richards, Bradley; Garg, Megha; McGarry, Kelly; Solomon, Sonja; Berman, Rebecca; Curry, Leslie; Moriarty, John; Huot, Stephen

    2016-12-01

    Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. This was a qualitative study based on semi-structured, in-person interviews. Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue

  15. Large Independent Primary Care Medical Groups

    PubMed Central

    Casalino, Lawrence P.; Chen, Melinda A.; Staub, C. Todd; Press, Matthew J.; Mendelsohn, Jayme L.; Lynch, John T.; Miranda, Yesenia

    2016-01-01

    PURPOSE In the turbulent US health care environment, many primary care physicians seek hospital employment. Large physician-owned primary care groups are an alternative, but few physicians or policy makers realize that such groups exist. We wanted to describe these groups, their advantages, and their challenges. METHODS We identified 21 groups and studied 5 that varied in size and location. We conducted interviews with group leaders, surveyed randomly selected group physicians, and interviewed external observers—leaders of a health plan, hospital, and specialty medical group that shared patients with the group. We triangulated responses from group leaders, group physicians, and external observers to identify key themes. RESULTS The groups’ physicians work in small practices, with the group providing economies of scale necessary to develop laboratory and imaging services, health information technology, and quality improvement infrastructure. The groups differ in their size and the extent to which they engage in value-based contracting, though all are moving to increase the amount of financial risk they take for their quality and cost performance. Unlike hospital-employed and multispecialty groups, independent primary care groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Each group was positively regarded by external observers. The groups are under pressure, however, to sell to organizations that can provide capital for additional infrastructure to engage in value-based contracting, as well as provide substantial income to physicians from the sale. CONCLUSIONS Large, independent primary care groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting. PMID:26755779

  16. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035.

    PubMed

    Petterson, Stephen M; Liaw, Winston R; Tran, Carol; Bazemore, Andrew W

    2015-03-01

    The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes. We used the 2010 National Ambulatory Medical Care Survey to calculate utilization of ambulatory primary care services and the US Census Bureau to project demographic changes. To determine the baseline number of primary care physicians and the number retiring at 66 years, we used the 2014 American Medical Association Masterfile. Using specialty board and American Osteopathic Association figures, we estimated the annual production of primary care residents. To calculate shortages, we subtracted the accumulated primary care physician production from the accumulated number of primary care physicians needed for each year from 2015 to 2035. More than 44,000 primary care physicians will be needed by 2035. Current primary care production rates will be unable to meet demand, resulting in a shortage in excess of 33,000 primary care physicians. Given current production, an additional 1,700 primary care residency slots will be necessary by 2035. A 10% reduction in the ratio of population per primary care physician would require more than 3,000 additional slots by 2035, whereas changing the expected retirement age from 66 years to 64 years would require more than 2,400 additional slots. To eliminate projected shortages in 2035, primary care residency production must increase by 21% compared with current production. Delivery models that shift toward smaller ratios of population to primary care physicians may substantially increase the shortage. © 2015 Annals of Family Medicine, Inc.

  17. The long term importance of English primary care groups for integration in primary health care and deinstitutionalisation of hospital care.

    PubMed

    Goodwin, N

    2001-01-01

    This article reviews the impact of successive experiments in the development of primary care organisations in England and assesses the long-term importance of English primary care groups for the integration of health and community and health and social care and the deinstitutionalisation of hospital care. Governments in a number of Western countries are attempting to improve the efficiency, appropriateness and equity of their health systems. One of the main ways of doing this is to devolve provision and commissioning responsibility from national and regional organisations to more local agencies based in primary care. Such primary care organisations are allocated budgets that span both primary and secondary (hospital) services and also, potentially, social care. This article is based on a systematic review of the literature forthcoming from the UK Government's Department of Health-funded evaluations of successive primary care organisational developments. These include total purchasing pilots, GP commissioning group pilots, personal medical services pilots and primary care groups and trusts. Primary care organisations in England have proved to be a catalyst in facilitating the development of integrated care working between primary and community health services. Conversely, primary care organisations have proved less effective in promoting integration between health and social care agencies where most progress has been made at the strategic commissioning level. The development of primary care trusts in England is heralding an end to traditional community hospitals. The development of primary care groups in England are but an intermediate step of a policy progression towards future primary care-based organisations that will functionally integrate primary and community health services with local authority services under a single management umbrella.

  18. Shifting hospital care to primary care: An evaluation of cardiology care in a primary care setting in the Netherlands.

    PubMed

    Quanjel, Tessa C C; Struijs, Jeroen N; Spreeuwenberg, Marieke D; Baan, Caroline A; Ruwaard, Dirk

    2018-05-09

    In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital. This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus. In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus. To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus. NTR6629 (Data registered: 25-08-2017) (registered retrospectively).

  19. Development and validation of the Vietnamese primary care assessment tool

    PubMed Central

    2018-01-01

    Objective To adapt the consumer version of the Primary Care Assessment Tool (PCAT) for Vietnam and determine its internal consistency and validity. Design A quantitative cross sectional study. Setting 56 communes in 3 representative provinces of central Vietnam. Participants Total of 3289 people who used health care services at health facility at least once over the past two years. Results The Vietnamese adult expanded consumer version of the PCAT (VN PCAT-AE) is an instrument for evaluation of primary care in Vietnam with 70 items comprising six scales representing four core primary care domains, and three additional scales representing three derivative domains. Sixteen other items from the original tool were not included in the final instrument, due to problems with missing values, floor or ceiling effects, and item-total correlations. All the retained scales have a Cronbach’s alpha above 0.70 except for the subscale of Family Centeredness. Conclusions The VN PCAT-AE demonstrates adequate internal consistency and validity to be used as an effective tool for measuring the quality of primary care in Vietnam from the consumer perspective. Additional work in the future to optimize valid measurement in all domains consistent with the original version of the tool may be helpful as the primary care system in Vietnam further develops. PMID:29324851

  20. Development and validation of the Vietnamese primary care assessment tool.

    PubMed

    Hoa, Nguyen Thi; Tam, Nguyen Minh; Peersman, Wim; Derese, Anselme; Markuns, Jeffrey F

    2018-01-01

    To adapt the consumer version of the Primary Care Assessment Tool (PCAT) for Vietnam and determine its internal consistency and validity. A quantitative cross sectional study. 56 communes in 3 representative provinces of central Vietnam. Total of 3289 people who used health care services at health facility at least once over the past two years. The Vietnamese adult expanded consumer version of the PCAT (VN PCAT-AE) is an instrument for evaluation of primary care in Vietnam with 70 items comprising six scales representing four core primary care domains, and three additional scales representing three derivative domains. Sixteen other items from the original tool were not included in the final instrument, due to problems with missing values, floor or ceiling effects, and item-total correlations. All the retained scales have a Cronbach's alpha above 0.70 except for the subscale of Family Centeredness. The VN PCAT-AE demonstrates adequate internal consistency and validity to be used as an effective tool for measuring the quality of primary care in Vietnam from the consumer perspective. Additional work in the future to optimize valid measurement in all domains consistent with the original version of the tool may be helpful as the primary care system in Vietnam further develops.

  1. [Primary care in Ireland].

    PubMed

    Sánchez-Sagrado, T

    Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis. Copyright © 2017 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

  2. Costs of health care across primary care models in Ontario.

    PubMed

    Laberge, Maude; Wodchis, Walter P; Barnsley, Jan; Laporte, Audrey

    2017-08-01

    The purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients' primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team. Utilization data for a one year period was measured using administrative databases for a 10% sample selected at random from the Ontario adult population. Primary care and total health care costs were calculated at the individual level and included costs from physician services, hospital visits and admissions, long term care, drugs, home care, lab tests, and visits to non-medical health care providers. Generalized linear model regressions were conducted to assess the differences in costs between primary care models. Patients not enrolled with a primary care physicians were younger, more likely to be males and of lower socio-economic status. Patients in blended capitation models were healthier and wealthier than FFS and enhanced-FFS patients. Primary care and total health care costs were significantly different across Ontario primary care models. Using the traditional FFS as the reference, we found that patients in the enhanced-FFS models had the lowest total health care costs, and also the lowest primary care costs. Patients in the blended capitation models had higher primary care costs but lower total health care costs. Patients that were in multidisciplinary teams (FHT), where physicians are also paid on a blended capitation basis, had higher total health care costs than non-FHT patients but still lower than the FFS reference group. Primary care and total health care costs increased with patients' age, morbidity, and lower income quintile across all primary care payment types. The new primary care models were associated with lower total health care costs for patients compared to the

  3. Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.

    PubMed

    Stokes, Tim; Tumilty, Emma; Doolan-Noble, Fiona; Gauld, Robin

    2017-04-05

    Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals' accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery. Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand's Otago region. Thematic analysis was conducted using the constant comparative method. Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of "satisficing" (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface. These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers.

  4. Embracing a diversified future for US primary care.

    PubMed

    Hoff, Timothy

    2013-01-01

    Although less focused upon given the current emphasis on the patient-centered medical home innovation, the future for US primary care is arguably one that will be characterized by diversity in service delivery structures and personnel. The drivers of this diversity include increased patient demand requiring a larger number of primary care access points; the need for lower-cost delivery structures that can flourish in a low-margin business model; greater interest in primary care delivery by retailers and hospitals that see their involvement as a means to enhance their core business goals; the increased desire by non-physician providers to gain work independence; and a growing cadre of younger PCPs whose career and job preferences leave them open to working in a variety of different settings and structures. A key issue to ask of a more diversified primary care system is whether or not it will be characterized by competition or cooperation. While a competitive system would not be unexpected given historical and current trends, such a system would likely stunt the prospects for a full revitalization of US primary care. However, there is reason to believe that a cooperative system is possible and would be advantageous, given the mutual dependencies that already exist among primary care stakeholders, and additional steps that could be taken to enhance such dependencies even more into the future.

  5. Pediatric primary care as a component of systems of care.

    PubMed

    Brown, Jonathan D

    2010-02-01

    Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of care is defined as serving only children and youth with serious emotional disturbance and their families and does not fully embrace the concept of primary prevention. Although similarities in the definitions of primary care and systems of care may provide a theoretical foundation for including primary care within the systems of care framework, a definition of systems of care that incorporates the idea of prevention and takes into account the broad population served in primary care would provide communities with a definition that can be used to further the work of integrating primary care into systems of care.

  6. Late-life depression in the primary care setting: Challenges, collaborative care, and prevention

    PubMed Central

    Hall, Charles A.; Reynolds, Charles F.

    2014-01-01

    Late-life depression is highly prevalent worldwide. In addition to being a debilitating illness, it is a risk factor for excess morbidity and mortality. Older adults with depression are at risk for dementia, coronary heart disease, stroke, cancer and suicide. Individuals with late-life depression often have significant medical comorbidity and, poor treatment adherence. Furthermore, psychosocial considerations such as gender, ethnicity, stigma and bereavement are necessary to understand the full context of late-life depression. The fact that most older adults seek treatment for depression in primary care settings led to the development of collaborative care interventions for depression. These interventions have consistently demonstrated clinically meaningful effectiveness in the treatment of late-life depression. We describe three pivotal studies detailing the management of depression in primary care settings in both high and low-income countries. Beyond effectively treating depression, collaborative care models address additional challenges associated with late-life depression. Although depression treatment interventions are effective compared to usual care, they exhibit relatively low remission rates and small to medium effect sizes. Several studies have demonstrated that depression prevention is possible and most effective in at-risk older adults. Given the relatively modest effects of treatment in averting years lived with disability, preventing late-life depression at the primary care level should be highly prioritized as a matter of health policy. PMID:24996484

  7. Improving pathways to primary health care among LGBTQ populations and health care providers: key findings from Nova Scotia, Canada.

    PubMed

    Gahagan, Jacqueline; Subirana-Malaret, Montse

    2018-06-13

    This study explores the perceived barriers to primary health care as identified among a sample of Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) identified individuals and health care providers in Nova Scotia, Canada. These findings, based on a province-wide anonymous online survey, suggest that additional efforts are needed to improve pathways to primary health among LGBTQ populations and in deepening our understanding of how to advance the unique primary health needs of these populations. Data were collected from the LGBTQ community through an online, closed-ended anonymous survey. Inclusion criteria for participation were self-identifying as LGBTQ, offering primary health care to LGBTQ patients, being able to understand English, being 16 years of age or older, and having lived in Nova Scotia for at least one year. A total of 283 LGBTQ respondents completed the online survey which included sociodemographic questions, perceptions of respondents' health status, and their primary health care experiences. In addition, a total of 109 health care providers completed the survey based on their experiences providing care in Nova Scotia, and in particular, their experiences and perceptions regarding LGBTQ access to primary health care and physician-patient interactions. Our results indicate that, in several key areas, the primary health care needs of LGBTQ populations in Nova Scotia are not being met and this may in turn contribute to their poor health outcomes across the life course. A framework of intersectionality and health equity was used to interpret and analyze the survey data. The key findings indicate the need to continue improving pathways to primary health care among LGBTQ populations, specifically in relation to additional training and related supports for health care providers who work with these populations.

  8. The Coming Primary Care Revolution.

    PubMed

    Ellner, Andrew L; Phillips, Russell S

    2017-04-01

    The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.

  9. Substitution of Hospital Care with Primary Care: Defining the Conditions of Primary Care Plus

    PubMed Central

    Kroese, Mariëlle Elisabeth Aafje Lydia; Spreeuwenberg, Marieke Dingena; Elissen, Arianne Mathilda Josephus; Meerlo, Ronald Johan; Hanraets, Monique Margaretha Henriëtte; Ruwaard, Dirk

    2016-01-01

    Objective: To analyse barriers and facilitators in substituting hospital care with primary care to define preconditions for successful implementation. Methods: A descriptive feasibility study was performed to collect information on the feasibility of substituting hospital care with primary care. General practitioners were able to refer patients, about whom they had doubts regarding diagnosis, treatment and/or the need to refer to hospital care, to medical specialists who performed low-complex consultations at general practitioner practices. Qualitative data were collected through interviews with general practitioners and medical specialists, focus groups and notes from meetings in the Netherlands between April 2013 and January 2014. Data were analysed using a conventional content analysis which resulted in categorised barriers, facilitators and policy adjustments, after which preconditions were formulated. Results: The most important preconditions were make arrangements on governmental level, arrange a collective integrated IT-system, determine the appropriate profile for medical specialists, design a referral protocol for eligible patients, arrange deliberation possibilities for general practitioners and medical specialists and formulate a diagnostic protocol. Conclusions: The barriers, facilitators and formulated preconditions provided relevant input to change the design of substituting hospital care with primary care. PMID:27616956

  10. Primary care ... where?

    PubMed

    Adcock, G B

    1999-07-01

    Corporate-based nurse managed centers are not the national norm. More prevalent is the use of an occupational health or physician-directed medical model of care. The author describes how a 14-year-old primary care center at a North Carolina computer software company is just "business as usual" when viewed in the context of the company's philosophy, goals, and culture. Included are considerations for nurse practitioners interested in the successful transplantation of this primary care model to other settings.

  11. Primary care in Switzerland gains strength.

    PubMed

    Djalali, Sima; Meier, Tatjana; Hasler, Susann; Rosemann, Thomas; Tandjung, Ryan

    2015-06-01

    Although there is widespread agreement on health- and cost-related benefits of strong primary care in health systems, little is known about the development of the primary care status over time in specific countries, especially in countries with a traditionally weak primary care sector such as Switzerland. The aim of our study was to assess the current strength of primary care in the Swiss health care system and to compare it with published results of earlier primary care assessments in Switzerland and other countries. A survey of experts and stakeholders with insights into the Swiss health care system was carried out between February and March 2014. The study was designed as mixed-modes survey with a self-administered questionnaire based on a set of 15 indicators for the assessment of primary care strength. Forty representatives of Swiss primary and secondary care, patient associations, funders, health care authority, policy makers and experts in health services research were addressed. Concordance between the indicators of a strong primary care system and the real situation in Swiss primary care was rated with 0-2 points (low-high concordance). A response rate of 62.5% was achieved. Participants rated concordance with five indicators as 0 (low), with seven indicators as 1 (medium) and with three indicators as 2 (high). In sum, Switzerland achieved 13 of 30 possible points. Low scores were assigned because of the following characteristics of Swiss primary care: inequitable local distribution of medical resources, relatively low earnings of primary care practitioners compared to specialists, low priority of primary care in medical education and training, lack of formal guidelines for information transfer between primary care practitioners and specialists and disregard of clinical routine data in the context of medical service planning. Compared to results of an earlier assessment in Switzerland, an improvement of seven indicators could be stated since 1995. As a

  12. Primary care at Swiss universities - current state and perspective

    PubMed Central

    2014-01-01

    Background There is increasing evidence that a strong primary care is a cornerstone of an efficient health care system. But Switzerland is facing a shortage of primary care physicians (PCPs). This pushed the Federal Council of Switzerland to introduce a multifaceted political programme to strengthen the position of primary care, including its academic role. The aim of this paper is to provide a comprehensive overview of the situation of academic primary care at the five Swiss universities by the end of year 2012. Results Although primary care teaching activities have a long tradition at the five Swiss universities with activities starting in the beginning of the 1980ies; the academic institutes of primary care were only established in recent years (2005 – 2009). Only one of them has an established chair. Human and financial resources vary substantially. At all universities a broad variety of courses and lectures are offered, including teaching in private primary care practices with 1331 PCPs involved. Regarding research, differences among the institutes are tremendous, mainly caused by entirely different human resources and skills. Conclusion So far, the activities of the existing institutes at the Swiss Universities are mainly focused on teaching. However, for a complete academic institutionalization as well as an increased acceptance and attractiveness, more research activities are needed. In addition to an adequate basic funding of research positions, competitive research grants have to be created to establish a specialty-specific research culture. PMID:24885148

  13. Primary care at Swiss universities--current state and perspective.

    PubMed

    Tandjung, Ryan; Ritter, Catherine; Haller, Dagmar M; Tschudi, Peter; Schaufelberger, Mireille; Bischoff, Thomas; Herzig, Lilli; Rosemann, Thomas; Sommer, Johanna

    2014-05-22

    There is increasing evidence that a strong primary care is a cornerstone of an efficient health care system. But Switzerland is facing a shortage of primary care physicians (PCPs). This pushed the Federal Council of Switzerland to introduce a multifaceted political programme to strengthen the position of primary care, including its academic role. The aim of this paper is to provide a comprehensive overview of the situation of academic primary care at the five Swiss universities by the end of year 2012. Although primary care teaching activities have a long tradition at the five Swiss universities with activities starting in the beginning of the 1980ies; the academic institutes of primary care were only established in recent years (2005 - 2009). Only one of them has an established chair. Human and financial resources vary substantially. At all universities a broad variety of courses and lectures are offered, including teaching in private primary care practices with 1331 PCPs involved. Regarding research, differences among the institutes are tremendous, mainly caused by entirely different human resources and skills. So far, the activities of the existing institutes at the Swiss Universities are mainly focused on teaching. However, for a complete academic institutionalization as well as an increased acceptance and attractiveness, more research activities are needed. In addition to an adequate basic funding of research positions, competitive research grants have to be created to establish a specialty-specific research culture.

  14. Symptomatology and health care utilization of women primary care patients who experienced childhood sexual abuse.

    PubMed

    Hulme, P A

    2000-11-01

    The purpose of this study was to (1) determine the symptomatology of women primary care patients who experienced childhood sexual abuse (CSA), using both a self-report survey and a chart review, and (2) determine their health care utilization patterns, using chart and information system reviews. An ex post facto research design was used. Women primary care patients who experienced CSA were compared with those who reported no CSA. Participants were recruited from a random sample of women patients from a large primary care clinic. They were mailed the survey; chart and information system reviews were conducted on those who returned surveys. Of the 395 participants, 23% reported past CSA on the survey. Women who experienced CSA reported 44 out of 51 physical and psychosocial symptoms more frequently than their counterparts who reported no past CSA. Further, they experienced these symptoms more intensely and in greater number. In their charts, however, far fewer differences in symptoms between groups were found. Nonetheless, women who experienced CSA visited the primary care clinic an average of 1.33 more times than women with no CSA, and they incurred an average of $150 more in primary care charges over a 2-year period. The findings indicate that many women primary care patients who experienced CSA suffer multiple symptoms that are not reflected in their charts. In addition, the findings demonstrate that not only is CSA associated with increased primary care visits, but also increased primary care costs, as measured by charges.

  15. Expansion of Coverage under the Patient Protection and Affordable Care Act and Primary Care Utilization

    PubMed Central

    Hofer, Adam N; Abraham, Jean Marie; Moscovice, Ira

    2011-01-01

    Context: Provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA) expand Medicaid to all individuals in families earning less than 133 percent of the federal poverty level (FPL) and make available subsidies to uninsured lower-income Americans (133 to 400 percent of FPL) without access to employer-based coverage to purchase insurance in new exchanges. Since primary care physicians typically serve as the point of entry into the health care delivery system, an adequate supply of them is critical to meeting the anticipated increase in demand for medical care resulting from the expansion of coverage. This article provides state-level estimates of the anticipated increases in primary care utilization given the PPACA's provisions for expanded coverage. Methods: Using the Medical Expenditure Panel Survey, this article estimates a multivariate regression model of annual primary care utilization. Using the model estimates and state-level information regarding the number of uninsured, it predicts, by state, the change in primary care visits expected from the expanded coverage. Finally, the article predicts the number of primary care physicians needed to accommodate this change in utilization. Findings: This expanded coverage is predicted to increase by 2019 the number of annual primary care visits between 15.07 million and 24.26 million. Assuming stable levels of physicians’ productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase. Conclusions: The PPACA's health insurance expansion parameters are expected to significantly increase the use of primary care. Two strategies that policymakers may consider are creating stronger financial incentives to attract medical school students to primary care and changing the delivery of care in ways that lead to operational improvements, higher throughput, and better quality of care. PMID:21418313

  16. Care of adults with developmental disabilities: Effects of a continuing education course for primary care providers.

    PubMed

    Balogh, Robert; Wood, Jessica; Lunsky, Yona; Isaacs, Barry; Ouellette-Kuntz, Hélène; Sullivan, William

    2015-07-01

    To evaluate the effects of an interdisciplinary, guideline-based continuing education course on measures related to the care of adults with developmental disabilities (DD). Before-and-after study with a control group. Ontario. Forty-seven primary care providers (physicians, registered nurses, and nurse practitioners). Participants either only received reference material about primary care of people with DD (control group) or participated in a continuing education course on primary care of people with DD in addition to receiving the reference material (intervention group). Participants reported on 5 key measures related to care of adults with DD: frequency of using guidelines, frequency of performing periodic health examinations, frequency of assessing patients who present with behaviour changes, level of comfort while caring for adults with DD, and knowledge of primary care related to adults with DD. Over time, the intervention group showed significant increases in 4 of the 5 key measures of care compared with the control group: the frequency of guideline use (P < .001), frequency of assessment of patients' behaviour change (P = .03), comfort level in caring for people with DD (P = .01), and knowledge of primary care related to adults with DD (P = .01). A continuing education course on primary care of adults with DD is a useful interdisciplinary model to train health professionals who provide primary care services to these patients.

  17. Alcohol-related problems in primary care patients in Nigeria.

    PubMed

    Abiodun, O A

    1996-04-01

    A total of 440 (50.1%) drinking patients were found in a study of 878 primary care patients in Nigeria, of whom 126 (28.6%) of drinking patients were observed to have alcohol-related problems. Those with alcohol-related problems were significantly more likely to be males, middle-aged and to belong to higher occupational groups. In addition, they were also more likely to be separated, divorced or widowed, made more frequent visits to health care facilities and were more likely to have associated mental morbidity. The primary health care (PHC) workers did not recognize these problem drinkers in their care. The need to improve the ability of PHC workers to detect and manage primary care patients with alcohol-related problems in developing countries through the use of reliable and valid short alcohol screening instruments (e.g. CAGE, AUDIT) and brief intervention techniques is emphasized. It is also suggested that, on a long-term basis, the training curricula for medical and paramedical primary care personnel in third world countries should include more hours on alcohol education.

  18. Primary Health Care

    PubMed Central

    Leslie, Laurel K.; Mehus, Christopher J.; Hawkins, J. David; Boat, Thomas; McCabe, Mary Ann; Barkin, Shari; Perrin, Ellen C.; Metzler, Carol W.; Prado, Guillermo; Tait, V. Fan; Brown, Randall; Beardslee, William

    2017-01-01

    Family-focused prevention programs have been shown to effectively reduce a range of negative behavioral health outcomes but have had limited reach. Three key barriers must be overcome to expand the reach of family-focused prevention programs and thereby achieve a significant public health impact. These barriers are: (1) current social norms and perceptions of parenting programs; (2) concerns about the expertise and legitimacy of sponsoring organizations to offer parenting advice; and (3) a paucity of stable, sustainable funding mechanisms. Primary healthcare settings are well positioned to overcome these barriers. Recent changes within health care make primary care settings an increasingly favorable home for family-focused prevention and suggest possibilities for sustainable funding of family-focused prevention programs. This paper discusses the existing advantages of primary care settings and lays out a plan to move toward realizing the potential public health impact of family-focused prevention through widespread implementation in primary healthcare settings. PMID:27498167

  19. Not Near Enough: Racial and Ethnic Disparities in Access to Nearby Behavioral Health Care and Primary Care

    PubMed Central

    VanderWielen, Lynn M.; Gilchrist, Emma C.; Nowels, Molly A.; Petterson, Stephen M.; Rust, George; Miller, Benjamin F.

    2016-01-01

    Background Racial, ethnic, and geographical health disparities have been widely documented in the United States. However, little attention has been directed towards disparities associated with integrated behavioral health and primary care services. Methods Access to behavioral health professionals among primary care physicians was examined using multinomial logistic regression analyses with 2010 National Plan and Provider Enumeration System, American Medical Association Physician Masterfile, and American Community Survey data. Results Primary care providers practicing in neighborhoods with higher percentages of African Americans and Hispanics were less likely to have geographically proximate behavioral health professionals. Primary care providers in rural areas were less likely to have geographically proximate behavioral health professionals. Conclusion Neighborhood-level factors are associated with access to nearby behavioral health and primary care. Additional behavioral health professionals are needed in racial/ ethnic minority neighborhoods and rural areas to provide access to behavioral health services, and to progress toward more integrated primary care. PMID:26320931

  20. Undergraduate students' perspectives on primary care.

    PubMed

    Gold, Jessica A; Barg, Frances K; Margo, Katherine

    2014-10-01

    Despite the need for more primary care physicians, the number of medical students choosing primary care careers remains lower than other specialties. While undergraduate premedical education is an essential component in the development of future physicians, little is known about undergraduate students' perspectives on becoming primary care physicians. To better understand the early factors in career selection, we asked premed and former premed students their perceptions of primary care. Open-ended, semistructured interviews were conducted with 58 undergraduate students who represented three different groups: those who were currently premed and science majors, those who were nonscience majors and were currently premed, and those who were formerly premed. Specifically, we asked, "Why do you think there is a shortage of people who go into primary care?" Undergraduates cited financial reasons, lack of "glamour," and the career being "uninteresting." Many believed that primary care lacked prestige, and others felt it had a negative stigma attached. Most had never even considered a career in primary care. A number of students also misunderstood what a career in primary care actually entailed. As early as freshman year in college, undergraduate students harbor misconceptions and negative opinions about primary care. Many of those who express interest in such a career seem to drop out of the premedical program. It is important to consider the early onset of these attitudes and a way to target this interested population when trying to address the shortage of primary care physicians. © The Author(s) 2014.

  1. Health coaching in primary care: a feasibility model for diabetes care.

    PubMed

    Liddy, Clare; Johnston, Sharon; Nash, Kate; Ward, Natalie; Irving, Hannah

    2014-04-03

    Health coaching is a new intervention offering a one-on-one focused self-management support program. This study implemented a health coaching pilot in primary care clinics in Eastern Ontario, Canada to evaluate the feasibility and acceptability of integrating health coaching into primary care for patients who were either at risk for or diagnosed with diabetes. We implemented health coaching in three primary care practices. Patients with diabetes were offered six months of support from their health coach, including an initial face-to-face meeting and follow-up by email, telephone, or face-to-face according to patient preference. Feasibility was assessed through provider focus groups and qualitative data analysis methods. All three sites were able to implement the program. A number of themes emerged from the focus groups, including the importance of physician buy-in, wide variation in understanding and implementing of the health coach role, the significant impact of different systems of team communication, and the significant effect of organizational structure and patient readiness on Health coaches' capacity to perform their role. It is feasible to implement health coaching as an integrated program within small primary care clinics in Canada without adding additional resources into the daily practice. Practices should review their organizational and communication processes to ensure optimal support for health coaches if considering implementing this intervention.

  2. Health coaching in primary care: a feasibility model for diabetes care

    PubMed Central

    2014-01-01

    Background Health coaching is a new intervention offering a one-on-one focused self-management support program. This study implemented a health coaching pilot in primary care clinics in Eastern Ontario, Canada to evaluate the feasibility and acceptability of integrating health coaching into primary care for patients who were either at risk for or diagnosed with diabetes. Methods We implemented health coaching in three primary care practices. Patients with diabetes were offered six months of support from their health coach, including an initial face-to-face meeting and follow-up by email, telephone, or face-to-face according to patient preference. Feasibility was assessed through provider focus groups and qualitative data analysis methods. Results All three sites were able to implement the program. A number of themes emerged from the focus groups, including the importance of physician buy-in, wide variation in understanding and implementing of the health coach role, the significant impact of different systems of team communication, and the significant effect of organizational structure and patient readiness on Health coaches’ capacity to perform their role. Conclusions It is feasible to implement health coaching as an integrated program within small primary care clinics in Canada without adding additional resources into the daily practice. Practices should review their organizational and communication processes to ensure optimal support for health coaches if considering implementing this intervention. PMID:24708783

  3. Primary Health Care: care coordinator in regionalized networks?

    PubMed Central

    de Almeida, Patty Fidelis; dos Santos, Adriano Maia

    2016-01-01

    RESUMO OBJECTIVE To analyze the breadth of care coordination by Primary Health Care in three health regions. METHODS This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia. RESULTS Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network. CONCLUSIONS Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries. PMID:28099663

  4. Learning in primary care--a report.

    PubMed

    de Villiers, M

    2000-11-01

    A symposium on Learning in Primary Care was held in Cape Town, South Africa, as a pre-conference workshop to the 9th International Ottawa Conference on Medical Education. The aim of this report is to inform medical educationalists of important issues in learning in primary care and to stimulate further debate. Four international speakers gave presentations on their experiences in teaching and learning in primary care. Objective positive outcome measures include acquiring clinical skills equally well in general practice as in hospital, and improved history taking, physical examination and communication skills learning. Students regard the course as an essential requirement for learning and are appreciative of the wider aspect to learning provided by the community, giving a more holistic view of health. A SWOT analysis (strengths, weaknesses, opportunities and threats) of teaching and learning in primary care identified that learning in primary care is of a generalist nature and reality based, but is hampered by a lack of resources. The increased professionalization of teaching in primary care results in better training, cost containment, and improved quality of health care at community level. It is important to focus on turning threats into opportunities. Academic credibility needs to be established by conducting research on learning in primary care and developing the conceptual basis of primary care.

  5. Primary care provider turnover and quality in managed care organizations.

    PubMed

    Plomondon, Mary E; Magid, David J; Steiner, John F; MaWhinney, Samantha; Gifford, Blair D; Shih, Sarah C; Grunwald, Gary K; Rumsfeld, John S

    2007-08-01

    To examine the association between primary care provider turnover in managed care organizations and measures of member satisfaction and preventive care. Retrospective cohort study of a national sample of 615 managed care organizations that reported HEDIS data to the National Committee for Quality Assurance from 1999 through 2001. Multivariable hierarchical regression modeling was used to evaluate the association between health plan primary care provider turnover rate and member satisfaction and preventive care measures, including childhood immunization, well-child visits, cholesterol, diabetes management, and breast and cervical cancer screening, adjusting for patient and organizational characteristics, time, and repeated measures. The median primary care provider turnover rate was 7.1% (range, 0%-53.3%). After adjustment for plan characteristics, health plans with higher primary care provider turnover rates had significantly lower measures of member satisfaction, including overall rating of healthcare (P < .01). A 10% higher primary care provider turnover rate was associated with 0.9% fewer members rating high overall satisfaction with healthcare. Health plans with higher provider turnover rates also had lower rates of preventive care, including childhood immunization (P = .045), well-child visits (P = .002), cholesterol screening after cardiac event (P = .042), and cervical cancer screening (P = .024). For example, a 10% higher primary care provider turnover was associated with a 2.7% lower rate of child-members receiving well-child visits in the first 15 months of life. Primary care provider turnover is associated with several measures of care quality, including aspects of member satisfaction and preventive care. Future studies should evaluate whether interventions to reduce primary care provider turnover can improve quality of care and patient outcomes.

  6. Primary care: current problems and proposed solutions.

    PubMed

    Bodenheimer, Thomas; Pham, Hoangmai H

    2010-05-01

    In 2005, approximately 400,000 people provided primary medical care in the United States. About 300,000 were physicians, and another 100,000 were nurse practitioners and physician assistants. Yet primary care faces a growing crisis, in part because increasing numbers of U.S. medical graduates are avoiding careers in adult primary care. Sixty-five million Americans live in what are officially deemed primary care shortage areas, and adults throughout the United States face difficulty obtaining prompt access to primary care. A variety of strategies are being tried to improve primary care access, even without a large increase in the primary care workforce.

  7. Factors Influencing Medical Students to Choose Primary Care or Non-primary Care Specialties.

    ERIC Educational Resources Information Center

    Rogers, Laura Q.; And Others

    1990-01-01

    A questionnaire was administered to 339 graduating senior medical students at the Medical College of Georgia to determine different potential sources of influence on career choice. Indebtedness may be associated with the choice of a non-primary care specialty with greater remuneration than primary care specialty. (MLW)

  8. How good are GPs at adhering to a pragmatic trial protocol in primary care? Results from the ADDITION-Cambridge cluster-randomised pragmatic trial

    PubMed Central

    Boothby, Clare E; Griffin, Simon J

    2018-01-01

    Objective To assess the fidelity of general practitioners’ (GPs) adherence to a long-term pragmatic trial protocol. Design Retrospective analyses of electronic primary care records of participants in the pragmatic cluster-randomised ADDITION (Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care)-Cambridge trial, comparing intensive multifactorial treatment (IT) versus routine care (RC). Data were collected from the date of diagnosis until December 2010. Setting Primary care surgeries in the East of England. Study sample/participants A subsample (n=189, RC arm: n=99, IT arm: n=90) of patients from the ADDITION-Cambridge cohort (867 patients), consisting of patients 40–69 years old with screen-detected diabetes mellitus. Interventions In the RC arm treatment was delivered according to concurrent treatment guidelines. Surgeries in the IT arm received funding for additional contacts between GPs/nurses and patients, and GPs were advised to follow more intensive treatment algorithms for the management of glucose, lipids and blood pressure and aspirin therapy than in the RC arm. Outcome measures The number of annual contacts between patients and GPs/nurses, the proportion of patients receiving prescriptions for cardiometabolic medication in years 1–5 after diabetes diagnosis and the adherence to prescription algorithms. Results The difference in the number of annual GP contacts (β=0.65) and nurse contacts (β=−0.15) between the study arms was small and insignificant. Patients in the IT arm were more likely to receive glucose-lowering (OR=3.27), ACE-inhibiting (OR=2.03) and lipid-lowering drugs (OR=2.42, all p values <0.01) than patients in the RC arm. The prescription adherence varied between medication classes, but improved in both trial arms over the 5-year follow-up. Conclusions The adherence of GPs to different aspects of the trial protocol was mixed. Background changes in healthcare policy need to be

  9. CLINICALLY SIGNIFICANT PSYCHOTROPIC DRUG-DRUG INTERACTIONS IN THE PRIMARY CARE SETTING

    PubMed Central

    English, Brett A.; Dortch, Marcus; Ereshefsky, Larry; Jhee, Stanford

    2014-01-01

    In recent years, the growing numbers of patients seeking care for a wide range of psychiatric illnesses in the primary care setting has resulted in an increase in the number of psychotropic medications prescribed. Along with the increased utilization of psychotropic medications, considerable variability is noted in the prescribing patterns of primary care providers and psychiatrists. Because psychiatric patients also suffer from a number of additional medical comorbidities, the increased utilization of psychotropic medications presents an elevated risk of clinically significant drug interactions in these patients. While life-threatening drug interactions are rare, clinically significant drug interactions impacting drug response or appearance of serious adverse drug reactions have been documented and can impact long-term outcomes. Additionally, the impact of genetic variability on the psychotropic drug’s pharmacodynamics and/or pharmacokinetics may further complicate drug therapy. Increased awareness of clinically relevant psychotropic drug interactions can aid clinicians to achieve optimal therapeutic outcomes in patients in the primary care setting. PMID:22707017

  10. OECD Health Care Quality Indicator Project. The expert panel on primary care prevention and health promotion.

    PubMed

    Marshall, Martin; Klazinga, Niek; Leatherman, Sheila; Hardy, Charlie; Bergmann, Eckhard; Pisco, Luis; Mattke, Soeren; Mainz, Jan

    2006-09-01

    This article describes a project undertaken as part of the Organization for Economic Co-operation and Development (OECD)'s Healthcare Quality Indicator (HCQI) Project, which aimed to develop a set of quality indicators representing the domains of primary care, prevention and health promotion, and which could be used to assess the performance of primary care systems. Existing quality indicators from around the world were mapped to an organizing framework which related primary care, prevention, and health promotion. The indicators were judged against the US Institute of Medicine's assessment criteria of importance and scientific soundness, and only those which met these criteria and were likely to be feasible were included. An initial large set of indicators was reduced by the primary care expert panel using a modified Delphi process. A set of 27 indicators was produced. Six of them were related to health promotion, covering health-related behaviours that are typically targeted by health education and outreach campaigns, 13 to preventive care with a focus on prenatal care and immunizations and eight to primary clinical care mainly addressing activities related to risk reduction. The indicators selected placed a strong emphasis on the public health aspects of primary care. This project represents an important but preliminary step towards a set of measures to evaluate and compare primary care quality. Further work is required to assess the operational feasibility of the indicators and the validity of any benchmarking data drawn from international comparisons. A conceptual framework needs to be developed that comprehensively captures the complex construct of primary care as a basis for the selection of additional indicators.

  11. Providing Primary Health Care to Children: Integrating Primary Care Services with Health Insurance Principles.

    ERIC Educational Resources Information Center

    Rosenbaum, Sara

    1993-01-01

    Examines how health care reform might be structured to provide support for a package of primary care services for children of all socioeconomic strata. An insurance-like financing system, such as the special Medicaid payment system adopted by New York State for public and nonprofit primary health care programs, may be useful as a model for a…

  12. Collaboration of midwives in primary care midwifery practices with other maternity care providers.

    PubMed

    Warmelink, J Catja; Wiegers, Therese A; de Cock, T Paul; Klomp, Trudy; Hutton, Eileen K

    2017-12-01

    interactions with physicians (GPs, obstetricians and paediatricians). Midwives with more work experience were more satisfied with their collaboration with GPs. Midwives from the southern region of the Netherlands were more satisfied with collaboration with GPs and obstetricians. Compared to the urban areas, in the rural or mixed areas the midwives were more satisfied regarding their collaboration with MCA(O)s and clinical midwives. Midwives from non-Dutch origin were less satisfied with the collaboration with paediatricians. No relations were found between the overall mean satisfaction of collaboration and work-related and personal characteristics and attitude towards work. Inter-professionals relations in maternity care in the Netherlands can be enhanced, especially the primary care midwives' interactions with physicians and with maternity care providers in the northern and central part of the Netherlands, and in urban areas. Future exploratory or deductive research may provide additional insight in the collaborative practice in everyday work setting. Copyright © 2017 Elsevier Ltd. All rights reserved.

  13. Somatization among older primary care attenders.

    PubMed

    Sheehan, B; Bass, C; Briggs, R; Jacoby, R

    2003-07-01

    The importance of somatization among older primary care attenders is unclear. We aimed to establish the prevalence, persistence and associations of somatization among older primary care attenders, and the associations of frequent attendance. One hundred and forty primary care attenders over 65 years were rated twice, 10 months apart, on measures of somatization, psychiatric status, physical health and attendance. The syndrome of GMS hypochondriacal neurosis had a prevalence of 5% but was transient. Somatized symptoms and attributions were persistent and associated with depression, physical illness and perceived poor social support. Frequent attenders (top third) had higher rates of depression, physical illness and somatic symptoms, and lower perceived support. Somatization is common among older primary care attenders and has similar correlates to younger primary care somatizers. Psychological distress among older primary care attenders is associated with frequent attendance. Improved recognition should result in benefits to patients and services.

  14. Welcome back? Frequent attenders to a pediatric primary care center.

    PubMed

    Klein, Melissa; Vaughn, Lisa M; Baker, Raymond C; Taylor, Trisha

    2011-09-01

    This study examines frequent attenders of a pediatric primary care clinic at a large urban children's hospital--who they are and their reasons for frequent attendance to the clinic. The literature suggests that some visits by frequent attenders may not be medically necessary, and these additional appointments may impair others' access to medical care within the same system. The key to eliminating excessive primary care visits is to determine if it is a problem in the primary care practice (quantify the problem), explore the reasons for the visits (from the patients' perspective), and then provide educational interventions that address the various causes for the extra visits and encourage the use of available resources, either ancillary services in the practice itself or resources and agencies available in the community (e.g. social service, legal aid).

  15. Integrated primary care, the collaboration imperative inter-organizational cooperation in the integrated primary care field: a theoretical framework

    PubMed Central

    Valentijn, Pim P; Bruijnzeels, Marc A; de Leeuw, Rob J; Schrijvers, Guus J.P

    2012-01-01

    Purpose Capacity problems and political pressures have led to a rapid change in the organization of primary care from mono disciplinary small business to complex inter-organizational relationships. It is assumed that inter-organizational collaboration is the driving force to achieve integrated (primary) care. Despite the importance of collaboration and integration of services in primary care, there is no unambiguous definition for both concepts. The purpose of this study is to examine and link the conceptualisation and validation of the terms inter-organizational collaboration and integrated primary care using a theoretical framework. Theory The theoretical framework is based on the complex collaboration process of negotiation among multiple stakeholder groups in primary care. Methods A literature review of health sciences and business databases, and targeted grey literature sources. Based on the literature review we operationalized the constructs of inter-organizational collaboration and integrated primary care in a theoretical framework. The framework is being validated in an explorative study of 80 primary care projects in the Netherlands. Results and conclusions Integrated primary care is considered as a multidimensional construct based on a continuum of integration, extending from segregation to integration. The synthesis of the current theories and concepts of inter-organizational collaboration is insufficient to deal with the complexity of collaborative issues in primary care. One coherent and integrated theoretical framework was found that could make the complex collaboration process in primary care transparent. This study presented theoretical framework is a first step to understand the patterns of successful collaboration and integration in primary care services. These patterns can give insights in the organization forms needed to create a good working integrated (primary) care system that fits the local needs of a population. Preliminary data of the

  16. Integrated primary health care in Australia.

    PubMed

    Davies, Gawaine Powell; Perkins, David; McDonald, Julie; Williams, Anna

    2009-10-14

    To fulfil its role of coordinating health care, primary health care needs to be well integrated, internally and with other health and related services. In Australia, primary health care services are divided between public and private sectors, are responsible to different levels of government and work under a variety of funding arrangements, with no overarching policy to provide a common frame of reference for their activities. Over the past decade, coordination of service provision has been improved by changes to the funding of private medical and allied health services for chronic conditions, by the development in some states of voluntary networks of services and by local initiatives, although these have had little impact on coordination of planning. Integrated primary health care centres are being established nationally and in some states, but these are too recent for their impact to be assessed. Reforms being considered by the federal government include bringing primary health care under one level of government with a national primary health care policy, establishing regional organisations to coordinate health planning, trialling voluntary registration of patients with general practices and reforming funding systems. If adopted, these could greatly improve integration within primary health care. Careful change management and realistic expectations will be needed. Also other challenges remain, in particular the need for developing a more population and community oriented primary health care.

  17. Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

    PubMed Central

    Loeb, Danielle F.; Binswanger, Ingrid A.; Candrian, Carey; Bayliss, Elizabeth A.

    2015-01-01

    PURPOSE Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. METHODS We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. RESULTS The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor—a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)—that complicated care for chronic medical illnesses. CONCLUSION This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. PMID:26371266

  18. Primary care physician insights into a typology of the complex patient in primary care.

    PubMed

    Loeb, Danielle F; Binswanger, Ingrid A; Candrian, Carey; Bayliss, Elizabeth A

    2015-09-01

    Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses. This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. © 2015 Annals of Family Medicine, Inc.

  19. Blueprint for an Undergraduate Primary Care Curriculum.

    PubMed

    Fazio, Sara B; Demasi, Monica; Farren, Erin; Frankl, Susan; Gottlieb, Barbara; Hoy, Jessica; Johnson, Amanda; Kasper, Jill; Lee, Patrick; McCarthy, Claire; Miller, Kathe; Morris, Juliana; O'Hare, Kitty; Rosales, Rachael; Simmons, Leigh; Smith, Benjamin; Treadway, Katherine; Goodell, Kristen; Ogur, Barbara

    2016-12-01

    In light of the increasing demand for primary care services and the changing scope of health care, it is important to consider how the principles of primary care are taught in medical school. While the majority of schools have increased students' exposure to primary care, they have not developed a standardized primary care curriculum for undergraduate medical education. In 2013, the authors convened a group of educators from primary care internal medicine, pediatrics, family medicine, and medicine-pediatrics, as well as five medical students to create a blueprint for a primary care curriculum that could be integrated into a longitudinal primary care experience spanning undergraduate medical education and delivered to all students regardless of their eventual career choice.The authors organized this blueprint into three domains: care management, specific areas of content expertise, and understanding the role of primary care in the health care system. Within each domain, they described specific curriculum content, including longitudinality, generalism, central responsibility for managing care, therapeutic alliance/communication, approach to acute and chronic care, wellness and prevention, mental and behavioral health, systems improvement, interprofessional training, and population health, as well as competencies that all medical students should attain by graduation.The proposed curriculum incorporates important core features of doctoring, which are often affirmed by all disciplines but owned by none. The authors argue that primary care educators are natural stewards of this curriculum content and can ensure that it complements and strengthens all aspects of undergraduate medical education.

  20. [Primary care in France].

    PubMed

    Sánchez-Sagrado, T

    2016-01-01

    The poor planning of health care professionals in Spain has led to an exodus of doctors leaving the country. France is one of the chosen countries for Spanish doctors to develop their professional career. The French health care system belongs to the Bismarck model. In this model, health care system is financed jointly by workers and employers through payroll deduction. The right to health care is linked to the job, and provision of services is done by sickness-funds controlled by the Government. Primary care in France is quite different from Spanish primary care. General practitioners are independent workers who have the right to set up a practice anywhere in France. This lack of regulation has generated a great problem of "medical desertification" with problems of health care access and inequalities in health. French doctors do not want to work in rural areas or outside cities because "they are not value for money". Medical salary is linked to professional activity. The role of doctors is to give punctual care. Team work team does not exist, and coordination between primary and secondary care is lacking. Access to diagnostic tests, hospitals and specialists is unlimited. Duplicity of services, adverse events and inefficiencies are the norm. Patients can freely choose their doctor, and they have a co-payment for visits and hospital care settings. Two years training is required to become a general practitioner. After that, continuing medical education is compulsory, but it is not regulated. Although the French medical Health System was named by the WHO in 2000 as the best health care system in the world, is it not that good. While primary care in Spain has room for improvement, there is a long way for France to be like Spain. Copyright © 2015 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

  1. Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: A mixed methods study.

    PubMed

    Song, Hummy; Ryan, Molly; Tendulkar, Shalini; Fisher, Josephine; Martin, Julia; Peters, Antoinette S; Frolkis, Joseph P; Rosenthal, Meredith B; Chien, Alyna T; Singer, Sara J

    Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to

  2. Primary care spirometry: test quality and the feasibility and usefulness of specialist reporting

    PubMed Central

    White, Patrick; Wong, Wun; Fleming, Tracey; Gray, Barry

    2007-01-01

    Background Provision of spirometry for chronic obstructive pulmonary disease (COPD) is a new requirement in primary care. Effective spirometry requires that tests and interpretations meet international criteria. Aim To assess the feasibility and usefulness of remote specialist reporting of primary care spirometry. Design of study Comparison of reporting by primary care clinicians and respiratory specialists of consecutive primary care spirometry tests. Setting South London primary care teams with patient lists ≥6000. Method Feasibility of remote reporting of spirometry was assessed by the frequency of electronic mailing of tests. Usefulness of remote reporting was defined by the frequency that specialist reports made a clinically significant addition. Usefulness was assessed by measuring agreement (κ) between primary care reports and those of specialists. Clinically significant disagreements were analysed with respect to test quality, diagnosis, and severity. Results Six practices emailed 312 tests over 3 months. Forty-nine tests sent without indices or curves (flow volume and time volume) were excluded. Mean age of patients tested was 65 years and 52% were female. Mean predicted forced expiratory volume in the first second (FEV1) was 69%. Clinically significant disagreements were identified in the interpretation of acceptability (quality) of 67/212 (32%) tests (κ = 0.07; 95% confidence interval [CI] = 0 to 0.24), of diagnosis in 49/168 (29%) tests (κ = 0.39; 95% CI = 0.25 to 0.55), and of severity in 62/191 (32%) tests (κ = 0.53; 95% CI = 0.43 to 0.63). Conclusion Remote reporting of primary care spirometry was feasible. Its usefulness was confirmed by the high rate of additional clinically significant information to the reports of primary care clinicians. The quality of primary care spirometry was so unsatisfactory that remote reporting of tests may be a means of establishing adequate spirometry. PMID:17761057

  3. Measuring the Attainment of Primary Care.

    ERIC Educational Resources Information Center

    Starfield, Barbara

    1979-01-01

    The definition of primary care is developed and a way is suggested to measure whether it is being achieved. Evaluative questions are identified that can determine whether a system of care is oriented toward primary care. They include assessing first-contact care, coordination of care, comprehensiveness, and longitudinality. (LBH)

  4. Expanding primary care capacity by reducing waste and improving the efficiency of care.

    PubMed

    Shipman, Scott A; Sinsky, Christine A

    2013-11-01

    Most solutions proposed for the looming shortage of primary care physicians entail strategies that fall into one of three categories: train more, lose fewer, or find someone else. A fourth strategy deserves more attention: waste less. This article examines the remarkable inefficiency and waste in primary care today and highlights practices that have addressed these problems. For example, delegating certain administrative tasks such as managing task lists in the electronic health record can give physicians more time to see additional patients. Flow managers who guide physicians from task to task throughout the clinical day have been shown to improve physicians' efficiency and capacity. Even something as simple as placing a printer in every exam room can save each physician twenty minutes per day. Modest but systemwide improvements could yield dramatic gains in physician capacity while potentially reducing physician burnout and its implications for the quality of care. If widely adopted, small efforts to empower nonphysicians, reengineer workflows, exploit technology, and update policies to eliminate wasted effort could yield the capacity for millions of additional patient visits per year in the United States.

  5. Who contracts for primary care?

    PubMed

    Lewis, R; Gillam, S; Gosden, T; Sheaff, R

    1999-12-01

    The implications of the 1997 NHS (Primary Care) Act have been largely overlooked in the rush to establish Primary Care Groups. Allowing health authorities to develop local contracts for primary care has far-reaching implications and is an important departure from the national system of negotiation that has characterized general practice to date. This paper describes a content analysis of a sample of Personal Medical Services (PMS) pilot contracts. In the first year little attention has been given to achieving cost savings or greater efficiency and few contracts promote clinical guidelines. The difficulties of specifying services sensitive to local health needs are highlighted and the national Statement of Fees and Allowances (the 'Red Book') may not be swiftly supplanted. However, the pilots have introduced innovations such as salaried general practitioners, nurse-led services and NHS trust-managed care. The development of local contracts provides a valuable learning experience for general practitioners and health authorities in advance of the establishment of Primary Care Trusts.

  6. 45 CFR 96.47 - Primary care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 45 Public Welfare 1 2010-10-01 2010-10-01 false Primary care. 96.47 Section 96.47 Public Welfare... and Tribal Organizations § 96.47 Primary care. Applications for direct funding of Indian tribes and tribal organizations under the primary care block grant must comply with 42 CFR Part 51c (Grants for...

  7. Improving care coordination in primary care.

    PubMed

    Wagner, Edward H; Sandhu, Nirmala; Coleman, Katie; Phillips, Kathryn E; Sugarman, Jonathan R

    2014-11-01

    Although coordinating care is a defining characteristic of primary care, evidence suggests that both patients and providers perceive failures in communication and care when care is received from multiple sources. To examine the utility of a newly developed Care Coordination Model in improving care coordination among participating practices in the Safety Net Medical Home Initiative (SNMHI). In this paper, we used correlation analysis to evaluate whether application of the elements of the Care Coordination Model by SNMHI sites, as measured by the Key Activities Checklist (KAC), was associated with more effective care coordination as measured by another instrument, the PCMH-A. SNMHI measures are practice self-assessments based on the 8 change concepts that define a PCMH, one of which is Care Coordination. For this study, we correlated 12 KAC items that describe activities felt to improve coordination of care with 5 PCMH-A items that indicate the extent to which a practice has developed the capability to effectively coordinate care. Practice staff indicated whether any of the KAC activities were being test, implemented, sustained, or not on 4 occasions. The Care Coordination Model elements-assume accountability, build relationships with care partners, support patients through the referral or transition process, and create connections to support information exchange-were positively correlated with some PCMH-A care coordination items but not others. Activities related to the model were most strongly correlated with following up patients seen in the Emergency Department or discharged from hospital. The analysis provides suggestive evidence that activities consistent with the 4 elements of the Care Coordination Model may enable safety net primary care to better coordinate care for its patients, but further study is clearly needed.

  8. Feasibility of a physical activity pathway for Irish primary care physiotherapy services.

    PubMed

    Barrett, Emer M; Hussey, Juliette; Darker, Catherine D

    2017-03-01

    To establish consensus on a physical activity pathway suitable for use by physiotherapists in Irish primary care. The physical activity pathway "Let's Get Moving" was examined to agree recruitment criteria and seek consensus on component parts. Modified Delphi approach which attempts to achieve a convergence of opinion, over a series of iterations. Three rounds of questionnaires were used. Primary care. 41 senior physiotherapists working in primary care for a median of 6 years (IQR 3.7 to 8.5). Statements achieving consensus; defined as at least 70% of participants scoring a 6 or a 7, indicating high agreement, on a 7 point Likert scale. The response rate was 98%. There was a high degree of consensus for many components of the pathway. Participants agreed that all patients attending physiotherapy should be eligible for recruitment onto the pathway as well as accepting referrals from other health professionals and direct access from the public. Private physiotherapists highlighted concerns about recruiting fee paying patients onto the pathway. The pathway should be integrated into other preventative and chronic disease programmes in primary care. Modifications to the original pathway included the use of a pedometer in addition to the General Practice Physical Activity Questionnaire. Training needs in physical activity screening and motivational interviewing, as well as additional staffing were identified to support implementation. The Physical Activity Pathway "Let's Get Moving" was accepted as a clinically feasible resource to primary care physiotherapists with some modifications and with the support of additional resources. Copyright © 2016 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

  9. Assessing primary care in Austria: room for improvement.

    PubMed

    Stigler, Florian L; Starfield, Barbara; Sprenger, Martin; Salzer, Helmut J F; Campbell, Stephen M

    2013-04-01

    There is emerging evidence that strong primary care achieves better health at lower costs. Although primary care can be measured, in many countries, including Austria, there is little understanding of primary care development. Assessing the primary care development in Austria. A primary care assessment tool developed by Barbara Starfield in 1998 was implemented in Austria. This tool defines 15 primary care characteristics and distinguishes between system and practice characteristics. Each characteristic was evaluated by six Austrian primary care experts and rated as 2 (high), 1 (intermediate) or 0 (low) points, respectively, to their primary care strength (maximum score: n = 30). Austria received 7 out of 30 points; no characteristic was rated as '2' but 8 were rated as '0'. Compared with the 13 previously assessed countries, Austria ranks 10th of 14 countries and is classified as a 'low primary care' country. This study provides the first evidence concerning primary care in Austria, benchmarking it as weak and in need of development. The practicable application of an existing assessment tool can be encouraging for other countries to generate evidence about their primary care system as well.

  10. Primary care training and the evolving healthcare system.

    PubMed

    Peccoralo, Lauren A; Callahan, Kathryn; Stark, Rachel; DeCherrie, Linda V

    2012-01-01

    With growing numbers of patient-centered medical homes and accountable care organizations, and the potential implementation of the Patient Protection and Affordable Care Act, the provision of primary care in the United States is expanding and changing. Therefore, there is an urgent need to create more primary-care physicians and to train physicians to practice in this environment. In this article, we review the impact that the changing US healthcare system has on trainees, strategies to recruit and retain medical students and residents into primary-care internal medicine, and the preparation of trainees to work in the changing healthcare system. Recruitment methods for medical students include early preclinical exposure to patients in the primary-care setting, enhanced longitudinal patient experiences in clinical clerkships, and primary-care tracks. Recruitment methods for residents include enhanced ambulatory-care training and primary-care programs. Financial-incentive programs such as loan forgiveness may encourage trainees to enter primary care. Retaining residents in primary-care careers may be encouraged via focused postgraduate fellowships or continuing medical education to prepare primary-care physicians as both teachers and practitioners in the changing environment. Finally, to prepare primary-care trainees to effectively and efficiently practice within the changing system, educators should consider shifting ambulatory training to community-based practices, encouraging resident participation in team-based care, providing interprofessional educational experiences, and involving trainees in quality-improvement initiatives. Medical educators in primary care must think innovatively and collaboratively to effectively recruit and train the future generation of primary-care physicians. © 2012 Mount Sinai School of Medicine.

  11. Primary care providers' lived experiences of genetics in practice.

    PubMed

    Harding, Brittany; Webber, Colleen; Ruhland, Lucia; Dalgarno, Nancy; Armour, Christine M; Birtwhistle, Richard; Brown, Glenn; Carroll, June C; Flavin, Michael; Phillips, Susan; MacKenzie, Jennifer J

    2018-04-26

    To effectively translate genetic advances into practice, engagement of primary care providers (PCPs) is essential. Using a qualitative, phenomenological methodology, we analyzed key informant interviews and focus groups designed to explore perspectives of urban and rural PCPs. PCPs endorsed a responsibility to integrate genetics into their practices and expected advances in genetic medicine to expand. However, PCPs reported limited knowledge and difficulties accessing resources, experts, and continuing education. Rural practitioners' additional concerns included cost, distance, and poor patient engagement. PCPs' perspectives are crucial to develop relevant educational and systems-based interventions to further expand genetic medicine in primary care.

  12. Primary care--opportunities and threats. Developing professional knowledge: making primary care education and research more relevant.

    PubMed Central

    Pearson, P.; Jones, K.

    1997-01-01

    The trio of recent government white papers heralds a new world for primary care. Many changes in the education of future primary health care professionals and in the research ethos of the discipline will be needed to realise this vision. New skills and attitudes, not least in multidisciplinary working; lifelong learning; and greater understanding of and participation in primary care research will have to emerge from educational efforts in the next few years. PMID:9081008

  13. Primary care-public health linkages: Older primary care patients with prediabetes & type 2 diabetes encouraged to attend community-based senior centers.

    PubMed

    Noël, Polly H; Parchman, Michael L; Finley, Erin P; Wang, Chen-Pin; Bollinger, Mary; Espinoza, Sara E; Hazuda, Helen P

    2016-12-01

    The Institute of Medicine (IOM) suggests that primary care-public health integration can improve health outcomes for vulnerable patients, but the extent to which formal linkages may enhance patients' use of community resources, or the factors that may influence providers to encourage their patients to use these resources, remain unclear. We conducted baseline assessments in 2014-2015 with 149 older adults with prediabetes or diabetes who had recently joined three senior centers linked to a network of primary care clinics in San Antonio, Texas. In addition to collecting sociodemographic and clinical characteristics, we asked members to identify their source of primary care and whether a health care provider had encouraged them to go to the senior center. We also asked members why they had joined the senior centers and which programs interested them the most. Members' source of primary care was not associated with being encouraged to attend the senior centers by a health care professional. Multivariable analysis indicated that participants with total annual household incomes of $20,000 or less [OR = 2.78; 95% CI = (1.05, 7.14)] and those reporting 12 years of education or less [OR = 3.57; 95% CI = (1.11, 11.11)] were significantly more likely to report being encouraged to attend the senior center by a health care provider. Providers who are aware of community-based resources to support patient self-management may be just as likely to encourage their socioeconomically vulnerable patients with prediabetes or diabetes to use them as providers who have a more formal partnership with the senior centers.

  14. Digital Media for Primary Health Care in Austria.

    PubMed

    Kriegel, Johannes; Tuttle-Weidinger, Linda; Reckwitz, Luise

    2017-01-01

    Primary health care (PHC) is currently being improved in all developed industries. The aim is to make healthcare more patient-centered and close to the patient's place of residence. In addition to the organizational and interdisciplinary reorientation, the use of digital media is increasingly being emphasized. Through literature research and an online survey among Austrian doctors and general practitioners, the current and future challenges for the use of digital media in networked and regional primary health care were identified and prioritized. It becomes clear that basic functions like documentation, communication and coordination in the individual medical practice are at the forefront. In the future it will be necessary to support regional and interprofessional networking through digital media.

  15. Contributors to patient engagement in primary health care: perceptions of patients with obesity.

    PubMed

    Forhan, Mary; Risdon, Cathy; Solomon, Patricia

    2013-10-01

    Patients with obesity are at risk for treatment avoidance and nonadherence. Factors that contribute to engagement in primary health care for patients with obesity are not fully understood. The purpose of this pilot study was to identify issues associated with engagement in primary health care for patients with obesity. Using qualitative methodology, 11 patients with a mean body mass index of 40.8 kg/m(2) registered with a primary health care practice were interviewed. Conventional content analysis was used to identify factors that contribute to engagement in primary health care. Barriers and facilitators to engagement in primary health care were categorized into the following themes: availability of resources, importance of the relationship, meaningful communication, feeling judged, lack of privacy, poor communication and limited provider knowledge about obesity. Obesity was identified as a health condition that requires additional considerations for patient engagement in their health care.

  16. Together Achieving More: Primary Care Team Communication and Alcohol-Related Health Care Utilization and Costs

    PubMed Central

    Mundt, Marlon P.; Zakletskaia, Larissa I.; Shoham, David A.; Tuan, Wen-Jan; Carayon, Pascale

    2015-01-01

    Background Identifying and engaging excessive alcohol users in primary care may be an effective way to improve patient health outcomes, reduce alcohol-related acute care events, and lower costs. Little is known about what structures of primary care team communication are associated with alcohol-related patient outcomes. Methods Using a sociometric survey of primary care clinic communication, this study evaluated the relation between team communication networks and alcohol-related utilization of care and costs. Between May 2013 and December 2013, a total of 155 healthcare employees at 6 primary care clinics participated in a survey on team communication. Three-level hierarchical modeling evaluated the link between connectedness within the care team and the number of alcohol-related emergency department visits, hospital days, and associated medical care costs in the past 12 months for each team’s primary care patient panel. Results Teams (n=31) whose RNs displayed more strong (at least daily) face-to-face ties and strong (at least daily) electronic communication ties had 10% fewer alcohol-related hospital days (RR=0.90; 95% CI: 0.84, 0.97). Furthermore, in an average team size of 19, each additional team member with strong interaction ties across the whole team was associated with $1030 (95% CI: −$1819, −$241) lower alcohol-related patient health care costs per 1000 team patients in the past 12 months. Conversely, teams whose primary care practitioner had more strong face-to-face communication ties and more weak (weekly or several times a week) electronic communication ties had 12% more alcohol-related hospital days (RR=1.12; 95: CI: 1.03, 1.23) and $1428 (95% CI: $378, $2478) higher alcohol-related healthcare costs per 1000 patients in the past 12 months. The analyses controlled for patient age, gender, insurance, and co-morbidity diagnoses. Conclusions Excessive alcohol-using patients may fair better if cared for by teams whose face-to-face and electronic

  17. Pediatric Primary Care as a Component of Systems of Care

    ERIC Educational Resources Information Center

    Brown, Jonathan D.

    2010-01-01

    Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of…

  18. Toward a Unified Integration Approach: Uniting Diverse Primary Care Strategies Under the Primary Care Behavioral Health (PCBH) Model.

    PubMed

    Sandoval, Brian E; Bell, Jennifer; Khatri, Parinda; Robinson, Patricia J

    2018-06-01

    Primary care continues to be at the center of health care transformation. The Primary Care Behavioral Health (PCBH) model of service delivery includes patient-centered care delivery strategies that can improve clinical outcomes, cost, and patient and primary care provider satisfaction with services. This article reviews the link between the PCBH model of service delivery and health care services quality improvement, and provides guidance for initiating PCBH model clinical pathways for patients facing depression, chronic pain, alcohol misuse, obesity, insomnia, and social barriers to health.

  19. Follow-up of cancer in primary care versus secondary care: systematic review

    PubMed Central

    Lewis, Ruth A; Neal, Richard D; Williams, Nefyn H; France, Barbara; Hendry, Maggie; Russell, Daphne; Hughes, Dyfrig A; Russell, Ian; Stuart, Nicholas SA; Weller, David; Wilkinson, Clare

    2009-01-01

    Background Cancer follow-up has traditionally been undertaken in secondary care, but there are increasing calls to deliver it in primary care. Aim To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients, determine the effectiveness of the integration of primary care in routine hospital follow-up, and evaluate the impact of patient-initiated follow-up on primary care. Design of study Systematic review. Setting Primary and secondary care settings. Method A search was carried out of 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. The review included comparative studies or economic evaluations of primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up, and hospital follow-up versus patient-initiated or minimal follow-up if the study reported the impact on primary care. Results There was no statistically significant difference for patient wellbeing, recurrence rate, survival, recurrence-related serious clinical events, diagnostic delay, or patient satisfaction. GP-led breast cancer follow-up was cheaper than hospital follow-up. Intensified primary health care resulted in increased home-care nurse contact, and improved discharge summary led to increased GP contact. Evaluation of patient-initiated or minimal follow-up found no statistically significant impact on the number of GP consultations or cancer-related referrals. Conclusion Weak evidence suggests that breast cancer follow-up in primary care is effective. Interventions improving communication between primary and secondary care could lead to greater GP involvement. Discontinuation of formal follow-up may not increase GP workload. However, the quality of the data in general was poor, and no firm conclusions can be reached. PMID:19566990

  20. Applying organizational behavior theory to primary care.

    PubMed

    Mullangi, Samyukta; Saint, Sanjay

    2017-03-01

    Addressing the mounting primary care shortage in the United States has been a focus of educators and policy makers, especially with the passage of the Affordable Care Act in 2010 and the Medicare Access and CHIP Reauthorization Act in 2015, placing increased pressure on the system. The Association of American Medical Colleges recently projected a shortage of as many as 65,000 primary care physicians by 2025, in part because fewer than 20% of medical students are picking primary care for a career. We examined the issue of attracting medical students to primary care through the lens of organizational behavior theory. Assuming there are reasons other than lower income potential for why students are inclined against primary care, we applied various principles of the Herzberg 2-factor theory to reimagine the operational flow and design of primary care. We conclude by proposing several solutions to enrich the job, such as decreasing documentation requirements, reducing the emphasis on specialty consultations, and elevating physicians to a supervisory role.

  1. Primary Care Collaborative Memory Clinics: Building Capacity for Optimized Dementia Care.

    PubMed

    Lee, Linda; Hillier, Loretta M; Molnar, Frank; Borrie, Michael J

    2017-01-01

    Increasingly, primary care collaborative memory clinics (PCCMCs) are being established to build capacity for person-centred dementia care. This paper reflects on the significance of PCCMCs within the system of care for older adults, supported with data from ongoing evaluation studies. Results highlight timelier access to assessment with a high proportion of patients being managed in primary care within a person-centred approach to care. Enhancing primary care capacity for dementia care with interprofessional and collaborative care will strengthen the system's ability to respond to increasing demands for service and mitigate the growth of wait times to access geriatric specialist assessment.

  2. Restructuring VA ambulatory care and medical education: the PACE model of primary care.

    PubMed

    Cope, D W; Sherman, S; Robbins, A S

    1996-07-01

    The Veterans Health Administration (VHA) Western Region and associated medical schools formulated a set of recommendations for an improved ambulatory health care delivery system during a 1988 strategic planning conference. As a result, the Department of Veterans Affairs (VA) Medical Center in Sepulveda, California, initiated the Pilot (now Primary) Ambulatory Care and Education (PACE) program in 1990 to implement and evaluate a model program. The PACE program represents a significant departure from traditional VA and non-VA academic medical center care, shifting the focus of care from the inpatient to the outpatient setting. From its inception, the PACE program has used an interdisciplinary team approach with three independent global care firms. Each firm is interdisciplinary in composition, with a matrix management structure that expands role function and empowers team members. Emphasis is on managed primary care, stressing a biopsychosocial approach and cost-effective comprehensive care emphasizing prevention and health maintenance. Information management is provided through a network of personal computers that serve as a front end to the VHA Decentralized Hospital Computer Program (DHCP) mainframe. In addition to providing comprehensive and cost-effective care, the PACE program educates trainees in all health care disciplines, conducts research, and disseminates information about important procedures and outcomes. Undergraduate and graduate trainees from 11 health care disciplines rotate through the PACE program to learn an integrated approach to managed ambulatory care delivery. All trainees are involved in a problem-based approach to learning that emphasizes shared training experiences among health care disciplines. This paper describes the transitional phases of the PACE program (strategic planning, reorganization, and quality improvement) that are relevant for other institutions that are shifting to training programs emphasizing primary and ambulatory care.

  3. Third sector primary care for vulnerable populations.

    PubMed

    Crampton, P; Dowell, A; Woodward, A

    2001-12-01

    This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based Mäori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion

  4. Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care.

    PubMed

    Hedrick, Susan C; Chaney, Edmund F; Felker, Bradford; Liu, Chuan-Fen; Hasenberg, Nicole; Heagerty, Patrick; Buchanan, Jan; Bagala, Rocco; Greenberg, Diane; Paden, Grady; Fihn, Stephan D; Katon, Wayne

    2003-01-01

    To compare collaborative care for treatment of depression in primary care with consult-liaison (CL) care. In collaborative care, a mental health team provided a treatment plan to the primary care provider, telephoned patients to support adherence to the plan, reviewed treatment results, and suggested modifications to the provider. In CL care, study clinicians informed the primary care provider of the diagnosis and facilitated referrals to psychiatry residents practicing in the primary care clinic. Patients were randomly assigned to treatment model by clinic firm. VA primary care clinic. One hundred sixty-eight collaborative care and 186 CL patients who met criteria for major depression and/or dysthymia. Hopkins Symptom Checklist (SCL-20), Short Form (SF)-36, Sheehan Disability Scale. Collaborative care produced greater improvement than CL in depressive symptomatology from baseline to 3 months (SCL-20 change scores), but at 9 months there was no significant difference. The intervention increased the proportion of patients receiving prescriptions and cognitive behavioral therapy. Collaborative care produced significantly greater improvement on the Sheehan at 3 months. A greater proportion of collaborative care patients exhibited an improvement in SF-36 Mental Component Score of 5 points or more from baseline to 9 months. Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment and supports the necessary changes in clinic structure and incentives.

  5. Care Coordination for Youth With Mental Health Disorders in Primary Care.

    PubMed

    Hobbs Knutson, Katherine; Meyer, Mark J; Thakrar, Nisha; Stein, Bradley D

    2018-01-01

    Many children are treated for mental health disorders in primary care settings. The system of care (SOC) provides a framework for collaboration among pediatric mental health providers, but it is unclear if youth treated for mental health disorders in primary care receive such coordination. At the South Boston Community Health Center from September /2012 to August 2013 for 74 individuals ≤18 years, the odds of contact with SOC agencies (mental health, education, child protective services, juvenile justice and developmental disabilities) were compared for mental health treatment in primary versus specialty care. The odds of SOC contact within primary care were lower compared to specialty care (OR = 0.43, 95% CI = 0.29-0.66), specifically for mental health (OR = 0.54, 95% CI = 0.25-1.2), education (OR = 0.12, 95% CI = 0.050-0.28), and child protective services (OR = 0.64, 95% CI = 0.22-1.9). As care coordination may improve health outcomes, increased support and education for care coordination specific to youth treated for mental health disorders in primary care settings may be warranted.

  6. Patient views on primary care services for epilepsy and areas where additional professional knowledge would be welcome.

    PubMed

    Chappell, B; Smithson, W H

    1998-12-01

    In the past decade there has been increasing interest in the part that general practice can play in the care of people with epilepsy. Primary care services for epilepsy vary from practice to practice. Some studies have suggested that people with epilepsy prefer secondary care services and are not keen for their epilepsy to be managed in general practice, but much of the data were collected in secondary care. This study collected data from various sources about present provision of services, patient satisfaction with services, views about service development, areas where GP knowledge may be improved and whether the site of data collection influenced the results. A questionnaire was piloted, then distributed and collected through branches of the British Epilepsy Association, general practice and secondary care clinics. Data collected were both quantitative and qualitative. One hundred and seventy-eight questionnaires were collected from three sources. The responders were a severe seizure group. Structured care in general practice was uncommon with 54% being seen only when needed. Dose and type of antiepileptic medication was rarely altered in general practice. Information about their condition was given to 44% of the responders by their GP. Sixty-one percent would prefer their epilepsy care to be 'shared' between primary and secondary services. The majority of patients were satisfied with GP services, felt they could easily discuss their epilepsy, but 58% felt they 'rarely' or 'never' received enough information about their condition in general practice. Satisfaction with GP care varied, dependent on where the data were collected. Patients would value more information and more time to discuss the effects of their epilepsy. In conclusion general practice care for epilepsy is still reactive. Patients value more information and more time to discuss implications. The data collection point affects the results; any conclusions about the organisation of epilepsy care should

  7. Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care.

    PubMed

    O'Malley, Denalee; Hudson, Shawna V; Nekhlyudov, Larissa; Howard, Jenna; Rubinstein, Ellen; Lee, Heather S; Overholser, Linda S; Shaw, Amy; Givens, Sarah; Burton, Jay S; Grunfeld, Eva; Parry, Carly; Crabtree, Benjamin F

    2017-02-01

    This study describes the experiences of early implementers of primary care-focused cancer survivorship delivery models. Snowball sampling was used to identify innovators. Twelve participants (five cancer survivorship primary care innovators and seven content experts) attended a working conference focused on cancer survivorship population strategies and primary care transformation. Data included meeting discussion transcripts/field notes, transcribed in-depth innovator interviews, and innovators' summaries of care models. We used a multistep immersion/crystallization analytic approach, guided by a primary care organizational change model. Innovative practice models included: (1) a consultative model in a primary care setting; (2) a primary care physician (PCP)-led, blended consultative/panel-based model in an oncology setting; (3) an oncology nurse navigator in a primary care practice; and (4) two subspecialty models where PCPs in a general medical practice dedicated part of their patient panel to cancer survivors. Implementation challenges included (1) lack of key stakeholder buy-in; (2) practice resources allocated to competing (non-survivorship) change efforts; and (3) competition with higher priority initiatives incentivized by payers. Cancer survivorship delivery models are potentially feasible in primary care; however, significant barriers to widespread implementation exist. Implementation efforts would benefit from increasing the awareness and potential value-add of primary care-focused strategies to address survivors' needs. Current models of primary care-based cancer survivorship care may not be sustainable. Innovative strategies to provide quality care to this growing population of survivors need to be developed and integrated into primary care settings.

  8. Human factors and ergonomics for primary care.

    PubMed

    Bowie, Paul; Jeffcott, Shelly

    2016-03-01

    In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting.

  9. Integration of Neuropsychology in Primary Care.

    PubMed

    Lanca, Margaret

    2018-05-01

    The field of neuropsychology is making inroads in primary care as the importance of cognition in physical health is increasingly acknowledged. With neuropsychology primary care integration, patients receive a range of cognitive assessments (e.g., screens, brief neuropsychological assessments, treatment recommendations through provider-to-neuropsychologist consultations) based on a stepped model of care which can more efficiently diagnose cognitive disorders/problems and assist with treatment. Two case studies are described to illuminate this process. Information is provided to illustrate how neuropsychology integration was introduced in two primary care clinics at a community-based hospital system.

  10. [Heart failure in primary care: Attitudes, knowledge and self-care].

    PubMed

    Salvadó-Hernández, Cristina; Cosculluela-Torres, Pilar; Blanes-Monllor, Carmen; Parellada-Esquius, Neus; Méndez-Galeano, Carmen; Maroto-Villanova, Neus; García-Cerdán, Rosa Maria; Núñez-Manrique, M Pilar; Barrio-Ruiz, Carmen; Salvador-González, Betlem

    2018-04-01

    To determine the attitudes, knowledge, and self-care practices in patients with heart failure (HF) in Primary Care, as well as to identify factors associated with better self-care. Cross-sectional and multicentre study. Primary Care. Subjects over 18 years old with HF diagnosis, attended in 10 Primary Health Care Centres in the Metropolitan Area of Barcelona. Self-care was measured using the European Heart Failure Self-Care Behaviour Scale. Sociodemographic and clinical characteristics, tests on attitudes (Self-efficacy Managing Chronic Disease Scale), knowledge (Patient Knowledge Questionnaire), level of autonomy (Barthel), and anxiety and depression screening (Goldberg Test), were also gathered in an interview. A multivariate mixed model stratified by centre was used to analyse the adjusted association of covariates with self-care. A total of 295 subjects (77.6%) agreed to participate, with a mean age of 75.6 years (SD: 11), 56.6% women, and 62% with no primary education. The mean self-care score was 28.65 (SD: 8.22), with 25% of patients scoring lower than 21 points. In the final stratified multivariate model (n=282; R 2 conditional=0.3382), better self-care was associated with higher knowledge (coefficient, 95% confidence interval: -1.37; -1.85 to -0.90), and coronary heart disease diagnosis (-2.41; -4.36: -0.46). Self-care was moderate. The correlation of better self-care with higher knowledge highlights the opportunity to implement strategies to improve self-care, which should consider the characteristics of heart failure patients attended in Primary Care. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

  11. Primary care team working in Ireland: a qualitative exploration of team members' experiences in a new primary care service.

    PubMed

    Kennedy, Norelee; Armstrong, Claire; Woodward, Oonagh; Cullen, Walter

    2015-07-01

    Team working is an integral aspect of primary care, but barriers to effective team working can limit the effectiveness of a primary care team (PCT). The establishment of new PCTs in Ireland provides an excellent opportunity to explore team working in action. The aim of this qualitative study was to explore the experiences of team members working in a PCT. Team members (n = 19) from two PCTs were interviewed from May to June 2010 using a semi-structured interview guide. All interviews were audio-recorded and transcribed. Data were analysed using NVivo (version 8). Thematic analysis was used to explore the data. We identified five main themes that described the experiences of the team members. The themes were support for primary care, managing change, communication, evolution of roles and benefits of team working. Team members were generally supportive of primary care and had experienced benefits to their practice and to the care of their patients from participation in the team. Regular team meetings enabled communication and discussion of complex cases. Despite the significant scope for role conflict due to the varied employment arrangements of the team members, neither role nor interpersonal conflict was evident in the teams studied. In addition, despite the unusual team structure in Irish PCTs - where there is no formally appointed team leader or manager - general issues around team working and its benefits and challenges were very similar to those found in other international studies. This suggests, in contrast to some studies, that some aspects of the leadership role may not be as important in successful PCT functioning as previously thought. Nonetheless, team leadership was identified as an important issue in the further development of the teams. © 2014 John Wiley & Sons Ltd.

  12. Primary health care in Canada: systems in motion.

    PubMed

    Hutchison, Brian; Levesque, Jean-Frederic; Strumpf, Erin; Coyle, Natalie

    2011-06-01

    During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert. © 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.

  13. Approach to economic evaluation in primary care: review of a useful tool for primary care reform.

    PubMed

    McBrien, Kerry A; Manns, Braden

    2013-06-01

    To present an overview of the methods of economic evaluation in health care, using examples of studies applicable to primary care. The main concepts discussed in this article were derived from expert opinion and substantiated with well respected textbooks and comprehensive Canadian guidelines. Examples of cost-effectiveness estimates were taken from the published literature. We describe the basic principles of economic evaluation and provide an introduction to its interpretation, using examples of studies applicable to primary care. A basic understanding of health economics will allow primary care practitioners to begin to incorporate economic data, including that from economic evaluations when they are available, into resource planning for their practices.

  14. Suicide Attempts among Depressed Adolescents in Primary Care

    ERIC Educational Resources Information Center

    Fordwood, Samantha R.; Asarnow, Joan R.; Huizar, Diana P.; Reise, Steven P.

    2007-01-01

    Although depression is strongly associated with suicide attempts and suicide deaths, most depressed youth do not make an attempt, indicating the need to identify additional risk factors. We examined suicide attempts among 451 depressed primary care patients, 13 to 21 years of age. In bivariate analyses, youth classified as suicide attempters…

  15. Slack resources and quality of primary care.

    PubMed

    Mohr, David C; Young, Gary J

    2012-03-01

    Research generally shows that greater resource utilization fails to translate into higher-quality healthcare. Organizational slack is defined as extra organizational resources needed to meet demand. Divergent views exist on organizational slack in healthcare. Some investigators view slack negatively because it is wasteful, inefficient, and costly, whereas others view slack positively because it allows flexibility in work practices, expanding available services, and protecting against environmental changes. We tested a curvilinear relationship between organizational slack and care quality. The study setting was primary care clinics (n=568) in the Veterans Health Administration. We examined organizational slack using the patient panel size per clinic capacity ratio and support staff per provider ratio staffing guidelines developed by the Veterans Health Administration. Patient-level measures were influenza vaccinations, continuity of care, and overall quality of care ratings. We obtained 2 independent patient samples with approximately 28,000 and 62,000 observations for the analysis. We used multilevel modeling and examined the linear and quadratic terms for both organizational slack measures. We found a significant curvilinear effect for panel size per clinic capacity for influenza vaccinations and overall quality of care. We also found support staff per provider exhibited a curvilinear effect for continuity of care and influenza vaccinations. Greater available resources led to better care, but at a certain point, additional resources provided minimal quality gains. Our findings highlight the importance of primary care clinic managers monitoring staffing levels. Healthcare systems managing a balanced provider workload and staff-mix may realize better patient care delivery and cost management.

  16. Negotiating and managing partnership in primary care.

    PubMed

    Charlesworth, J

    2001-09-01

    In the UK public service organisations are increasingly working together in new partnerships, networks and alliances, largely stimulated by government legislation, which aims to encourage 'joined-up' policy-making. This is particularly prevalent in health-care where local government, health authorities and trusts, voluntary and community groups are extending existing, and developing new, forms of partnership, particularly around Health Improvement Programmes and new primary care organisations. This paper explores two main aspects of how these new interorganizational relationships are being developed and managed and is based on research conducted in one case study locality. First, the new structures of partnership in primary care are mapped out, together with discussion on why these particular patterns of relationship between statutory and voluntary sector organisations have emerged, exploring both centrally and locally determined influences. Secondly, the paper explores the tensions associated with working within new policy-making and management structures, and how the additional demands of audit, performance measurement and the sheer pace of change, pose a potential threat to the partnership process.

  17. Enhancing diabetes care by adding a pharmacist to the primary care team.

    PubMed

    Ip, Eric J; Shah, Bijal M; Yu, Junhua; Chan, James; Nguyen, Lynda T; Bhatt, Deempal C

    2013-05-15

    The impact of pharmacist interventions on short-term clinical markers and long-term cardiovascular risk in patients with type 2 diabetes is investigated. Selected health outcomes were retrospectively analyzed in 147 adults with type 2 diabetes whose care was managed by a team of providers including a pharmacist (the enhanced care group) and a matched sample of patients (n = 147) managed by a primary care physician only (the control group). All patients received services through the same health maintenance organization (HMO). The primary study endpoints were (1) the changes from baseline to 12-month follow-up in glycosylated hemoglobin (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and blood pressure (BP) values, (2) rates of attainment of HbA(1c), LDL-C and BP goals, and (3) changes from baseline in predicted 10-year risks of coronary heart disease (CHD) and stroke. During the 12-month study period, the mean HbA(1c) value was decreased from 9.5% to 6.9% in the enhanced care group and from 9.3% to 8.4% in the control group (p < 0.001); patients in the enhanced care group were significantly more likely to attain goals for HbA(1c) (odds ratio [OR], 3.9), LDL-C (OR, 2.0), and BP reduction (OR, 2.0) and three times more likely to attain all three goals (OR, 3.2). The estimated 10-year risk of CHD was decreased from 16.4% to 9.3% with enhanced care versus a reduction from 17.4% to 14.8% with usual care (p < 0.001). The addition of a pharmacist to an HMO primary care team improved short-term surrogate markers as well as long-term cardiovascular risk in adult patients with type 2 diabetes.

  18. Patient-reported care coordination: associations with primary care continuity and specialty care use.

    PubMed

    Liss, David T; Chubak, Jessica; Anderson, Melissa L; Saunders, Kathleen W; Tuzzio, Leah; Reid, Robert J

    2011-01-01

    Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use. We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use. Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77). High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

  19. Recognition of depression by primary care clinicians in rural Ethiopia.

    PubMed

    Fekadu, Abebaw; Medhin, Girmay; Selamu, Medhin; Giorgis, Tedla W; Lund, Crick; Alem, Atalay; Prince, Martin; Hanlon, Charlotte

    2017-04-21

    Depression is a common health condition affecting up to a third of patients attending primary care, where most of the care for people with depression is provided. Adequate recognition of depression is the critical step in the path to effective care, particularly in low income countries. As part of the Programme for Improving Mental healthcare (PRIME), a project supporting the implementation of integrated mental healthcare in primary care, we evaluated the level of recognition of depression by clinicians working in primary care in rural Ethiopia prior to in service training. We hypothesised that the detection rate of depression will be under 10% and that detection would be affected by gender, education and severity of depression. Cross-sectional survey in eight health centres serving a population of over 160,000 people. A validated version of the 9-item patient health questionnaire (PHQ-9) was administered as an indicator of probable depression. In addition, primary care clinicians completed a clinician encounter form. Participants were consecutive primary care attendees aged 18 years and above. A total of 1014 participants were assessed. Primary care clinicians diagnosed 13 attendees (1.3%) with depression. The PHQ9 prevalence of depression at a cut-off score of ten was 11.5% (n = 117), of whom 5% (n = 6/117) had received a diagnosis of depression by primary care clinicians. Attendees with higher PHQ scores and suicidality were significantly more likely to receive a diagnosis of depression by clinicians. Women (n = 9/13) and participants with higher educational attainment were more likely to be diagnosed with depression, albeit non-significantly. All cases diagnosed with depression by the clinicians had presented with psychological symptoms. Although not based on a gold standard diagnosis, over 98% of cases with PHQ-9 depression were undetected. Failure of recognition of depression may pose a serious threat to the scale up of mental healthcare in low

  20. Primary care providers' experiences caring for complex patients in primary care: a qualitative study.

    PubMed

    Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A

    2016-03-22

    Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of

  1. Addressing the primary care workforce: a study of nurse practitioner students' plans after graduation.

    PubMed

    Budd, Geraldine M; Wolf, Andrea; Haas, Richard Eric

    2015-03-01

    Primary care is a growing area, and nurse practitioners (NPs) hold promise for meeting the need for additional providers. This article reports on the future plans of more than 300 primary care NP students in family, adult, and adult gerontology programs. The sample was obtained through NP faculty, and data were collected via an online survey. Results indicated that although these students chose primary care, only 48% anticipated working in primary care; 26% planned to practice in rural areas, and 16% planned to work in an inner city. Reasons cited as important for pursuing a primary care position included the long-term patient relationship, faculty and preceptor mentors from the NP program, and clinical experiences as a student. Implications include providing more intensive faculty mentoring to increase the number of individuals seeking primary care positions after graduation and help with future career planning to meet personal career and nursing profession needs. Copyright 2015, SLACK Incorporated.

  2. Screening and Identification in Pediatric Primary Care

    ERIC Educational Resources Information Center

    Simonian, Susan J.

    2006-01-01

    This article reviews issues related to behavioral screening in pediatric primary care settings. Structural-organizational issues affecting the use of pediatric primary care screening are discussed. This study also reviewed selected screening instruments that have utility for use in the primary care setting. Clinical and research issues related to…

  3. Managing depression in primary care

    PubMed Central

    Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping

    2017-01-01

    Major depression is common in the primary care setting. In the final article of this series, we illustrate the approach to the management of depression in primary care. Psychotherapy has been shown to be as effective as antidepressants for mild to moderate major depression. The common myth that antidepressants are addictive should be addressed. Antidepressants should be started at a subtherapeutic dose to assess tolerability, then gradually increased until a minimally effective dose is achieved. Apart from pharmacotherapy and psychotherapy, management of depression should include managing stressors, engaging social and community support, dealing with stigma and discrimination, and managing concomitant comorbidities. A strong therapeutic relationship and empathic listening are important between the primary care physician and patient. PMID:28848991

  4. The Impact of a Primary Care Education Program Regarding Cancer Survivorship Care Plans: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.

    PubMed

    Donohue, SarahMaria; Haine, James E; Li, Zhanhai; Trowbridge, Elizabeth R; Kamnetz, Sandra A; Feldstein, David A; Sosman, James M; Wilke, Lee G; Sesto, Mary E; Tevaarwerk, Amye J

    2017-09-20

    Survivorship care plans (SCPs) have been recommended as tools to improve care coordination and outcomes for cancer survivors. SCPs are increasingly being provided to survivors and their primary care providers. However, most primary care providers remain unaware of SCPs, limiting their potential benefit. Best practices for educating primary care providers regarding SCP existence and content are needed. We developed an education program to inform primary care providers of the existence, content, and potential uses for SCPs. The education program consisted of a 15-min presentation highlighting SCP basics presented at mandatory primary care faculty meetings. An anonymous survey was electronically administered via email (n = 287 addresses) to evaluate experience with and basic knowledge of SCPs pre- and post-education. A total of 101 primary care advanced practice providers (APPs) and physicians (35% response rate) completed the baseline survey with only 23% reporting prior receipt of a SCP. Only 9% could identify the SCP location within the electronic health record (EHR). Following the education program, primary care physicians and APPs demonstrated a significant improvement in SCP knowledge, including improvement in their ability to locate one within the EHR (9 vs 59%, p < 0.0001). A brief educational program containing information about SCP existence, content, and location in the EHR increased primary care physician and APP knowledge in these areas, which are prerequisites for using SCP in clinical practice.

  5. Verbal communication among Alzheimer's disease patients, their caregivers, and primary care physicians during primary care office visits.

    PubMed

    Schmidt, Karen L; Lingler, Jennifer H; Schulz, Richard

    2009-11-01

    Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions. To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation. Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.

  6. Physicians, the Affordable Care Act, and primary care: disruptive change or business as usual?

    PubMed

    Jacobson, Peter D; Jazowski, Shelley A

    2011-08-01

    The Patient Protection and Affordable Care Act 1 (ACA) presages disruptive change in primary care delivery. With expanded access to primary care for millions of new patients, physicians and policymakers face increased pressure to solve the perennial shortage of primary care practitioners. Despite the controversy surrounding its enactment, the ACA should motivate organized medicine to take the lead in shaping new strategies for meeting the nation's primary care needs. In this commentary, we argue that physicians should take the lead in developing policies to address the primary care shortage. First, physicians and medical professional organizations should abandon their long-standing opposition to non-physician practitioners (NPPs) as primary care providers. Second, physicians should re-imagine how primary care is delivered, including shifting routine care to NPPs while retaining responsibility for complex patients and oversight of the new primary care arrangements. Third, the ACA's focus on wellness and prevention creates opportunities for physicians to integrate population health into primary care practice.

  7. [Primary Health Care in Austria - Tu Felix Austria nube - Concept for networking in the primary care of Upper Austria].

    PubMed

    Kriegel, Johannes; Rebhandl, Erwin; Hockl, Wolfgang; Stöbich, Anna-Maria

    2017-10-01

    The primary health care in rural areas in Austria is currently determined by challenges such as ageing of the population, the shift towards chronic and age-related illnesses, the specialist medical and hospital-related education and training of physicians' as well growing widespread difficulty of staffing doctor's office. The objective is to realize a general practitioner centered and team-oriented primary health care (PHC) approach by establishing networked primary health care in rural areas of Austria. Using literature research, online survey, expert interviews and expert workshops, we identified different challenges in terms of primary health care in rural areas. Further, current resources and capacities of primary health care in rural areas were identified using the example of the district of Rohrbach. Twelve design dimensions and 51 relevant measurement indicators of a PHC network were delineated and described. Based on this, 12 design approaches of PHC concept for the GP-centered and team-oriented primary health care in rural areas have been developed.

  8. A sustainable primary care system: lessons from the Netherlands.

    PubMed

    Faber, Marjan J; Burgers, Jako S; Westert, Gert P

    2012-01-01

    The Dutch primary care system has drawn international attention, because of its high performance at low cost. Primary care practices are easily accessible during office hours and collaborate in a unique out-of-hours system. After the reforms in 2006, there are no copayments for patients receiving care in the primary care practice in which they are registered. Financial incentives support the transfer of care from hospital specialists to primary care physicians, and task delegation from primary care physicians to practice nurses. Regional collaborative care groups of primary care practices offer disease management programs. The quality assessment system and the electronic medical record system are predominantly driven by health care professionals. Bottom-up and top-down activities contributed to a successful Dutch primary care system.

  9. Implementation strategies for collaborative primary care-mental health models.

    PubMed

    Franx, Gerdien; Dixon, Lisa; Wensing, Michel; Pincus, Harold

    2013-09-01

    Extensive research exists that collaborative primary care-mental health models can improve care and outcomes for patients. These programs are currently being implemented throughout the United States and beyond. The purpose of this study is to review the literature and to generate an overview of strategies currently used to implement such models in daily practice. Six overlapping strategies to implement collaborative primary care-mental health models were described in 18 selected studies. We identified interactive educational strategies, quality improvement change processes, technological support tools, stakeholder engagement in the design and execution of implementation plans, organizational changes in terms of expanding the task of nurses and financial strategies such as additional collaboration fees and pay for performance incentives. Considering the overwhelming evidence about the effectiveness of primary care-mental health models, there is a lack of good studies focusing on their implementation strategies. In practice, these strategies are multifaceted and locally defined, as a result of intensive and required stakeholder engagement. Although many barriers still exist, the implementation of collaborative models could have a chance to succeed in the United States, where new service delivery and payment models, such as the Patient-Centered Medical Home, the Health Home and the Accountable Care Organization, are being promoted.

  10. A comparison of father-infant interaction between primary and non-primary care giving fathers.

    PubMed

    Lewis, S N; West, A F; Stein, A; Malmberg, L-E; Bethell, K; Barnes, J; Sylva, K; Leach, P

    2009-03-01

    This study examined the socio-demographic characteristics and attitudes of primary care giving fathers and non-primary care giving fathers and the quality of their interaction with their infants. Two groups of fathers of 11.9-month old infants were compared - 25 primary care giving fathers (20 h per week or more of sole infant care) and 75 non-primary care giving fathers - with regard to socio-demographic characteristics, attitudinal differences and father-infant interaction during play and mealtimes. The quality of father-child interaction in relation to the total number of hours of primary care provided by fathers was also examined. Primary care giving fathers had lower occupational status and earned a smaller proportion of the family income but did not differ in educational level or attitudes compared with non-primary care giving fathers. There were no differences between the partners of the two groups of fathers on any variables, and their infants did not differ in temperament. Primary care giving fathers and their infants exhibited more positive emotional tone during play than non-primary care giving fathers, although fathers did not differ in responsivity. There were no differences between the groups during mealtimes. There was a positive association between total number of child care hours provided by all fathers and infant positive emotional tone. Primary and non-primary care giving fathers were similar in many respects, but primary care giving fathers and their infants were happier during play. This suggests a possible link between the involvement of fathers in the care of their children and their children's emotional state. The finding of a trend towards increased paternal happiness with increased hours of child care suggests that there may also be a gain for fathers who are more involved in the care of their infants. Further research is needed to determine whether these differences ultimately have an effect on children's development.

  11. Increasing the Capacity of Primary Care Through Enabling Technology.

    PubMed

    Young, Heather M; Nesbitt, Thomas S

    2017-04-01

    Primary care is the foundation of effective and high-quality health care. The role of primary care clinicians has expanded to encompass coordination of care across multiple providers and management of more patients with complex conditions. Enabling technology has the potential to expand the capacity for primary care clinicians to provide integrated, accessible care that channels expertise to the patient and brings specialty consultations into the primary care clinic. Furthermore, technology offers opportunities to engage patients in advancing their health through improved communication and enhanced self-management of chronic conditions. This paper describes enabling technologies in four domains (the body, the home, the community, and the primary care clinic) that can support the critical role primary care clinicians play in the health care system. It also identifies challenges to incorporating these technologies into primary care clinics, care processes, and workflow.

  12. Issues in Primary Care: The Academic Perspective

    ERIC Educational Resources Information Center

    Petersdorf, Robert G.

    1975-01-01

    Outlines the problems requiring restructuring of programs to prepare two new types of primary care physicians: a family physician who is predominantly an ambulatory care specialist and a primary care internist, pediatrician, or obstetrician who cares for most diseases in office and hospital. (JT)

  13. Managing depression in primary care.

    PubMed

    Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping

    2017-08-01

    Major depression is common in the primary care setting. In the final article of this series, we illustrate the approach to the management of depression in primary care. Psychotherapy has been shown to be as effective as antidepressants for mild to moderate major depression. The common myth that antidepressants are addictive should be addressed. Antidepressants should be started at a subtherapeutic dose to assess tolerability, then gradually increased until a minimally effective dose is achieved. Apart from pharmacotherapy and psychotherapy, management of depression should include managing stressors, engaging social and community support, dealing with stigma and discrimination, and managing concomitant comorbidities. A strong therapeutic relationship and empathic listening are important between the primary care physician and patient. Copyright: © Singapore Medical Association.

  14. The global burden of diagnostic errors in primary care.

    PubMed

    Singh, Hardeep; Schiff, Gordon D; Graber, Mark L; Onakpoya, Igho; Thompson, Matthew J

    2017-06-01

    Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care ', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  15. Do accountable care organizations (ACOs) help or hinder primary care physicians' ability to deliver high-quality care?

    PubMed

    Berenson, Robert A; Burton, Rachel A; McGrath, Megan

    2016-09-01

    Many view advanced primary care models such as the patient-centered medical home as foundational for accountable care organizations (ACOs), but it remains unclear how these two delivery reforms are complementary and how they may produce conflict. The objective of this study was to identify how joining an ACO could help or hinder a primary care practice's efforts to deliver high-quality care. This qualitative study involved interviews with a purposive sample of 32 early adopters of advanced primary care and/or ACO models, drawn from across the U.S. and conducted in mid-2014. Interview notes were coded using qualitative data analysis software, permitting topic-specific queries which were then summarized. Respondents perceived many potential benefits of joining an ACO, including care coordination staff, data analytics, and improved communication with other providers. However, respondents were also concerned about added "bureaucratic" requirements, referral restrictions, and a potential inability to recoup investments in practice improvements. Interviewees generally thought joining an ACO could complement a practice's efforts to deliver high-quality care, yet noted some concerns that could undermine these synergies. Both the advantages and disadvantages of joining an ACO seemed exacerbated for small practices, since they are most likely to benefit from additional resources yet are most likely to chafe under added bureaucratic requirements. Our identification of the potential pros and cons of joining an ACO may help providers identify areas to examine when weighing whether to enter into such an arrangement, and may help ACOs identify potential areas for improvement. Copyright © 2016 Elsevier Inc. All rights reserved.

  16. Assessing primary care data quality.

    PubMed

    Lim, Yvonne Mei Fong; Yusof, Maryati; Sivasampu, Sheamini

    2018-04-16

    Purpose The purpose of this paper is to assess National Medical Care Survey data quality. Design/methodology/approach Data completeness and representativeness were computed for all observations while other data quality measures were assessed using a 10 per cent sample from the National Medical Care Survey database; i.e., 12,569 primary care records from 189 public and private practices were included in the analysis. Findings Data field completion ranged from 69 to 100 per cent. Error rates for data transfer from paper to web-based application varied between 0.5 and 6.1 per cent. Error rates arising from diagnosis and clinical process coding were higher than medication coding. Data fields that involved free text entry were more prone to errors than those involving selection from menus. The authors found that completeness, accuracy, coding reliability and representativeness were generally good, while data timeliness needs to be improved. Research limitations/implications Only data entered into a web-based application were examined. Data omissions and errors in the original questionnaires were not covered. Practical implications Results from this study provided informative and practicable approaches to improve primary health care data completeness and accuracy especially in developing nations where resources are limited. Originality/value Primary care data quality studies in developing nations are limited. Understanding errors and missing data enables researchers and health service administrators to prevent quality-related problems in primary care data.

  17. Strengthening primary health care through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors.

    PubMed

    Valaitis, Ruta K; O'Mara, Linda; Wong, Sabrina T; MacDonald, Marjorie; Murray, Nancy; Martin-Misener, Ruth; Meagher-Stewart, Donna

    2018-04-12

    AimThe aim of this paper is to examine Canadian key informants' perceptions of intrapersonal (within an individual) and interpersonal (among individuals) factors that influence successful primary care and public health collaboration. Primary health care systems can be strengthened by building stronger collaborations between primary care and public health. Although there is literature that explores interpersonal factors that can influence successful inter-organizational collaborations, a few of them have specifically explored primary care and public health collaboration. Furthermore, no papers were found that considered factors at the intrapersonal level. This paper aims to explore these gaps in a Canadian context. This interpretative descriptive study involved key informants (service providers, managers, directors, and policy makers) who participated in one h telephone interviews to explore their perceptions of influences on successful primary care and public health collaboration. Transcripts were analyzed using NVivo 9.FindingsA total of 74 participants [from the provinces of British Columbia (n=20); Ontario (n=19); Nova Scotia (n=21), and representatives from other provinces or national organizations (n=14)] participated. Five interpersonal factors were found that influenced public health and primary care collaborations including: (1) trusting and inclusive relationships; (2) shared values, beliefs and attitudes; (3) role clarity; (4) effective communication; and (5) decision processes. There were two influencing factors found at the intrapersonal level: (1) personal qualities, skills and knowledge; and (2) personal values, beliefs, and attitudes. A few differences were found across the three core provinces involved. There were several complex interactions identified among all inter and intra personal influencing factors: One key factor - effective communication - interacted with all of them. Results support and extend our understanding of what influences

  18. Learning the Landscape: Implementation Challenges of Primary Care Innovators around Cancer Survivorship Care

    PubMed Central

    O’Malley, Denalee; Hudson, Shawna V.; Nekhlyudov, Larissa; Howard, Jenna; Rubinstein, Ellen; Lee, Heather S.; Overholser, Linda S.; Shaw, Amy; Givens, Sarah; Burton, Jay S.; Grunfeld, Eva; Parry, Carly; Crabtree, Benjamin F.

    2016-01-01

    PURPOSE This study describes the experiences of early implementers of primary care-focused cancer survivorship delivery models. METHODS Snowball sampling was used to identify innovators. Twelve participants (five cancer survivorship primary care innovators and seven content experts) attended a working conference focused on cancer survivorship population strategies and primary care transformation. Data included meeting discussion transcripts/field notes, transcribed in-depth innovator interviews, and innovators’ summaries of care models. We used a multi-step immersion/crystallization analytic approach, guided by a primary care organizational change model. RESULTS Innovative practice models included: 1) a consultative model in a primary care setting; 2) a primary care physician (PCP)-led, blended consultative/panel-based model in an oncology setting; 3) an oncology nurse navigator in a primary care practice; and 4) two sub-specialty models where PCPs in a general medical practice dedicated part of their patient panel to cancer survivors. Implementation challenges included: (1) lack of key stakeholder buy-in; (2) practice resources allocated to competing (non-survivorship) change efforts; and (3) competition with higher priority initiatives incentivized by payers. CONCLUSIONS Cancer survivorship delivery models are potentially feasible in primary care; however, significant barriers to widespread implementation exist. Implementation efforts would benefit from increasing the awareness and potential value-add of primary care-focused strategies to address survivors’ needs. PMID:27277895

  19. The global burden of diagnostic errors in primary care

    PubMed Central

    Singh, Hardeep; Schiff, Gordon D; Graber, Mark L; Onakpoya, Igho; Thompson, Matthew J

    2017-01-01

    Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, ‘Improving Diagnosis in Health Care’, concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a ‘magic bullet’ and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO’s leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error. PMID:27530239

  20. Protocol for the Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER) Trial: Comparing three obesity treatment models in rural primary care.

    PubMed

    Befort, Christie A; VanWormer, Jeffrey J; DeSouza, Cyrus; Ellerbeck, Edward F; Kimminau, Kim S; Greiner, Allen; Gajewski, Byron; Huang, Terry; Perri, Michael G; Fazzino, Tera L; Christifano, Danielle; Eiland, Leslie; Drincic, Andjela

    2016-03-01

    Obesity disproportionately affects rural residents in the United States, and primary care has the potential to fill a major gap in the provision of weight management services for rural communities. The objective of this cluster-randomized pragmatic trial is to evaluate the comparative effectiveness of three obesity treatment models in rural primary care: the Intensive Behavior Therapy fee-for-service (FFS) model reimbursed by Medicare, a team-based model that recognizes the patient-centered medical home (PCMH) as a preferred delivery approach, and the centralized disease management (DM) model, in which phone-based counseling is provided outside of the primary care practice. We hypothesize that the PCMH and DM treatments will be more effective than FFS in reducing weight at 24 months. Thirty-six practices from the rural Midwestern U.S. are randomized to deliver one of the three interventions to 40 patients (N=1440) age 20 to 75 with a BMI 30-45 kg/m(2). In the FFS arm, primary care providers and their personnel counsel patients to follow evidence-based weight loss guidelines using the Medicare-designated treatment schedule. In the PCMH arm, patients receive a comprehensive weight management intervention delivered locally by practice personnel using a combination of in-person and phone-based group sessions. In the DM arm, the same intervention is delivered remotely by obesity treatment specialists via group conference calls. The primary outcome is weight loss at 24 months. Additional measures include fasting glucose, lipids, quality of life indicators, and implementation process measures. Findings will illuminate effective obesity treatment intervention(s) in rural primary care. Copyright © 2016. Published by Elsevier Inc.

  1. Cancer Survivorship Care Plan Utilization and Impact on Clinical Decision-Making at Point-of-Care Visits with Primary Care: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.

    PubMed

    Donohue, SarahMaria; Haine, James E; Li, Zhanhai; Feldstein, David A; Micek, Mark; Trowbridge, Elizabeth R; Kamnetz, Sandra A; Sosman, James M; Wilke, Lee G; Sesto, Mary E; Tevaarwerk, Amye J

    2017-11-02

    Every cancer survivor and his/her primary care provider should receive an individualized survivorship care plan (SCP) following curative treatment. Little is known regarding point-of-care utilization at primary care visits. We assessed SCP utilization in the clinical context of primary care visits. Primary care physicians and advanced practice providers (APPs) who had seen survivors following provision of an SCP were identified. Eligible primary care physicians and APPs were sent an online survey, evaluating SCP utilization and influence on decision-making at the point-of-care, accompanied by copies of the survivor's SCP and the clinic note. Eighty-eight primary care physicians and APPs were surveyed November 2016, with 40 (45%) responding. Most respondents (60%) reported discussing cancer or related issues during the visit. Information needed included treatment (66%) and follow-up visits, and the cancer team was responsible for (58%) vs primary care (58%). Respondents acquired this information by asking the patient (79%), checking oncology notes (75%), the SCP (17%), or online resources (8%). Barriers to SCP use included being unaware of the SCP (73%), difficulty locating it (30%), and finding needed information faster via another mechanism (15%). Despite largely not using the SCP for the visit (90%), most respondents (61%) believed one would be quite or very helpful for future visits. Most primary care visits included discussion of cancer or cancer-related issues. SCPs may provide the information necessary to deliver optimal survivor care but efforts are needed to reduce barriers and design SCPs for primary care use.

  2. The Value of Continuity between Primary Care and Surgical Care in Colon Cancer.

    PubMed

    Hussain, Tanvir; Chang, Hsien-Yen; Luu, Ngoc-Phuong; Pollack, Craig Evan

    2016-01-01

    Improving continuity between primary care and cancer care is critical for improving cancer outcomes and curbing cancer costs. A dimension of continuity, we investigated how regularly patients receive their primary care and surgical care for colon cancer from the same hospital and whether this affects mortality and costs. Using Surveillance, Epidemiology, and End Results Program Registry (SEER)-Medicare data, we performed a retrospective cohort study of stage I-III colon cancer patients diagnosed between 2000 and 2009. There were 23,305 stage I-III colon cancer patients who received primary care in the year prior to diagnosis and underwent operative care for colon cancer. Patients were assigned to the hospital where they had their surgery and to their primary care provider's main hospital, and then classified according to whether these two hospitals were same or different. Outcomes examined were hazards for all-cause mortality, subhazard for colon cancer specific mortality, and generalized linear estimate for costs at 12 months, from propensity score matched models. Fifty-two percent of stage I-III colon patients received primary care and surgical care from the same hospital. Primary care and surgical care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality, but was associated with lower inpatient, outpatient, and total costs of care. Total cost difference was $8,836 (95% CI $2,746-$14,577), a 20% reduction in total median cost of care at 12 months. Receiving primary care and surgical care at the same hospital, compared to different hospitals, was associated with lower costs but still similar survival among stage I-III colon cancer patients. Nonetheless, health care policy which encourages further integration between primary care and cancer care in order to improve outcomes and decrease costs will need to address the significant proportion of patients receiving health care across more than one hospital.

  3. Primary care physician supply and other key determinants of health care utilisation: the case of Switzerland

    PubMed Central

    Busato, André; Künzi, Beat

    2008-01-01

    Background The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland. Methods The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data. Results Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care. Conclusion The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted

  4. Primary care physician supply and other key determinants of health care utilisation: the case of Switzerland.

    PubMed

    Busato, André; Künzi, Beat

    2008-01-11

    The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland. The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data. Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care. The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted in the different cultural backgrounds

  5. A nursing solution to primary care delivery shortfall.

    PubMed

    Carter, Michael; Moore, Phillip; Sublette, Nina

    2018-05-21

    Many countries project that they will have difficulty to meet their demand for primary care based on an inadequate supply of primary care doctors. There are many reasons for this, and they tend to vary by country. The policy options available to these countries are to increase the number of local primary care doctors, recruit doctors from other countries, ration primary care, shift more primary care to specialists, or authorize other disciplines to provide primary care. This article examines lessons learned in the United States over the past 50 years and proposes that expanding the use of nurse practitioners is the best solution when measured by feasibility, costs, ethics, and scope of the care delivered. Using nurse practitioners trained in country meets the World Health Organization global code of practice regarding the international recruitment of health personnel. © 2018 John Wiley & Sons Ltd.

  6. Phytotherapy in primary health care

    PubMed Central

    Antonio, Gisele Damian; Tesser, Charles Dalcanale; Moretti-Pires, Rodrigo Otavio

    2014-01-01

    OBJECTIVE To characterize the integration of phytotherapy in primary health care in Brazil. METHODS Journal articles and theses and dissertations were searched for in the following databases: SciELO, Lilacs, PubMed, Scopus, Web of Science and Theses Portal Capes, between January 1988 and March 2013. We analyzed 53 original studies on actions, programs, acceptance and use of phytotherapy and medicinal plants in the Brazilian Unified Health System. Bibliometric data, characteristics of the actions/programs, places and subjects involved and type and focus of the selected studies were analyzed. RESULTS Between 2003 and 2013, there was an increase in publications in different areas of knowledge, compared with the 1990-2002 period. The objectives and actions of programs involving the integration of phytotherapy into primary health care varied: including other treatment options, reduce costs, reviving traditional knowledge, preserving biodiversity, promoting social development and stimulating inter-sectorial actions. CONCLUSIONS Over the past 25 years, there was a small increase in scientific production on actions/programs developed in primary care. Including phytotherapy in primary care services encourages interaction between health care users and professionals. It also contributes to the socialization of scientific research and the development of a critical vision about the use of phytotherapy and plant medicine, not only on the part of professionals but also of the population. PMID:25119949

  7. Integrating primary care with occupational health services: a success story.

    PubMed

    Griffith, Karen; Strasser, Patricia B

    2010-12-01

    This article describes the process used by a large U.S. manufacturing company to successfully integrate full-service primary care centers at two locations. The company believed that by providing employees with health promotion and disease prevention services, including screening, early diagnosis, and uncomplicated illness treatment, its health care costs could be significantly reduced while saving employees money. To accurately demonstrate the cost-effectiveness of adding primary care to existing occupational health services, a thorough financial analysis projected the return on investment (ROI) of the program. Decisions were made about center size, the scope of services, and staffing. A critical part of the ROI analysis involved evaluating employee health claim data to identify the actual cost of health care services for each center and the projected costs if the services were provided on-site. The pilot initiative included constructing two on-site health center facilities staffed with primary care physicians, nurse practitioners, physical therapists, and other health care professionals. Key outcome metrics from the pilot clinics exceeded goals in three of four categories. In addition, clinic use after 12 months far exceeded benchmarks for similar clinics. Most importantly, the pilot clinics were operating with a positive cash flow within the first year and demonstrated an increasingly positive ROI. Copyright 2010, SLACK Incorporated.

  8. Characteristics of primary care practices associated with high quality of care

    PubMed Central

    Beaulieu, Marie-Dominique; Haggerty, Jeannie; Tousignant, Pierre; Barnsley, Janet; Hogg, William; Geneau, Robert; Hudon, Éveline; Duplain, Réjean; Denis, Jean-Louis; Bonin, Lucie; Del Grande, Claudio; Dragieva, Natalyia

    2013-01-01

    Background: No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. Methods: We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. Results: The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0–35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8–14.4), presence of allied health professionals (15.3; 95% CI 5.4–25.2) and/or specialist physicians (19.6; 95% CI 8.3–30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0–12.4) and average organizational access to the practice (4.9; 95% CI 2.6–7.2). The number of physicians (1.2; 95% CI 0.6–1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1–2.5) were modestly associated with high-quality care. Interpretation: We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes. PMID:23877669

  9. An analysis of computerization in primary care practices.

    PubMed

    Condon, James V; Smith, Sherry P

    2002-12-01

    To remain profitable, primary care practices, the front-line health care providers, must provide excellent patient care and reduce expenses while providing payers with accurate data. Many primary care practices have turned to computer technology to achieve these goals. This study examined the degree of computerization of primary care providers in the Augusta, Georgia, metropolitan area as well as the level of awareness of the Health Insurance Portability and Accountability Act (HIPAA) by primary care providers and its potential effect on their future computerization plans. The study's findings are presented and discussed as well as a number of recommendations for practice managers.

  10. New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS

    PubMed Central

    Baron, Richard J.

    2012-01-01

    Those in practice find that the fee-for-service system does not adequately value the contributions made by primary care. The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs. All programs coming out of the Innovation Center are tests of new payment and service delivery models. By changing both payment and delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, we may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide. PMID:22412007

  11. Older Patients' Perspectives on Quality of Serious Illness Care in Primary Care.

    PubMed

    Abu Al Hamayel, Nebras; Isenberg, Sarina R; Hannum, Susan M; Sixon, Joshua; Smith, Katherine Clegg; Dy, Sydney M

    2018-01-01

    Despite increased focus on measuring and improving quality of serious illness care, there has been little emphasis on the primary care context or incorporation of the patient perspective. To explore older patients' perspectives on the quality of serious illness care in primary care. Qualitative interview study. Twenty patients aged 60 or older who were at risk for or living with serious illness and who had participated in the clinic's quality improvement initiative. We used a semistructured, open-ended guide focusing on how older patients perceived quality of serious illness care, particularly in primary care. We transcribed interviews verbatim and inductively identified codes. We identified emergent themes using a thematic and constant comparative method. We identified 5 key themes: (1) the importance of patient-centered communication, (2) coordination of care, (3) the shared decision-making process, (4) clinician competence, and (5) access to care. Communication was an overarching theme that facilitated coordination of care between patients and their clinicians, empowered patients for shared decision-making, related to clinicians' perceived competence, and enabled access to primary and specialty care. Although access to care is not traditionally considered an aspect of quality, patients considered this integral to the quality of care they received. Patients perceived serious illness care as a key aspect of quality in primary care. Efforts to improve quality measurement and implementation of quality improvement initiatives in serious illness care should consider these aspects of care that patients deem important, particularly communication as an overarching priority.

  12. A review of instruments to measure interprofessional team-based primary care.

    PubMed

    Shoemaker, Sarah J; Parchman, Michael L; Fuda, Kathleen Kerwin; Schaefer, Judith; Levin, Jessica; Hunt, Meaghan; Ricciardi, Richard

    2016-07-01

    Interprofessional team-based care is increasingly regarded as an important feature of delivery systems redesigned to provide more efficient and higher quality care, including primary care. Measurement of the functioning of such teams might enable improvement of team effectiveness and could facilitate research on team-based primary care. Our aims were to develop a conceptual framework of high-functioning primary care teams to identify and review instruments that measure the constructs identified in the framework, and to create a searchable, web-based atlas of such instruments (available at: http://primarycaremeasures.ahrq.gov/team-based-care/ ). Our conceptual framework was developed from existing frameworks, the teamwork literature, and expert input. The framework is based on an Input-Mediator-Output model and includes 12 constructs to which we mapped both instruments as a whole, and individual instrument items. Instruments were also reviewed for relevance to measuring team-based care, and characterized. Instruments were identified from peer-reviewed and grey literature, measure databases, and expert input. From nearly 200 instruments initially identified, we found 48 to be relevant to measuring team-based primary care. The majority of instruments were surveys (n = 44), and the remainder (n = 4) were observational checklists. Most instruments had been developed/tested in healthcare settings (n = 30) and addressed multiple constructs, most commonly communication (n = 42), heedful interrelating (n = 42), respectful interactions (n = 40), and shared explicit goals (n = 37). The majority of instruments had some reliability testing (n = 39) and over half included validity testing (n = 29). Currently available instruments offer promise to researchers and practitioners to assess teams' performance, but additional work is needed to adapt these instruments for primary care settings.

  13. Implementing Dementia Care Models in Primary Care Settings: The Aging Brain Care Medical Home (Special Supplement)

    PubMed Central

    Callahan, Christopher M.; Boustani, Malaz A.; Weiner, Michael; Beck, Robin A.; Livin, Lee R.; Kellams, Jeffrey J.; Willis, Deanna R.; Hendrie, Hugh C.

    2010-01-01

    Objectives The purpose of this paper is to describe our experience in implementing a primary care-based dementia and depression care program focused on providing collaborative care for dementia and late-life depression. Methods Capitalizing on the substantial interest in the US on the patient-centered medical home concept, the Aging Brain Care Medical Home targets older adults with dementia and/or late life depression in the primary care setting. We describe a structured set of activities that laid the foundation for a new partnership with the primary care practice and the lessons learned in implementing this new care model. We also provide a description of the core components of this innovative memory care program. Results Findings from three recent randomized clinical trials provided the rationale and basic components for implementing the new memory care program. We used the reflective adaptive process as a relationship building framework that recognizes primary care practices as complex adaptive systems. This framework allows for local adaptation of the protocols and procedures developed in the clinical trials. Tailored care for individual patients is facilitated through a care manager working in collaboration with a primary care physician and supported by specialists in a memory care clinic as well as by information technology resources. Conclusions We have successfully overcome many system-level barriers in implementing a collaborative care program for dementia and depression in primary care. Spontaneous adoption of new models of care is unlikely without specific attention to the complexities and resource constraints of health care systems. PMID:20945236

  14. Primary care clinicians' recognition and management of depression: a model of depression care in real-world primary care practice.

    PubMed

    Baik, Seong-Yi; Crabtree, Benjamin F; Gonzales, Junius J

    2013-11-01

    Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered. This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions. Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data. Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners. A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression. The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.

  15. Mental health collaborative care and its role in primary care settings.

    PubMed

    Goodrich, David E; Kilbourne, Amy M; Nord, Kristina M; Bauer, Mark S

    2013-08-01

    Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.

  16. Insurance-related disparities in primary care quality among U.S. Type 2 diabetes patients.

    PubMed

    Lee, De-Chih; Liang, Hailun; Shi, Leiyu

    2016-08-02

    This study explored insurance-related disparities in primary care quality among Americans with type 2 diabetes. Data came from the household component of the 2012 Medical Expenditure Panel Survey (MEPS). Analysis focused on adult subjects with type 2 diabetes. Logistic regressions were performed to investigate the associations between insurance status and primary care attributes related to first contact, longitudinality, comprehensiveness, and coordination, while controlling for confounding factors. Preliminary findings revealed differences among three insurance groups in the first contact domain of primary care quality. After controlling for confounding factors, these differences were no longer apparent, with all insurance groups reporting similar primary care quality according to the four domains of interest in the study. There were significant differences in socioeconomic status among different insurance groups. This study reveals equitable primary care quality for diabetes patients despite their health insurance status. In addition to insurance-related differences, the other socioeconomic stratification factors are assumed to be the root cause of disparities in care. This research emphasizes the crucial role that primary care plays in the accessibility and quality of care for chronically ill patients. Policy makers should continue their commitment to reduce gaps in insurance coverage and improve access as well as quality of diabetic care.

  17. LGBTQ Youth's Perceptions of Primary Care.

    PubMed

    Snyder, Barbara K; Burack, Gail D; Petrova, Anna

    2017-05-01

    Despite published guidelines on the need to provide comprehensive care to lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) youth, there has been limited research related to the deliverance of primary health care to this population. The goals of this study were to learn about LGBTQ youth's experiences with their primary care physicians and to identify areas for improvement. Youth attending 1 of 5 community-based programs completed a written questionnaire and participated in a focus group discussion regarding experiences at primary care visits, including topics discussed, counselling received, and physician communication. Most of the youth did not feel their health care needs were well met. The majority acknowledged poor patient-provider communication, disrespect, and lack of discussions about important topics such as sexual and emotional health. Participants cited concerns about confidentiality and inappropriate comments as barriers to care. Youth expressed a strong desire to have physicians be more aware of their needs and concerns.

  18. Proactive cancer care in primary care: a mixed-methods study.

    PubMed

    Kendall, Marilyn; Mason, Bruce; Momen, Natalie; Barclay, Stephen; Munday, Dan; Lovick, Roberta; Macpherson, Stella; Paterson, Euan; Baughan, Paul; Cormie, Paul; Kiehlmann, Peter; Free, Amanda; Murray, Scott A

    2013-06-01

    Current models of post-treatment cancer care are based on traditional practices and clinician preference rather than evidence of benefit. To assess the feasibility of using a structured template to provide holistic follow-up of patients in primary care from cancer diagnosis onwards. A two-phase mixed methods action research project. An electronic cancer ongoing review document (CORD) was first developed with patients and general practitioners, and used with patients with a new diagnosis of cancer. This was evaluated through documentary analysis of the CORDs, qualitative interviews with patients, family carers and health professionals and record reviews. The records of 107 patients from 13 primary care teams were examined and 45 interviews conducted. The document was started in 54% of people with newly diagnosed cancer, and prompted clear documentation of multidimension needs and understanding. General practitioners found using the document helped to structure consultations and cover psychosocial areas, but they reported it needed to be better integrated in their medical records with computerized prompts in place. Few clinicians discussed the review openly with patients, and the template was often completed afterwards. Anticipatory cancer care from diagnosis to cure or death, 'in primary care', is feasible in the U.K. and acceptable to patients, although there are barriers. The process promoted continuity of care and holism. A reliable system for proactive cancer care in general practice supported by hospital specialists may allow more survivorship care to be delivered in primary care, as in other long-term conditions.

  19. [Primary care in Sweden].

    PubMed

    Sánchez-Sagrado, T

    2016-09-01

    Sweden was one of the first European Union countries that saw the opportunity in the free movement of professionals. First offers for jobs were managed in 2000. Since then, a large number of professionals have taken the opportunity of a decent job and have moved from Spain to Sweden. The Swedish health care model belongs to the group of national health systems. The right to health care is linked to legal citizenship. Health is financed through regional taxes, but there is a compulsory co-payment regardless of the financial situation of the patient. The provision of health care is decentralised at a regional level, and there is a mixture of private and public medical centres. Primary care is similar to that in Spain. Health professionals work as a team with a division of tasks. Like in Spain, waiting lists and coordination between primary and specialised care are a great problem. Patients may register with any public or private primary care centre and hospital provider within their region. Access to diagnostic tests and specialists are restricted to those selected by specialists. Doctors are salaried and their job and salary depend on their experience, professional abilities and regional needs. Medicine is curative. General practitioners are the gateway to the system, but they do not act as gatekeeper. Hospitals offer a number of training post, and the access is through an interview. Continuing medical education is encouraged and financed by the health centre in order to increase its revenues. Copyright © 2015 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

  20. After-hours care and its coordination with primary care in the U.S.

    PubMed

    O'Malley, Ann S; Samuel, Divya; Bond, Amelia M; Carrier, Emily

    2012-11-01

    Despite expectations that medical homes provide "24 × 7 coverage" there is little to guide primary care practices in developing sustainable models for accessible and coordinated after-hours care. To identify and describe models of after-hours care in the U.S. that are delivered in primary care sites or coordinated with a patient's usual primary care provider. Qualitative analysis of data from in-depth telephone interviews. Primary care practices in 16 states and the organizations they partner with to provide after-hours coverage. Forty-four primary care physicians, practice managers, nurses and health plan representatives from 28 organizations. Analyses examined after-hours care models, facilitators, barriers and lessons learned. Based on 28 organizations interviewed, five broad models of after-hours care were identified, ranging in the extent to which they provide continuity and patient access. Key themes included: 1) The feasibility of a model varies for many reasons, including patient preferences and needs, the local health care market supply, and financial compensation; 2) A shared electronic health record and systematic notification procedures were extremely helpful in maintaining information continuity between providers; and 3) after-hours care is best implemented as part of a larger practice approach to access and continuity. After-hours care coordinated with a patient's usual primary care provider is facilitated by consideration of patient demand, provider capacity, a shared electronic health record, systematic notification procedures and a broader practice approach to improving primary care access and continuity. Payer support is important to increasing patients' access to after-hours care.

  1. Out-of-hours primary care. Implications of organisation on costs

    PubMed Central

    van Uden, Caro JT; Ament, Andre JHA; Voss, Gemma BWE; Wesseling, Geertjan; Winkens, Ron AG; van Schayck, Onno CP; Crebolder, Harry FJM

    2006-01-01

    Background To perform out-of-hours primary care, Dutch general practitioners (GPs) have organised themselves in large-scale GP cooperatives. Roughly, two models of out-of-hours care can be distinguished; GP cooperatives working separate from the hospital emergency department (ED) and GP cooperatives integrated with the hospital ED. Research has shown differences in care utilisation between these two models; a significant shift in the integrated model from utilisation of ED care to primary care. These differences may have implications on costs, however, until now this has not been investigated. This study was performed to provide insight in costs of these two different models of out-of-hours care. Methods Annual reports of two GP cooperatives (one separate from and one integrated with a hospital emergency department) in 2003 were analysed on costs and use of out-of-hours care. Costs were calculated per capita. Comparisons were made between the two cooperatives. In addition, a comparison was made between the costs of the hospital ED of the integrated model before and after the set up of the GP cooperative were analysed. Results Costs per capita of the GP cooperative in the integrated model were slightly higher than in the separate model (ε 11.47 and ε 10.54 respectively). Differences were mainly caused by personnel and other costs, including transportation, interest, cleaning, computers and overhead. Despite a significant reduction in patients utilising ED care as a result of the introduction of the GP cooperative integrated within the ED, the costs of the ED remained the same. Conclusion The study results show that the costs of primary care appear to be more dependent on the size of the population the cooperative covers than on the way the GP cooperative is organised, i.e. separated versus integrated. In addition, despite the substantial reduction of patients, locating the GP cooperative at the same site as the ED was found to have little effect on costs of the ED

  2. Out-of-hours primary care. Implications of organisation on costs.

    PubMed

    van Uden, Caro J T; Ament, Andre J H A; Voss, Gemma B W E; Wesseling, Geertjan; Winkens, Ron A G; van Schayck, Onno C P; Crebolder, Harry F J M

    2006-05-04

    To perform out-of-hours primary care, Dutch general practitioners (GPs) have organised themselves in large-scale GP cooperatives. Roughly, two models of out-of-hours care can be distinguished; GP cooperatives working separate from the hospital emergency department (ED) and GP cooperatives integrated with the hospital ED. Research has shown differences in care utilisation between these two models; a significant shift in the integrated model from utilisation of ED care to primary care. These differences may have implications on costs, however, until now this has not been investigated. This study was performed to provide insight in costs of these two different models of out-of-hours care. Annual reports of two GP cooperatives (one separate from and one integrated with a hospital emergency department) in 2003 were analysed on costs and use of out-of-hours care. Costs were calculated per capita. Comparisons were made between the two cooperatives. In addition, a comparison was made between the costs of the hospital ED of the integrated model before and after the set up of the GP cooperative were analysed. Costs per capita of the GP cooperative in the integrated model were slightly higher than in the separate model (epsilon 11.47 and epsilon 10.54 respectively). Differences were mainly caused by personnel and other costs, including transportation, interest, cleaning, computers and overhead. Despite a significant reduction in patients utilising ED care as a result of the introduction of the GP cooperative integrated within the ED, the costs of the ED remained the same. The study results show that the costs of primary care appear to be more dependent on the size of the population the cooperative covers than on the way the GP cooperative is organised, i.e. separated versus integrated. In addition, despite the substantial reduction of patients, locating the GP cooperative at the same site as the ED was found to have little effect on costs of the ED. Sharing more facilities

  3. Primary Care-Based Memory Clinics: Expanding Capacity for Dementia Care.

    PubMed

    Lee, Linda; Hillier, Loretta M; Heckman, George; Gagnon, Micheline; Borrie, Michael J; Stolee, Paul; Harvey, David

    2014-09-01

    The implementation in Ontario of 15 primary-care-based interprofessional memory clinics represented a unique model of team-based case management aimed at increasing capacity for dementia care at the primary-care level. Each clinic tracked referrals; in a subset of clinics, charts were audited by geriatricians, clinic members were interviewed, and patients, caregivers, and referring physicians completed satisfaction surveys. Across all clinics, 582 patients were assessed, and 8.9 per cent were referred to a specialist. Patients and caregivers were very satisfied with the care received, as were referring family physicians, who reported increased capacity to manage dementia. Geriatricians' chart audits revealed a high level of agreement with diagnosis and management. This study demonstrated acceptability, feasibility, and preliminary effectiveness of the primary-care memory clinic model. Led by specially trained family physicians, it provided timely access to high-quality collaborative dementia care, impacting health service utilization by more-efficient use of scarce geriatric specialist resources.

  4. [Levers in Primary Health Care - Identifying Strategic Success Factors for Improved Primary Care in Upper Austria].

    PubMed

    Kriegel, J; Rebhandl, E; Reckwitz, N; Hockl, W

    2016-12-01

    Current and projected general practitioner (GP) and primary care in Austria shows structural and process inadequacies in the quality as well as assurance of healthcare supply. The aim is therefore to develop solution- and patient-oriented measures that take patient-related requirements and medical perspectives into account. Using an effect matrix, subjective expert and user priorities were ascertained, cause and effect relationships were examined, and an expanded circle of success for the optimization of GP and primary care in Upper Austria was developed. Through this, the relevant levers for target-oriented development and optimization of the complex system of GP and primary care in Upper Austria were identified; these are training to become general practitioners, entrepreneurs as well as management and coordination. It is necessary to further adapt the identified levers conceptually and operationally in a targeted approach. This is to be achieved by means of the primary health care (PHC) concept as well as management tools and information and communication technologies (ICT) associated with it. © Georg Thieme Verlag KG Stuttgart · New York.

  5. A future for primary care for the Greek population.

    PubMed

    Groenewegen, Peter P; Jurgutis, Arnoldas

    2013-01-01

    Greece is hit hard by the state debt crisis. This calls for comprehensive reforms to restore sustainable and balanced growth. Healthcare is one of the public sectors needing reform. The European Union (EU) Task Force for Greece asked the authors to assess the situation of primary care and to make recommendations for reform. Primary healthcare is especially relevant in that it might increase the efficiency of the healthcare system, and improve access to good quality healthcare. Assessment of the state of primary care in Greece was made on the basis of existing literature, site visits in primary care and consultations with stakeholders. The governance of primary care (and healthcare in general) is fragmented. There is no system of gatekeeping or patient lists. Private payments (formal and informal) are high. There are too many physicians, but too few general practitioners and nurses, and they are unevenly spread across the country. As a consequence, there are problems of access, continuity, co-ordination and comprehensiveness of primary care. The authors recommend the development of a clear vision and development strategy for strengthening primary care. Stepped access to secondary care should be realised through the introduction of mandatory referrals. Primary care should be accessible through the lowest possible out-of-pocket payments. The roles of purchaser and provider of care should be split. Quality of care should be improved through development of clinical guidelines and quality indicators. The education of health professionals should put more emphasis on primary care and medical specialists working in primary care should be (re-)trained to acquire the necessary competences to satisfy the job descriptions to be developed for primary care professionals. The advantages of strong primary care should be communicated to patients and the wider public.

  6. Leadership in primary health care: an international perspective.

    PubMed

    McMurray, Anne

    2007-08-01

    A primary health care approach is essential to contemporary nursing roles such as practice nursing. This paper examines the evolution of primary health care as a global strategy for responding to the social determinants of health. Primary health care roles require knowledge of, and a focus on social determinants of health, particularly the societal factors that allow and perpetuate inequities and disadvantage. They also require a depth and breadth of leadership skills that are responsive to health needs, appropriate in the social and regulatory context, and visionary in balancing both workforce and client needs. The key to succeeding in working with communities and groups under a primary health care umbrella is to balance the big picture of comprehensive primary health care with operational strategies for selective primary health care. The other essential element involves using leadership skills to promote inclusiveness, empowerment and health literacy, and ultimately, better health.

  7. Exemplars in the use of technology for management of depression in primary care.

    PubMed

    Serrano, Neftali; Molander, Rachel; Monden, Kimberley; Grosshans, Ashley; Krahn, Dean D

    2012-06-01

    Depression care management as part of larger efforts to integrate behavioral health care into primary care has been shown to be effective in helping patients and primary care clinicians achieve improved outcomes within the primary care environment. Central to care management systems is the use of registries which enable effective clinic population management. The aim of this article is to detail the methods and utility of technology in depression care management processes while also highlighting the real-world variations and barriers that exist in different clinical environments, namely a federally qualified health center and a Veterans Administration clinic. We analyzed descriptive data from the registries of Access Community Health Centers and the William S. Middleton Veterans Administration clinics along with historical reviews of their respective care management processes. Both registry reviews showed trend data indicating improvement in scores of depression and provided baseline data on important system variables, such as the number of patients who are not making progress, the percentage of patients who are unreachable by phone, and the kind of actions needed to ensure evidence-based and efficient care. Both sites also highlighted systemic technical barriers to more complete implementation of care management processes. Care management processes are an effective and efficient part of population-based care for depression in primary care. Implementation depends on available resources including hardware, software, and clinical personnel. Additionally, care management processes and technology have evolved over time based on local needs and are part of an integrated method to support the work of primary care clinicians in providing care for patients with depression.

  8. Multidisciplinary care planning in the primary care management of completed stroke: a systematic review

    PubMed Central

    Mitchell, Geoffrey K; Brown, Robyn M; Erikssen, Lars; Tieman, Jennifer J

    2008-01-01

    Background Chronic disease management requires input from multiple health professionals, both specialist and primary care providers. This study sought to assess the impact of co-ordinated multidisciplinary care in primary care, represented by the delivery of formal care planning by primary care teams or shared across primary-secondary teams, on outcomes in stroke, relative to usual care. Methods A Systematic review of Medline, EMBASE, CINAHL (all 1990–2006), Cochrane Library (Issue 1 2006), and grey literature from web based searching of web sites listed in the CCOHA Health Technology Assessment List Analysis used narrative analysis of findings of randomised and non-randomised trials, and observational and qualitative studies of patients with completed stroke in the primary care setting where care planning was undertaken by 1) a multi-disciplinary primary care team or 2) through shared care by primary and secondary providers. Results One thousand and forty-five citations were retrieved. Eighteen papers were included for analysis. Most care planning took part in the context of multidisciplinary team care based in hospitals with outreach to community patients. Mortality rates are not impacted by multidisciplinary care planning. Functional outcomes of the studies were inconsistent. It is uncertain whether the active engagement of GPs and other primary care professionals in the multidisciplinary care planning contributed to the outcomes in the studies showing a positive effect. There may be process benefits from multidisciplinary care planning that includes primary care professionals and GPs. Few studies actually described the tasks and roles GPs fulfilled and whether this matched what was presumed to be provided. Conclusion While multidisciplinary care planning may not unequivocally improve the care of patients with completed stroke, there may be process benefits such as improved task allocation between providers. Further study on the impact of active GP involvement

  9. Mental Health Collaborative Care and Its Role in Primary Care Settings

    PubMed Central

    Goodrich, David E.; Kilbourne, Amy M.; Nord, Kristina M.; Bauer, Mark S.

    2013-01-01

    Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims under healthcare reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components. PMID:23881714

  10. Primary care in a new era: disillusion and dissolution?.

    PubMed

    Sandy, Lewis G; Schroeder, Steven A

    2003-02-04

    The current dilemmas in primary care stem from 1) the unintended consequences of forces thought to promote primary care and 2) the "disruptive technologies of care" that attack the very function and concept of primary care itself. This paper suggests that these forces, in combination with "tiering" in the health insurance market, could lead to the dissolution of primary care as a single concept, to be replaced by alignment of clinicians by economic niche. Evidence already exists in the marketplace for both tiering of health insurance benefits and corresponding practice changes within primary care. In the future, primary care for the top tier will cater to the affluent as "full-service brokers" and will be delivered by a wide variety of clinicians. The middle tier will continue to grapple with tensions created by patient demand and bureaucratic systems but will remain most closely aligned to primary care as a concept. The lower tier will become increasingly concerned with community health and social justice. Each primary care specialty will adapt in a unique way to a tiered world, with general internal medicine facing the most challenges. Given this forecast for the future, those concerned about primary care should focus less on workforce issues and more on macro health care financing and organization issues (such as Medicare reform); appropriate training models; and the development of a conception of primary care that emphasizes values and ethos, not just function.

  11. Op HERRICK primary care casualties: the forgotten many.

    PubMed

    Nelson, T G; Wall, C; Driver, J; Simpson, R

    2012-09-01

    The number of battle casualties generated during war is far outnumbered by non-battle casualties. Each year the current conflict in Afghanistan sees hundreds of service personnel medically evacuated direct from the front line to the care of their home units' primary care facility. To date these casualties remain undiscovered by medical research. This is the first study to look at the care pathway of primary care casualties from Operation HERRICK using information from the Defence Patient Tracking System (DPTS). Information relating to all casualties from Afghanistan discharged at the airhead between 1 January 2009 and 31 December 2010 was collected from the DPTS. Common conditions were identified and information relating to the follow up care extracted to provide an overview of the care pathway. 387 aeromedical evacuations were identified as primary care casualties. The three commonest conditions were musculoskeletal (183 cases), mental health (29) and noise-induced hearing loss (26). 205 (53%) were not seen outside of primary care for the tracked condition. 166 (81%) of those that remained under primary care had two or less consultations during the time period of the study. The mean time frame between the 1st and 2nd consultation was 5.4 weeks. A significant number of aeromedical evacuations from Afghanistan are for primary care casualties. The DPTS can be used to provide a basic overview of the care pathway of repatriated personnel. Little contact with the medical services would appear to occur for these types of casualties. There is a significant gap in military medical research looking at primary care casualties repatriated from operations.

  12. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care.

    PubMed

    Goroll, Allan H; Berenson, Robert A; Schoenbaum, Stephen C; Gardner, Laurence B

    2007-03-01

    Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.

  13. Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care

    PubMed Central

    Berenson, Robert A.; Schoenbaum, Stephen C.; Gardner, Laurence B.

    2007-01-01

    Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed. PMID:17356977

  14. Physician and Staff Acceptance of Care Managers in Primary Care Offices.

    PubMed

    Malouin, Jean M; Malouin, Rebecca A; Sarinopoulos, Issidoros; Beisel, Marie; Bechel-Marriot, Diane; First, Amanda; Gamble, Ginger M; Tanner, Clare

    2017-01-01

    Embedded care managers are increasingly implemented as part of the care team within primary care practices, yet previous studies have indicated variability in acceptance by physicians and staff. This study assesses the acceptability of care managers among staff and physicians within the Michigan Primary Care Transformation (MiPCT) demonstration. Care manager acceptance was measured using a web-based survey distributed to practices participating in the MiPCT demonstration. Both physicians and staff reported high levels of care manager acceptance. Longer length of care manager employment at the practice, higher care manager FTE dedicated to care management, and care manager employed by practice were all significantly associated with care manager acceptance. The MiPCT demonstration found high care manager acceptance across all care team members. The high level of acceptance may be due to the structures and processes developed by MiPCT to support implementation of care managers and the length of the intervention period. The MiPCT demonstration confirms that following three years of implementation, embedded care managers are acceptable to both physicians and staff within primary care practices. Importantly, embeddedness, or the amount of time care managers are located within practices, is associated with increased acceptance. © Copyright 2017 by the American Board of Family Medicine.

  15. Verbal Communication among Alzheimer’s Disease Patients, their Caregivers, and Primary Care Physicians during Primary Care Office Visits

    PubMed Central

    Schmidt, Karen L.; Lingler, Jennifer H.; Schulz, Richard

    2009-01-01

    Objective Primary care visits of patients with Alzheimer’s disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual’s verbal participation in these triadic interactions. Methods To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. Results PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver’s own verbal participation. Conclusion Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Practice Implications Encouraging verbal participation by AD patients and their caregivers may increase the AD patient’s active role and caregiver satisfaction with primary care visits. PMID:19395224

  16. Evolution, current structure, and role of a primary care clinical pharmacy service in an integrated managed care organization.

    PubMed

    Heilmann, Rachel M F; Campbell, Stephanie M; Kroner, Beverly A; Proksel, Jenel R; Billups, Sarah J; Witt, Daniel M; Helling, Dennis K

    2013-01-01

    The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.

  17. Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

    PubMed

    Cumming, Jacqueline; Mays, Nicholas; Gribben, Barry

    2008-11-06

    In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005. Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices. The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.

  18. Cost-effectiveness of a Primary Care Intervention to Treat Obesity

    PubMed Central

    Tsai, Adam G.; Wadden, Thomas A.; Volger, Sheri; Sarwer, David B.; Vetter, Marion; Kumanyika, Shiriki; Berkowitz, Robert I.; Diewald, Lisa; Perez, Joanna; Lavenberg, Jeffrey; Panigrahi, Eva R.; Glick, Henry A.

    2013-01-01

    Background Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive. The cost-effectiveness of treatment in primary care settings is particularly relevant. Methods We conducted a within-trial cost-effectiveness analysis of a primary care-based obesity intervention. Study participants were randomized to: Usual Care (quarterly visits with their primary care provider); Brief Lifestyle Counseling (Brief LC; quarterly provider visits plus monthly weight loss counseling visits; or Enhanced Brief Lifestyle Counseling (Enhanced Brief LC; all above interventions, plus choice of meal replacements or weight loss medication). A health care payer perspective was used. Intervention costs were estimated from tracking data obtained prospectively. Quality adjusted life years (QALYs) were estimated with the EuroQol-5D. We estimated cost per kilogram-year of weight loss and cost per QALY. Results Weight losses after 2 years were 1.7, 2.9, and 4.6 kg for Usual Care, Brief LC, and Enhanced Brief LC, respectively (p = 0.003 for comparison of Enhanced Brief LC vs. Usual Care). The incremental cost per kilogram-year lost was $292 for Enhanced Brief LC compared to Usual Care (95% CI $38 to $394). The incremental cost per QALY was $115,397, but the 95% CI were undefined. Comparison of short term cost per kg with published estimates of longer term cost per QALYs suggested that the intervention could be cost-effective over the long term (≥ 10 years). Conclusions A primary care intervention that included monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term. However, additional studies are needed on the cost-effectiveness of behavioral treatment of obesity. PMID:23921780

  19. Primary Care Practice: Uncertainty and Surprise

    NASA Astrophysics Data System (ADS)

    Crabtree, Benjamin F.

    I will focus my comments on uncertainty and surprise in primary care practices. I am a medical anthropologist by training, and have been a full-time researcher in family medicine for close to twenty years. In this talk I want to look at primary care practices as complex systems, particularly taking the perspective of translating evidence into practice. I am going to discuss briefly the challenges we have in primary care, and in medicine in general, of translating new evidence into the everyday care of patients. To do this, I will look at two studies that we have conducted on family practices, then think about how practices can be best characterized as complex adaptive systems. Finally, I will focus on the implications of this portrayal for disseminating new knowledge into practice.

  20. Improving Health Care Management in Primary Care for Homeless People: A Literature Review.

    PubMed

    Jego, Maeva; Abcaya, Julien; Ștefan, Diana-Elena; Calvet-Montredon, Céline; Gentile, Stéphanie

    2018-02-10

    Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. We performed a literature review that included articles which described and evaluated primary care programs for homeless people. Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community's health. Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model.

  1. Better Together: Co-Location of Dental and Primary Care Provides Opportunities to Improve Oral Health.

    PubMed

    Pourat, Nadereh; Martinez, Ana E; Crall, James J

    2015-09-01

    Community Health Centers (CHCs) are one of the principal safety-net providers of health care for low-income and uninsured populations. Co-locating dental services in primary care settings provides an opportunity to improve access to dental care. Yet this study of California CHCs that provide primary care services shows that only about one-third of them co-located primary and dental care services on-site. An additional one-third were members of multisite organizations in which at least one other site provided dental care. The remaining one-third of CHC sites had no dental care capacity. Policy options to promote co-location include requiring on-site availability of dental services, providing infrastructure funding to build and equip dental facilities, and offering financial incentives to provide dental care and recruit dental providers.

  2. Examining organizational change in primary care practices: experiences from using ethnographic methods.

    PubMed

    Russell, Grant; Advocat, Jenny; Geneau, Robert; Farrell, Barbara; Thille, Patricia; Ward, Natalie; Evans, Samantha

    2012-08-01

    Qualitative methods are an important part of the primary care researcher's toolkit providing a nuanced view of the complexity in primary care reform and delivery. Ethnographic research is a comprehensive approach to qualitative data collection, including observation, in-depth interviews and document analysis. Few studies have been published outlining methodological issues related to ethnography in this setting. This paper examines some of the challenges of conducting an ethnographic study in primary care setting in Canada, where there recently have been major reforms to traditional methods of organizing primary care services. This paper is based on an ethnographic study set in primary care practices in Ontario, Canada, designed to investigate changes to organizational and clinical routines in practices undergoing transition to new, interdisciplinary Family Health Teams (FHTs). The study was set in six new FHTs in Ontario. This paper is a reflexive examination of some of the challenges encountered while conducting an ethnographic study in a primary care setting. Our experiences in this study highlight some potential benefits of and difficulties in conducting an ethnographic study in family practice. Our study design gave us an opportunity to highlight the changes in routines within an organization in transition. A study with a clinical perspective requires training, support, a mixture of backgrounds and perspectives and ongoing communication. Despite some of the difficulties, the richness of this method has allowed the exploration of a number of additional research questions that emerged during data analysis.

  3. Private ownership of primary care providers associated with patient perceived quality of care

    PubMed Central

    Wei, Xiaolin; Yin, Jia; Wong, Samuel Y.S.; Griffiths, Sian M.; Zou, Guanyang; Shi, Leiyu

    2017-01-01

    Abstract Ownership of primary care providers varies in different cities in China. Shanghai represented the full public ownership model of primary providers; Shenzhen had public-owned but private-operated providers; and Hong Kong represented the full private ownership. The study aims to assess the association of primary care ownership and patient perceived quality of care in 3 Chinese megacities. We conducted multistage stratified random surveys in 2013 in the 3 cities. Quality scores of primary care were measured using the validated primary care assessment tools. Multivariate linear regression models were used to compare quality scores after controlling potential confounders of patient demographic, socioeconomic, and healthcare utilization factors. Overall, 797 primary care users in Shanghai, 802 in Shenzhen, and 1325 in Hong Kong participated in the study. The mean total quality scores were reported the highest in Shanghai (28.39), followed by Shenzhen (25.82) and then Hong Kong (25.21) (P < 0.001). Shanghai participants reported the highest scores for 1st contact accessibility, coordination of information, comprehensiveness of service availability, and culture competence, while Hong Kong participants reported the lowest for these domains (P < 0.001). Hong Kong participants from rich households reported higher total scores than those from poor households (P < 0.05); however, this was not found in Shanghai and Shenzhen. The study suggests that private primary care ownership may be associated with lower quality and less equitable care distribution. In China, it suggests that it may be beneficial to promote public-owned and nonprofit providers. Promoting privatization in primary care may be at the cost of quality and equity of primary care. PMID:28072718

  4. The strength of primary care in Europe: an international comparative study.

    PubMed

    Kringos, Dionne; Boerma, Wienke; Bourgueil, Yann; Cartier, Thomas; Dedeu, Toni; Hasvold, Toralf; Hutchinson, Allen; Lember, Margus; Oleszczyk, Marek; Rotar Pavlic, Danica; Svab, Igor; Tedeschi, Paolo; Wilm, Stefan; Wilson, Andrew; Windak, Adam; Van der Zee, Jouke; Groenewegen, Peter

    2013-11-01

    A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.

  5. How patients understand physicians' solicitations of additional concerns: implications for up-front agenda setting in primary care.

    PubMed

    Robinson, Jeffrey D; Heritage, John

    2016-01-01

    In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians.

  6. Training the Internist for Primary Care: A View From Nevada

    PubMed Central

    Kurtz, Kenneth J.

    1982-01-01

    The recent establishment of primary care residencies at the University of Nevada School of Medicine has raised important questions about local priorities in the training of physicians to provide primary care for adults. Because the amount of money available for health care training is decreasing, these questions also have national importance. Primary care internal medicine, not synonymous with general internal medicine, offers distinct advantages to patients over family practice adult care and primary care offered by internist subspecialists. The University of Nevada has a singular opportunity to organize a strong primary care internal medicine residency, but national problems of internal medicine emphasis exist. Nationwide changes in internal medicine residency programs (ongoing) and American Board of Internal Medicine nationalization of the fledgling primary care internal medicine fellowship movement are suggested. Specifically proposed is an extra year for primary care training with a single examination after four years, producing general internists with a primary care “minor.” Alternately, and ideally, there would be a full two-year primary care fellowship with a separate internal medicine primary care subspecialty board examination. Either of the above options would provide necessary training and academic credibility for primary care internists, and would redirect internal medicine certification and training. PMID:7072246

  7. Training the internist for primary care: a view from Nevada.

    PubMed

    Kurtz, K J

    1982-01-01

    The recent establishment of primary care residencies at the University of Nevada School of Medicine has raised important questions about local priorities in the training of physicians to provide primary care for adults. Because the amount of money available for health care training is decreasing, these questions also have national importance. Primary care internal medicine, not synonymous with general internal medicine, offers distinct advantages to patients over family practice adult care and primary care offered by internist subspecialists. The University of Nevada has a singular opportunity to organize a strong primary care internal medicine residency, but national problems of internal medicine emphasis exist. Nationwide changes in internal medicine residency programs (ongoing) and American Board of Internal Medicine nationalization of the fledgling primary care internal medicine fellowship movement are suggested. Specifically proposed is an extra year for primary care training with a single examination after four years, producing general internists with a primary care "minor." Alternately, and ideally, there would be a full two-year primary care fellowship with a separate internal medicine primary care subspecialty board examination. Either of the above options would provide necessary training and academic credibility for primary care internists, and would redirect internal medicine certification and training.

  8. Remission in Depressed Geriatric Primary Care Patients: A Report From the PROSPECT Study

    PubMed Central

    Alexopoulos, George S.; Katz, Ira R.; Bruce, Martha L.; Heo, Moonseong; Have, Thomas Ten; Raue, Patrick; Bogner, Hillary R.; Schulberg, Herbert C.; Mulsant, Benoit H.; Reynolds, Charles F.

    2009-01-01

    Objective This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists. Method Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (≥60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months. Results First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety. Conclusions Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled. PMID:15800144

  9. Decision Aid Use in Primary Care: An Overview and Theory-Based Framework.

    PubMed

    Shultz, Cameron G; Jimbo, Masahito

    2015-10-01

    Increasing patients' participation in health care is a commonly cited goal. While patient decision aids can promote participation, they remain underutilized. Theory-based models that assess barriers and facilitators to sustained decision aid use are needed. The ready, willing, and able model specifies three preconditions for behavioral change. We present a descriptive analysis of the uptake of patient decision aids in the primary care setting and show how the ready, willing, and able model can be used to identify potential barriers and facilitators. An Ovid Medline literature search from January 2004 to November 2014 was used; additional sources were identified from reference lists and through peer consultations. Barriers and facilitators to decision aid use were identified and grouped into salient themes. The ready, willing, and able model provided a simple yet practical framework for identifying the mechanisms that facilitate (or work against) the adoption of patient decision aids within primary care. While time was a prominent barrier, additional barriers such as perceived legitimacy, clinic capacity, processes of care, and the overarching health care environment were also noted. The ready, willing, and able model posits that several preconditions must first be satisfied before sustained use of patient decision aids can take hold. By pinpointing bottlenecks, the model can inform policies and tailored interventions to target identified problems. Using the model to troubleshoot for bottlenecks prior to the implementation of a decision aid could help to improve uptake and sustained use within the primary care setting.

  10. Counselling in Primary Care: Past, Present, and Future.

    ERIC Educational Resources Information Center

    Eatock, John

    2000-01-01

    Presents a brief history of the growth of counseling in primary care. Discusses the challenges for primary care counselors and counseling, as well as the need for coordination, regulation and management. Also discusses the imperative for research support and the unique nature of counseling in primary care including challenges to its survival. (MKA)

  11. The Chief Primary Care Medical Officer: Restoring Continuity

    PubMed Central

    Doohan, Noemi; DeVoe, Jennifer

    2017-01-01

    The year 2016 marked the 20th anniversary of the hospitalist profession, with more than 50,000 physicians identifying as hospitalists. The Achilles heel of hospitalist medicine, however, is discontinuity. Despite many current payment and delivery systems rewarding this discontinuity and severing long-term relationships between patient and primary care teams at the hospital door, primary care does not stop being important when a person is admitted to the hospital. The notion of a broken primary care continuum is not an academic construct, it causes real harm to patients. As a step toward fixing the discontinuity in our health care systems, we propose that every hospital needs a Chief Primary Care Medical Officer (CPCMO), an expert in practice across the spectrum of care. The CPCMO can lead hospital efforts to create systems that ensure primary care’s continuum is complete, while strengthening physician collaboration across specialties, and moving toward achieving the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers. For hospitals operating on value-based payment structures, anticipated improvement in measurable outcomes such as decreased length of stay, decreased readmission rates, improved transitions of care, improved patient satisfaction, improved access to primary care, and improved patient health, will enhance the rate of return on the hospital’s investment. The speciality of family medicine should reevaluate our purpose, and reembrace our mission as personal physicians by championing the creation of Chief Primary Care Medical Officers. PMID:28694275

  12. Primary care health issues among men who have sex with men.

    PubMed

    Gee, Royal

    2006-04-01

    The purpose of the article is to examine "appropriate" health care for men who have sex with men (MSM), which is not to suggest "special" health care. As a group, MSM are at increased risk for sexually transmitted infections, anal cancer, and mental health disorders. Focus areas in this article will address health issues that the primary care nurse practitioner (NP) may encounter in clinical practice: anal carcinoma, sexually transmitted diseases (STDs), high-risk sexual practices, depression, and substance abuse were topics chosen for inclusion in this article. These topics were among those highlighted in the Healthy People 2010 Companion Document for LGBT Health, which served to examine the healthcare disparities and lack of access to needed services related to sexual orientation. Extensive literature review of research articles, journals, clinical practice guidelines, books, and public health department Internet Web sites. There are unique health disparities that exist for MSM related to social, emotional, and mental health factors, in addition to physical issues such as STDs. There is an increasing need for primary care providers to be aware of these disparities, as well as the factors that influence these disparities, in order to provide multidimensional care and health counseling that is unique to NP practice. Both the primary care NP and the patient should be aware of the unique healthcare issues among MSM that should be incorporated into the patient's routine health maintenance program. As primary care providers, it is within the standards of practice for NPs to provide culturally competent care, along with health promotion and disease prevention for MSM.

  13. Specialist outreach clinics in primary care and rural hospital settings.

    PubMed

    Gruen, R L; Weeramanthri, T S; Knight, S E; Bailie, R S

    2004-01-01

    ' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes. This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

  14. Managing multimorbidity in primary care in patients with chronic respiratory conditions.

    PubMed

    Morrison, Deborah; Agur, Karolina; Mercer, Stewart; Eiras, Andreia; González-Montalvo, Juan I; Gruffydd-Jones, Kevin

    2016-09-15

    The term multimorbidity is usually defined as the coexistence of two or more chronic conditions within an individual, whereas the term comorbidity traditionally describes patients with an index condition and one or more additional conditions. Multimorbidity of chronic conditions markedly worsens outcomes in patients, increases treatment burden and increases health service costs. Although patients with chronic respiratory disease often have physical comorbidities, they also commonly experience psychological problems such as depression and anxiety. Multimorbidity is associated with increased health-care utilisation and specifically with an increased number of prescription drugs in individuals with multiple chronic conditions such as chronic obstructive pulmonary disease. This npj Primary Care Respiratory Medicine Education Section case study involves a patient in a primary care consultation presenting several common diseases prevalent in people of this age. The patient takes nine different drugs at this moment, one or more pills for each condition, which amounts to polypharmacy. The problems related with polypharmacy recommend that a routine medication review by primary care physicians be performed to reduce the risk of adverse effects of polypharmacy among those with multiple chronic conditions. The primary care physician has the challenging role of integrating all of the clinical problems affecting the patient and reviewing all medicaments (including over-the-counter medications) taken by the patient at any point in time, and has the has the key to prevent the unwanted consequences of polypharmacy. Multimorbid chronic disease management can be achieved with the use of care planning, unified disease templates, use of information technology with appointment reminders and with the help of the wider primary care and community teams.

  15. Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

    PubMed Central

    Cumming, Jacqueline; Mays, Nicholas; Gribben, Barry

    2008-01-01

    Background In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005. Results Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices. Conclusion The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care. PMID:18990236

  16. Proactive cancer care in primary care: a mixed-methods study

    PubMed Central

    Murray, Scott A

    2013-01-01

    Background. Current models of post-treatment cancer care are based on traditional practices and clinician preference rather than evidence of benefit. Objectives. To assess the feasibility of using a structured template to provide holistic follow-up of patients in primary care from cancer diagnosis onwards. Methods. A two-phase mixed methods action research project. An electronic Cancer Ongoing Review Document (CORD) was first developed with patients and general practitioners, and used with patients with a new diagnosis of cancer. This was evaluated through documentary analysis of the CORDs, qualitative interviews with patients, family carers and health professionals and record reviews. Results. The records of 107 patients from 13 primary care teams were examined and 45 interviews conducted. The document was started in 54% of people with newly diagnosed cancer, and prompted clear documentation of multidimension needs and understanding. General practitioners found using the document helped to structure consultations and cover psychosocial areas, but they reported it needed to be better integrated in their medical records with computerized prompts in place. Few clinicians discussed the review openly with patients, and the template was often completed afterwards. Conclusions. Anticipatory cancer care from diagnosis to cure or death, ‘in primary care’, is feasible in the UK and acceptable to patients, although there are barriers. The process promoted continuity of care and holism. A reliable system for proactive cancer care in general practice supported by hospital specialists may allow more survivorship care to be delivered in primary care, as in other long-term conditions. PMID:23382502

  17. The role of the primary care team in the rapid response system.

    PubMed

    O'Horo, John C; Sevilla Berrios, Ronaldo A; Elmer, Jennifer L; Velagapudi, Venu; Caples, Sean M; Kashyap, Rahul; Jensen, Jeffrey B

    2015-04-01

    The purpose of the study is to evaluate the impact of primary service involvement on rapid response team (RRT) evaluations. The study is a combination of retrospective chart review and prospective survey-based evaluation. Data included when and where the activations occurred and the patient's code status, primary service, and ultimate disposition. These data were correlated with survey data from each event. A prospective survey evaluated the primary team's involvement in decision making and the overall subjective quality of the interaction with primary service through a visual analog scale. We analyzed 4408 RRTs retrospectively and an additional 135 prospectively. The primary team's involvement by telephone or in person was associated with significantly more transfers to higher care levels in retrospective (P < .01) and prospective data sets. Code status was addressed more frequently in primary team involvement, with more frequent changes seen in the retrospective analysis (P = .01). Subjective ratings of communication by the RRT leader were significantly higher when the primary service was involved (P < .001). Active primary team involvement influences RRT activation processes of care. The RRT role should be an adjunct to, but not a substitute for, an engaged and present primary care team. Copyright © 2014 Elsevier Inc. All rights reserved.

  18. Improving Health Care Management in Primary Care for Homeless People: A Literature Review

    PubMed Central

    Abcaya, Julien; Ștefan, Diana-Elena; Calvet-Montredon, Céline; Gentile, Stéphanie

    2018-01-01

    Background: Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. Methods: We performed a literature review that included articles which described and evaluated primary care programs for homeless people. Results: Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community’s health. Conclusions: Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model. PMID:29439403

  19. Integrated primary care in Germany: the road ahead.

    PubMed

    Schlette, Sophia; Lisac, Melanie; Blum, Kerstin

    2009-04-20

    Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult. Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and 'community medicine nurses'. Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans-sectoral education and training of providers.

  20. Integrated primary care in Germany: the road ahead

    PubMed Central

    Schlette, Sophia; Lisac, Melanie; Blum, Kerstin

    2009-01-01

    Problem statement Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult. Description of policy development Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and ‘community medicine nurses’. Conclusion and discussion Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans-sectoral education and training of

  1. Primary care in the United States and its precarious future.

    PubMed

    Starfield, Barbara; Oliver, Thomas

    1999-09-01

    Primary care has not secured a firm place within the US health services system. Since primary care lacks a strong research base, is not institutionalized in medical education or in policy-making and is marginalized in both proposed and actual reforms, it has not developed into a central component of the health care infrastructure. We discuss recent efforts that promised modest improvements, including the Clinton health care reform proposals and subsequent federal and state actions, in the role of primary care within the health services system. We also assess the likely fate of primary care given the accelerated growth of managed care and market competition, the dissatisfaction of large segments of the population with managed care and misperceptions of managed care as synonymous with primary care. We highlight how managed care fails to achieve the cardinal functions of primary care and summarize initiatives that, at a minimum, would be required to secure a stronger position for primary care in the future.

  2. Medical students' attitudes toward underserved populations: changing associations with choice of primary care versus non-primary care residency.

    PubMed

    Wayne, Sharon; Timm, Craig; Serna, Lisa; Solan, Brian; Kalishman, Summers

    2010-05-01

    The number of medical students entering primary care residencies continues to decrease. The association between student attitudes toward underserved populations and residency choice has received little attention even though primary care physicians see a larger proportion of underserved patients than most other specialists. We evaluated attitudes toward underserved populations in 826 medical students using a standardized survey, and used logistic regression to assess the effect of attitudes, along with other variables, on selection of a primary care residency. We compared results between two groups defined by year of entry to medical school (1993-99 and 2000-05) to determine whether associations differed by time period. Students' attitudes regarding professional responsibility toward underserved populations remained high over the study period; however, there was a statistically. significant association between positive attitudes and primary care residency in the early cohort only. This association was not found in the more recent group.

  3. The Surgical Nosology In Primary-care Settings (SNIPS): a simple bridging classification for the interface between primary and specialist care

    PubMed Central

    Gruen, Russell L; Knox, Stephanie; Britt, Helena; Bailie, Ross S

    2004-01-01

    Background The interface between primary care and specialist medical services is an important domain for health services research and policy. Of particular concern is optimising specialist services and the organisation of the specialist workforce to meet the needs and demands for specialist care, particularly those generated by referral from primary care. However, differences in the disease classification and reporting of the work of primary and specialist surgical sectors hamper such research. This paper describes the development of a bridging classification for use in the study of potential surgical problems in primary care settings, and for classifying referrals to surgical specialties. Methods A three stage process was undertaken, which involved: (1) defining the categories of surgical disorders from a specialist perspective that were relevant to the specialist-primary care interface; (2) classifying the 'terms' in the International Classification of Primary Care Version 2-Plus (ICPC-2 Plus) to the surgical categories; and (3) using referral data from 303,000 patient encounters in the BEACH study of general practice activity in Australia to define a core set of surgical conditions. Inclusion of terms was based on the probability of specialist referral of patients with such problems, and specialists' perception that they constitute part of normal surgical practice. Results A four-level hierarchy was developed, containing 8, 27 and 79 categories in the first, second and third levels, respectively. These categories classified 2050 ICPC-2 Plus terms that constituted the fourth level, and which covered the spectrum of problems that were managed in primary care and referred to surgical specialists. Conclusion Our method of classifying terms from a primary care classification system to categories delineated by specialists should be applicable to research addressing the interface between primary and specialist care. By describing the process and putting the bridging

  4. Building COPD care on shaky ground: a mixed methods study from Swedish primary care professional perspective.

    PubMed

    Lundell, Sara; Tistad, Malin; Rehn, Börje; Wiklund, Maria; Holmner, Åsa; Wadell, Karin

    2017-07-10

    inadequate routines and lack of resources. There is a gap between COPD treatment guidelines and the healthcare that is provided in primary care. To facilitate implementation of the guidelines several actions are needed, such as further training for professionals, additional resources, and improved organisational structure for interprofessional collaboration and patient education.

  5. Primary Health Care and tuberculosis: services evaluation.

    PubMed

    Wysocki, Anneliese Domingues; Ponce, Maria Amélia Zanon; Brunello, Maria Eugênia Firmino; Beraldo, Aline Ale; Vendramini, Silvia Helena Figueiredo; Scatena, Lúcia Marina; Ruffino, Antonio; Villa, Tereza Cristina Scatena

    2017-01-01

    In order to control tuberculosis, the Brazilian Ministry of Health recommends the decentralization of control actions directed to the Primary Health Care, and there are few studies on the performance of the Tuberculosis Control Program in decentralized contexts. To evaluate the performance of Primary Health Care services in tuberculosis treatment. This is an evaluative study with cross-sectional approach conducted in 2011. Two hundred and thirty-nine health professionals from Primary Health Care units were interviewed using a structured instrument based on the evaluation reference of the health services quality (structure - process - results). The performance of these services was analyzed applying techniques of descriptive statistics, validation, and construction of indicators and by determining the reduced variable "Z". The indicators "participation of professionals in tuberculosis patients' care" (structure) and "reference and counterreference" (process) had the best evaluations, whereas "professional training" (structure) and "external actions for tuberculosis control" (process) had the worst results. The decentralization of tuberculosis control actions has been taking place in a vertical manner in Primary Health Care. The challenge of controlling tuberculosis involves overcoming constraints related to the engagement, training, and turnover rates among health professionals, which is a coordination between services and monitoring of control actions in Primary Health Care.

  6. Retail clinic visits and receipt of primary care.

    PubMed

    Reid, Rachel O; Ashwood, J Scott; Friedberg, Mark W; Weber, Ellerie S; Setodji, Claude M; Mehrotra, Ateev

    2013-04-01

    An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care. To assess the association between retail clinic use and receipt of key primary care functions. We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009. We identified patients who had a visit for a simple acute condition in 2008, the "index visit". We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic. We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice-Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias. Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice-Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management. Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.

  7. 42 CFR 440.168 - Primary care case management services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Primary care case management services. 440.168... care case management services. (a) Primary care case management services means case management related services that— (1) Include location, coordination, and monitoring of primary health care services; and (2...

  8. 42 CFR 440.168 - Primary care case management services.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... care case management services. (a) Primary care case management services means case management related services that— (1) Include location, coordination, and monitoring of primary health care services; and (2... 42 Public Health 4 2014-10-01 2014-10-01 false Primary care case management services. 440.168...

  9. 42 CFR 440.168 - Primary care case management services.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... care case management services. (a) Primary care case management services means case management related services that— (1) Include location, coordination, and monitoring of primary health care services; and (2... 42 Public Health 4 2011-10-01 2011-10-01 false Primary care case management services. 440.168...

  10. 42 CFR 440.168 - Primary care case management services.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... care case management services. (a) Primary care case management services means case management related services that— (1) Include location, coordination, and monitoring of primary health care services; and (2... 42 Public Health 4 2012-10-01 2012-10-01 false Primary care case management services. 440.168...

  11. 42 CFR 440.168 - Primary care case management services.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... care case management services. (a) Primary care case management services means case management related services that— (1) Include location, coordination, and monitoring of primary health care services; and (2... 42 Public Health 4 2013-10-01 2013-10-01 false Primary care case management services. 440.168...

  12. Impact of the California breast density law on primary care physicians.

    PubMed

    Khong, Kathleen A; Hargreaves, Jonathan; Aminololama-Shakeri, Shadi; Lindfors, Karen K

    2015-03-01

    To investigate primary physician awareness of the California Breast Density Notification Law and its impact on primary care practice. An online survey was distributed to 174 physicians within a single primary care network system 10 months after California's breast density notification law took effect. The survey assessed physicians' awareness of the law, perceived changes in patient levels of concern about breast density, and physician comfort levels in handling breast density management issues. The survey was completed by 77 physicians (45%). Roughly half of those surveyed (49%) reported no knowledge of the breast density notification legislation. Only 32% of respondents noted an increase in patient levels of concern about breast density compared to prior years. The majority were only "somewhat comfortable" (55%) or "not comfortable" (12%) with breast density questions, and almost one-third (32%) had referred patients to a breast health clinic for these discussions. A total of 75% of those surveyed would be interested in more specific education on the subject. Awareness among primary care clinicians of the California Breast Density Notification Law is low, and many do not feel comfortable answering breast density-related patient questions. Breast imagers and institutions may need to devote additional time and resources to primary physician education in order for density notification laws to have significant impact on patient care. Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.

  13. A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce?

    PubMed

    Gordon, Christopher J; Aggar, Christina; Williams, Anna M; Walker, Lynne; Willcock, Simon M; Bloomfield, Jacqueline

    2014-01-01

    This debate discusses the potential merits of a New Graduate Nurse Transition to Primary Health Care Program as an untested but potential nursing workforce development and sustainability strategy. Increasingly in Australia, health policy is focusing on the role of general practice and multidisciplinary teams in meeting the service needs of ageing populations in the community. Primary health care nurses who work in general practice are integral members of the multidisciplinary team - but this workforce is ageing and predicted to face increasing shortages in the future. At the same time, Australia is currently experiencing a surplus of and a corresponding lack of employment opportunities for new graduate nurses. This situation is likely to compound workforce shortages in the future. A national nursing workforce plan that addresses supply and demand issues of primary health care nurses is required. Innovative solutions are required to support and retain the current primary health care nursing workforce, whilst building a skilled and sustainable workforce for the future. This debate article discusses the primary health care nursing workforce dilemma currently facing policy makers in Australia and presents an argument for the potential value of a New Graduate Transition to Primary Health Care Program as a workforce development and sustainability strategy. An exploration of factors that may contribute or hinder transition program for new graduates in primary health care implementation is considered. A graduate transition program to primary health care may play an important role in addressing primary health care workforce shortages in the future. There are, however, a number of factors that need to be simultaneously addressed if a skilled and sustainable workforce for the future is to be realised. The development of a transition program to primary health care should be based on a number of core principles and be subjected to both a summative and cost

  14. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care

    PubMed Central

    Valentijn, Pim P.; Schepman, Sanneke M.; Opheij, Wilfrid; Bruijnzeels, Marc A.

    2013-01-01

    Introduction Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care. Methods The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. Results The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels. Discussion The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective. PMID:23687482

  15. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care.

    PubMed

    Valentijn, Pim P; Schepman, Sanneke M; Opheij, Wilfrid; Bruijnzeels, Marc A

    2013-01-01

    Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care. The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels. The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.

  16. Integrating nutrition services into primary care

    PubMed Central

    Crustolo, Anne Marie; Kates, Nick; Ackerman, Sari; Schamehorn, Sherri

    2005-01-01

    PROBLEM BEING ADDRESSED Nutrition services can have an important role in prevention and management of many conditions seen by family physicians, but access to these services in primary care is limited. OBJECTIVE OF PROGRAM To integrate specialized nutrition services into the offices of family physicians in Hamilton, Ont, in order to improve patient access to those services, to expand the range of problems seen in primary care, and to increase collaboration between family physicians and registered dietitians. PROGRAM DESCRIPTION Registered dietitians were integrated into the offices of 80 family physicians. In collaboration with physicians, they assessed, treated, and consulted on a variety of nutrition-related problems. A central management team coordinated the dietitians’ activities. CONCLUSION Registered dietitians can augment and complement family physicians’ activities in preventing, assessing, and treating nutrition-related problems. This model of shared care can be applied to integrating other specialized services into primary care practices. PMID:16805083

  17. Primary care patients in the emergency department: who are they? A review of the definition of the 'primary care patient' in the emergency department.

    PubMed

    Bezzina, Andrew J; Smith, Peter B; Cromwell, David; Eagar, Kathy

    2005-01-01

    To review the definition of 'primary care' and 'inappropriate' patients in ED and develop a generally acceptable working definition of a 'primary care' presentation in ED. A Medline review of articles on primary care in ED and the definitions used. A total of 34 reviewed papers contained a proposed definition or comment on the definition for potential 'primary care', 'general practice', or 'inappropriate' patients in ED. A representative definition was developed premised on the common factors in these papers: low urgency/acuity--triage categories four or five in the Australasian Triage Scale, self-referred--by definition, patients referred by general practitioner/community primary medical services are not primary care cases because a primary care service has referred them on, presenting for a new episode of care (i.e. not a planned return because planned returns are not self-referred), unlikely to be admitted (in the opinion of Emergency Nurse interviewers) or ultimately not admitted. This definition can be applied either prospectively or retrospectively, depending on the purpose. Appropriateness must be considered in light of a legitimate role for ED in primary care and the balance of resources between primary care and emergency medicine in local settings.

  18. Challenges in referral communication between VHA primary care and specialty care.

    PubMed

    Zuchowski, Jessica L; Rose, Danielle E; Hamilton, Alison B; Stockdale, Susan E; Meredith, Lisa S; Yano, Elizabeth M; Rubenstein, Lisa V; Cordasco, Kristina M

    2015-03-01

    Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. 191 VHA PCPs from one regional network were surveyed (54% response rate), and 41 VHA PCPs and primary care staff were interviewed. PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral. Primary-specialty communication is a continuing

  19. Primary care access barriers as reported by nonurgent emergency department users: implications for the US primary care infrastructure.

    PubMed

    Hefner, Jennifer L; Wexler, Randy; McAlearney, Ann Scheck

    2015-01-01

    The objective was to explore variation by insurance status in patient-reported barriers to accessing primary care. The authors fielded a brief, anonymous, voluntary survey of nonurgent emergency department (ED) visits at a large academic medical center and conducted descriptive analysis and thematic coding of 349 open-ended survey responses. The privately insured predominantly reported primary care infrastructure barriers-wait time in clinic and for an appointment, constraints related to conventional business hours, and difficulty finding a primary care provider (because of geography or lack of new patient openings). Half of those insured by Medicaid and/or Medicare also reported these infrastructure barriers. In contrast, the uninsured predominantly reported insurance, income, and transportation barriers. Given that insured nonurgent ED users frequently report infrastructure barriers, these should be the focus of patient-level interventions to reduce nonurgent ED use and of health system-level policies to enhance the capacity of the US primary care infrastructure. © 2014 by the American College of Medical Quality.

  20. Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers.

    PubMed

    Taylor, Erin Fries; Machta, Rachel M; Meyers, David S; Genevro, Janice; Peikes, Deborah N

    2013-01-01

    Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.

  1. Gaps In Primary Care And Health System Performance In Six Latin American And Caribbean Countries.

    PubMed

    Macinko, James; Guanais, Frederico C; Mullachery, Pricila; Jimenez, Geronimo

    2016-08-01

    The rapid demographic and epidemiological transitions occurring in Latin America and the Caribbean have led to high levels of noncommunicable diseases in the region. In addition to reduced risk factors for chronic conditions, a strong health system for managing chronic conditions is vital. This study assessed the extent to which populations in six Latin American and Caribbean countries receive high-quality primary care, and it examined the relationship between experiences with care and perceptions of health system performance. We applied a validated survey on access, use, and satisfaction with health care services to nationally representative samples of the populations of Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama. Respondents reported considerable gaps in the ways in which primary care is organized, financed, and delivered. Nearly half reported using the emergency department for a condition they considered treatable in a primary care setting. Reports of more primary care problems were associated with worse perceptions of health system performance and quality and less receipt of preventive care. Urgent attention to primary care performance is required as the region's population continues to age at an unprecedented rate. Project HOPE—The People-to-People Health Foundation, Inc.

  2. Behavioural health consultants in integrated primary care teams: a model for future care.

    PubMed

    Dale, Hannah; Lee, Alyssa

    2016-07-29

    Significant challenges exist within primary care services in the United Kingdom (UK). These include meeting current demand, financial pressures, an aging population and an increase in multi-morbidity. Psychological services also struggle to meet waiting time targets and to ensure increased access to psychological therapies. Innovative ways of delivering effective primary care and psychological services are needed to improve health outcomes. In this article we argue that integrated care models that incorporate behavioural health care are part of the solution, which has seldom been argued in relation to UK primary care. Integrated care involves structural and systemic changes to the delivery of services, including the co-location of multi-disciplinary primary care teams. Evidence from models of integrated primary care in the United States of America (USA) and other higher-income countries suggest that embedding continuity of care and collaborative practice within integrated care teams can be effective in improving health outcomes. The Behavioural Health Consultant (BHC) role is integral to this, working psychologically to support the team to improve collaborative working, and supporting patients to make changes to improve their health across management of long-term conditions, prevention and mental wellbeing. Patients' needs for higher-intensity interventions to enable changes in behaviour and self-management are, therefore, more fully met within primary care. The role also increases accessibility of psychological services, delivers earlier interventions and reduces stigma, since psychological staff are seen as part of the core primary care service. Although the UK has trialled a range of approaches to integrated care, these fall short of the highest level of integration. A single short pilot of integrated care in the UK showed positive results. Larger pilots with robust evaluation, as well as research trials are required. There are clearly challenges in adopting

  3. Measuring primary care organizational capacity for diabetes care coordination: the Diabetes Care Coordination Readiness Assessment.

    PubMed

    Weeks, Douglas L; Polello, Jennifer M; Hansen, Daniel T; Keeney, Benjamin J; Conrad, Douglas A

    2014-01-01

    Not all primary care clinics are prepared to implement care coordination services for chronic conditions, such as diabetes. Understanding true capacity to coordinate care is an important first-step toward establishing effective and efficient care coordination. Yet, we could identify no diabetes-specific instruments to systematically assess readiness and/or status of primary care clinics to engage in diabetes care coordination. This report describes the development and initial validation of the Diabetes Care Coordination Readiness Assessment (DCCRA), which is intended to measure primary care clinic readiness to coordinate care for adult patients with diabetes. The instrument was developed through iterative item generation within a framework of five domains of care coordination: Organizational Capacity, Care Coordination, Clinical Management, Quality Improvement, and Technical Infrastructure. Validation data was collected on 39 primary care clinics. Content validity, inter-rater reliability, internal consistency, and construct validity of the 49-item instrument were assessed. Inter-rater agreement indices per item ranged from 0.50 to 1.0. Cronbach's alpha of the entire instrument was 0.964, and for the five domain scales ranged from 0.688 to 0.961. Clinics with existing care coordinators were rated as more ready to support care coordination than clinics without care coordinators for the entire DCCRA and for each domain, supporting construct validity. As providers increasingly attempt to adopt patient-centered approaches, introduction of the DCCRA is timely and appropriate for assisting clinics with identifying gaps in provision of care coordination services. The DCCRA's strengths include promising psychometric properties. A valid measure of diabetes care coordination readiness should be useful in diabetes program evaluation, assistance with quality improvement initiatives, and measurement of patient-centered care in research.

  4. Health care provider experiences in primary care memory clinics: a phenomenological study.

    PubMed

    Sheiban, Linda; Stolee, Paul; McAiney, Carrie; Boscart, Veronique

    2018-05-19

    There is a growing need for community-based services for persons with Alzheimer's disease and related dementias (ADRD). Memory clinic (MC) teams in primary care settings have been established to provide care to people with ADRD. To consider wider adoption of these MC teams, insight is needed into the experiences of practitioners working in these models. The purpose of the current study is to explore the experiences of health care providers (HCPs) who work in primary care Memory Clinic (MC) teams to provide care to persons with Alzheimer's disease and related dementias (ADRD). This study utilized a phenomenological methodology to explore experiences of 12 HCPs in two primary care MCs. Semi-structured interviews were completed with each HCP. Interviews were recorded and transcribed verbatim. Colaizzi's steps for analyzing phenomenological data was utilized by the authors. Three themes emerged from the analysis to describe HCP experiences: supporting patients and family members during ADRD diagnosis and treatment, working in a team setting, and personal and professional rewards of caring for people with ADRD and their family members. Findings provide insight into current practices in primary care MCs and on the motivation of HCPs working with persons with ADRD.

  5. Primary prevention of chronic obstructive pulmonary disease in primary care.

    PubMed

    van der Molen, Thys; Schokker, Siebrig

    2009-12-01

    Chronic obstructive pulmonary disease (COPD) is a prevalent disease, with cigarette smoking being the main risk factor. Prevention is crucial in the fight against COPD. Whereas primary prevention is targeted on whole populations, patient populations are the focus of primary care; therefore, prevention in this setting is mainly aimed at preventing further deterioration of the disease in patients who present with the first signs of disease (secondary prevention). Prevention of COPD in primary care requires detection of COPD at an early stage. An accurate definition of COPD is crucial in this identification process. The benefits of detecting new patients with COPD should be determined before recommending screening and case-finding programs in primary care. No evidence is available that screening by spirometry results in significant health gains. Effective treatment options in patients with mild disease are lacking. Smoking cessation is the cornerstone of COPD prevention. Because cigarette smoking is not only a major cause of COPD but is also a major cause of many other diseases, a decline in tobacco smoking would result in substantial health benefits.

  6. Occupational Therapy and Primary Care: Updates and Trends

    PubMed Central

    Mroz, Tracy M.; Fogelberg, Donald J.; Leland, Natalie E.

    2018-01-01

    As our health care system continues to change, so do the opportunities for occupational therapy. This article provides an update to a 2012 Health Policy Perspectives on this topic. We identify new initiatives and opportunities in primary care, explore common challenges to integrating occupational therapy in primary care environments, and highlight international works that can support our efforts. We conclude by discussing next steps for occupational therapy practitioners in order to continue to progress our efforts in primary care. PMID:29689169

  7. Management of Simple Clavicle Fractures by Primary Care Physicians.

    PubMed

    Stepanyan, Hayk; Gendelberg, David; Hennrikus, William

    2017-05-01

    The clavicle is the most commonly fractured bone. Children with simple fractures are often referred to orthopedic surgeons by primary care physician to ensure adequate care. The objective of this study was to show that simple clavicle fractures have excellent outcomes and are within the scope of primary care physician's practice. We performed a retrospective chart review of 16 adolescents with simple clavicle fractures treated with a sling. Primary outcomes were bony union, pain, and function. The patients with simple clavicle fractures had excellent outcomes with no complications or complaints of pain or restriction of their activities of daily living. The outcomes are similar whether treated by an orthopedic surgeon or a primary care physician. The cost to society and the patient is less when the primary care physician manages the fracture. Therefore, primary care physicians should manage simple clavicle fractures.

  8. Ethical quandaries in caring for primary-care patients with chronic pain.

    PubMed

    Robinson, Patricia J; Rickard, Julie A

    2013-03-01

    In the past decade, more and more behavioral health providers have begun consultation practices in primary-care settings. Their availability makes multidisciplinary care a reality and the possibility of improved outcomes for patients with chronic pain more feasible. However, behavioral health providers encounter new ethical quandaries in providing services to patients with chronic pain and to the primary-care providers who plan their treatment. This article presents two cases to illustrate the questions that arise in delivery of primary-care behavioral health services to patients with chronic pain. Relevant professional ethical guidelines for psychologists, social workers, and physicians are examined and recommendations for addressing the gaps in extant guides are offered. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

  9. Fibromyalgia: management strategies for primary care providers.

    PubMed

    Arnold, L M; Gebke, K B; Choy, E H S

    2016-02-01

    Fibromyalgia (FM), a chronic disorder defined by widespread pain, often accompanied by fatigue and sleep disturbance, affects up to one in 20 patients in primary care. Although most patients with FM are managed in primary care, diagnosis and treatment continue to present a challenge, and patients are often referred to specialists. Furthermore, the lack of a clear patient pathway often results in patients being passed from specialist to specialist, exhaustive investigations, prescription of multiple drugs to treat different symptoms, delays in diagnosis, increased disability and increased healthcare resource utilisation. We will discuss the current and evolving understanding of FM, and recommend improvements in the management and treatment of FM, highlighting the role of the primary care physician, and the place of the medical home in FM management. We reviewed the epidemiology, pathophysiology and management of FM by searching PubMed and references from relevant articles, and selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements. The implementation of a framework for chronic pain management in primary care would limit unnecessary, time-consuming, and costly tests, reduce diagnostic delay and improve patient outcomes. The patient-centred medical home (PCMH), a management framework that has been successfully implemented in other chronic diseases, might improve the care of patients with FM in primary care, by bringing together a team of professionals with a range of skills and training. Although there remain several barriers to overcome, implementation of a PCMH would allow patients with FM, like those with other chronic conditions, to be successfully managed in the primary care setting. © 2016 John Wiley & Sons Ltd.

  10. The association between the supply of primary care physicians and population health outcomes in Korea.

    PubMed

    Lee, Juhyun; Park, Sangmin; Choi, Kyunghyun; Kwon, Soon-Man

    2010-10-01

    Several studies reported that primary care improves health outcomes for populations. The objective of this study was to examine the relationship between the supply of primary care physicians and population health outcomes in Korea. Data were extracted from the 2007 report of the Health Insurance Review, the 2005 report from the Korean National Statistical Office, and the 2008 Korean Community Health Survey. The dependent variables were age-adjusted all-cause and disease-specific mortality rates, and independent variables were the supply of primary care physicians, the ratio of primary care physicians to specialists, the number of beds, socioeconomic factors (unemployment rate, local tax, education), population (population size, proportion of the elderly over age 65), and health behaviors (smoking, exercise, using seat belts rates). We used multivariate linear regression as well as ANOVA and t tests. A higher number of primary care physicians was associated with lower all-cause mortality, cancer mortality, and cardiovascular mortality. However, the ratio of primary care physicians to specialists was not related to all-cause mortality. In addition, the relationship between socioeconomic variables and mortality rates was similar in strength to the relationship between the supply of primary care physicians and mortality rates. Accident mortality, suicide mortality, infection mortality, and perinatal mortality were not related to the supply of primary care physicians. The supply of primary care physicians is associated with improved health outcomes, especially in chronic diseases and cancer. However, other variables such as the socioeconomic factors and population factors seem to have a more significant influence on these outcomes.

  11. From managing access to managing care: the impact of primary care on health care delivery organizations.

    PubMed

    Hickey, M E

    1995-10-01

    Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article.

  12. Advancing the Science of Implementation in Primary Health Care.

    PubMed

    Bazemore, Andrew; Neale, Anne Victoria; Lupo, Phillip; Seehusen, Dean

    2018-01-01

    Implementation Science is commonly described as the study of methods and approaches that promote the uptake and use of evidence-based interventions into routine practice and policymaking. In this issue of JABFM , investigators share a wealth of new insights from the frontlines of Implementation Science in primary care: what it is, how we are doing it, and how it is advancing the evidence base of primary care. The breadth of implementation science in primary care is affirmed by the range of topics covered, from thought leader recommendations on future directions for the field, to reports on how best practices in policy and practice are shaping primary care implementation in the United States and Canada. There are also important updates on agents of primary care implementation themselves, such as practice facilitators, geriatric care teams, and family physicians interested in providing obstetric care. Other articles report on novel practice transformation efforts that advance health promotion and disease prevention, and innovative approaches to identifying and addressing social determinants of health in primary care practices and the communities they serve. The articles seem to generate as many new questions as they answer, and highlight the need for continued emphasis on advancing the science of implementation in primary health care. © Copyright 2018 by the American Board of Family Medicine.

  13. Primary care and communication in shared cancer care: A Qualitative Study

    PubMed Central

    Sada, Yvonne; Street, Richard L.; Singh, Hardeep; Shada, Rachel; Naik, Aanand D.

    2013-01-01

    Objective To explore perceptions of primary care physicians’ (PCPs) and oncologists’ roles, responsibilities, and patterns of communication related to shared cancer care in three integrated health systems that used electronic health records (EHRs). Study design Qualitative study. Methods We conducted semi-structured interviews with ten early stage colorectal cancer patients and fourteen oncologists and PCPs. Sample sizes were determined by thematic saturation. Dominant themes and codes were identified and subsequently applied to all transcripts. Results Physicians reported that EHRs improved communication within integrated systems, but communication with physicians outside their system was still difficult. PCPs expressed uncertainty about their role during cancer care, even though medical oncologists emphasized the importance of co-morbidity control during cancer treatment. Both patients and physicians described additional roles for PCPs, including psychological distress support and behavior modification. Conclusions Integrated systems that use EHRs likely facilitate shared cancer care through improved PCP-oncologist communication. However, strategies to facilitate a more active role for PCPs in managing co-morbidities, psychological distress and behavior modification, as well as to overcome communication challenges between physicians not practicing within the same integrated system, are still needed to improve shared cancer care. PMID:21615196

  14. [Quality Indicators of Primary Health Care Facilities in Austria].

    PubMed

    Semlitsch, Thomas; Abuzahra, Muna; Stigler, Florian; Jeitler, Klaus; Posch, Nicole; Siebenhofer, Andrea

    2017-07-11

    Background The strengthening of primary health care is one major goal of the current national health reform in Austria. In this context, a new interdisciplinary concept was developed in 2014 that defines structures and requirements for future primary health care facilities. Objective The aim of this project was the development of quality indicators for the evaluation of the scheduled primary health care facilities in Austria, which are in accordance with the new Austrian concept. Methods We used the RAND/NPCRDC method for the development and selection of the quality indicators. We conducted systematic literature searches for existing measures in international databases for quality indicators as well as in bibliographic databases. All retrieved measures were evaluated and rated by an expert panel in a 2-step process regarding relevance and feasibility. Results Overall, the literature searches yielded 281 potentially relevant quality indicators, which were summarized to 65 different quality measures for primary health care. Out of these, the panel rated and accepted 30 measures as relevant and feasible for use in Austria. Five of these indicators were structure measures, 14 were process measures and the remaining 11 were outcome measures. Based on the Austrian primary health care concept, the final set of quality indicators was grouped in the 5 following domains: Access to primary health care (5), quality of care (15), continuity of care (5), coordination of care (4), and safety (1). Conclusion This set of quality measures largely covers the four defined functions of primary health care. It enables standardized evaluation of primary health care facilities in Austria regarding the implementation of the Austrian primary health care concept as well as improvement in healthcare of the population. © Georg Thieme Verlag KG Stuttgart · New York.

  15. Spirometry in primary care

    PubMed Central

    Coates, Allan L; Graham, Brian L; McFadden, Robin G; McParland, Colm; Moosa, Dilshad; Provencher, Steeve; Road, Jeremy

    2013-01-01

    Canadian Thoracic Society (CTS) clinical guidelines for asthma and chronic obstructive pulmonary disease (COPD) specify that spirometry should be used to diagnose these diseases. Given the burden of asthma and COPD, most people with these diseases will be diagnosed in the primary care setting. The present CTS position statement was developed to provide guidance on key factors affecting the quality of spirometry testing in the primary care setting. The present statement may also be used to inform and guide the accreditation process for spirometry in each province. Although many of the principles discussed are equally applicable to pulmonary function laboratories and interpretation of tests by respirologists, they are held to a higher standard and are outside the scope of the present statement. PMID:23457669

  16. The Empirical Foundations of Telemedicine Interventions in Primary Care.

    PubMed

    Bashshur, Rashid L; Howell, Joel D; Krupinski, Elizabeth A; Harms, Kathryn M; Bashshur, Noura; Doarn, Charles R

    2016-05-01

    This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world. The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost. The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective. Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral component of primary care around the world.

  17. The Empirical Foundations of Telemedicine Interventions in Primary Care

    PubMed Central

    Howell, Joel D.; Krupinski, Elizabeth A.; Harms, Kathryn M.; Bashshur, Noura; Doarn, Charles R.

    2016-01-01

    Abstract Introduction: This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world. Materials and Methods: The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost. Results: The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective. Conclusions: Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral

  18. The 10 building blocks of high-performing primary care.

    PubMed

    Bodenheimer, Thomas; Ghorob, Amireh; Willard-Grace, Rachel; Grumbach, Kevin

    2014-01-01

    Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements-engaged leadership, data-driven improvement, empanelment, and team-based care-that assist the implementation of the other 6 building blocks-patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.

  19. [Increasing participation of primary care in the management of people with human immunodeficiency virus: hospital care professionals express their views].

    PubMed

    Ortega López, Angela; Morales Asencio, José Miguel; Rengel Díaz, Cristóbal; Peñas Cárdenas, Eloísa María; González Rodríguez, María José; Prado de la Sierra, Rut

    2014-04-01

    To determine the opinions of infectious diseases professionals on the possibilities of monitoring patients with HIV in Primary Care. Qualitative study using in-depth interviews. Infectious Diseases Unit in the University Hospital "Virgen de la Victoria" in Málaga. Health professionals with more than one year experience working in infectious diseases. A total of 25 respondents: 5 doctors, 15 nurses and 5 nursing assistants. Convenience sample. Semi-structured interviews were used that were later transcribed verbatim. Content analysis was performed according to the Taylor and Bogdan approach with computer support. Validation of information was made through additional analysis, expert participation, and feedback of part of the results to the participants. Hospital care professionals considered the disease-related complexity of HIV, treatment and social aspects that may have an effect on the organizational level of care. Professionals highlighted the benefits of specialized care, although opinions differed between doctors and nurses as regards follow up in Primary Care. Some concerns emerged about the level of training, confidentiality and workload in Primary Care, although they mentioned potential advantages related to accessibility of patients. Physicians perceive difficulties in following up HIV patients in Primary Care, even for those patients with a good control of their disease. Nurses and nursing assistants are more open to this possibility due to the proximity to home and health promotion in Primary Care. Copyright © 2013 Elsevier España, S.L. All rights reserved.

  20. Health care reform and care at the behavioral health--primary care interface.

    PubMed

    Druss, Benjamin G; Mauer, Barbara J

    2010-11-01

    The historic passage of the Patient Protection and Affordable Care Act in March 2010 offers the potential to address long-standing deficits in quality and integration of services at the interface between behavioral health and primary care. Many of the efforts to reform the care delivery system will come in the form of demonstration projects, which, if successful, will become models for the broader health system. This article reviews two of the programs that might have a particular impact on care on the two sides of that interface: Medicaid and Medicare patient-centered medical home demonstration projects and expansion of a Substance Abuse and Mental Health Services Administration program that colocates primary care services in community mental health settings. The authors provide an overview of key supporting factors, including new financing mechanisms, quality assessment metrics, information technology infrastructure, and technical support, that will be important for ensuring that initiatives achieve their potential for improving care.

  1. [Differences and similarities of primary care in the German and Spanish health care systems].

    PubMed

    Salvador Comino, María Rosa; Krane, Sibylla; Schelling, Jörg; Regife García, Víctor

    2016-02-01

    An efficient primary care is of particular importance for any countries' health care system. Many differences exist on how distinctive countries try to obtain the goal of an efficient, cost-effective primary care for its population. In this article we conducted a selective literature review, which includes both scientific and socio-political publications. The findings are complemented with the experience of a Spanish physician from Seville in her last year of training in family medicine, who completed a four months long rotation in the German health care system. We highlighted different features by comparing both countries, including their health care expenditure, the relation between primary and secondary care, the organization in the academic field and the training of future primary care physicians. It is clear that primary care in both countries plays a central role, have to deal with shortcomings, and in some points one system can learn from the other. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

  2. Rural health care bypass behavior: how community and spatial characteristics affect primary health care selection.

    PubMed

    Sanders, Scott R; Erickson, Lance D; Call, Vaughn R A; McKnight, Matthew L; Hedges, Dawson W

    2015-01-01

    (1) To assess the prevalence of rural primary care physician (PCP) bypass, a behavior in which residents travel farther than necessary to obtain health care, (2) To examine the role of community and non-health-care-related characteristics on bypass behavior, and (3) To analyze spatial bypass patterns to determine which rural communities are most affected by bypass. Data came from the Montana Health Matters survey, which gathered self-reported information from Montana residents on their health care utilization, satisfaction with health care services, and community and demographic characteristics. Logistic regression and spatial analysis were used to examine the probability and spatial patterns of bypass. Overall, 39% of respondents bypass local health care. Similar to previous studies, dissatisfaction with local health care was found to increase the likelihood of bypass. Dissatisfaction with local shopping also increases the likelihood of bypass, while the number of friends in a community, and commonality with community reduce the likelihood of bypass. Other significant factors associated with bypass include age, income, health, and living in a highly rural community or one with high commuting flows. Our results suggest that outshopping theory, in which patients bundle services and shopping for added convenience, extends to primary health care selection. This implies that rural health care selection is multifaceted, and that in addition to perceived satisfaction with local health care, the quality of local shopping and levels of community attachment also influence bypass behavior. © 2014 National Rural Health Association.

  3. Care guides: an examination of occupational conflict and role relationships in primary care.

    PubMed

    Wholey, Douglas R; White, Katie M; Adair, Richard; Christianson, Jon B; Lee, Suhna; Elumba, Deborah

    2013-01-01

    Improving the efficiency and effectiveness of primary care treatment of patients with chronic illness is an important goal in reforming the U.S. health care system. Reducing occupational conflicts and creating interdependent primary care teams is crucial for the effective functioning of new models being developed to reorganize chronic care. Occupational conflict, role interdependence, and resistance to change in a proof-of-concept pilot test of one such model that uses a new kind of employee in the primary care office, a "care guide," were analyzed. Care guides are lay individuals who help chronic disease patients and their providers achieve standard health goals. The aim of this study was to examine the development of occupational boundaries, interdependence of care guides and primary care team members, and acceptance by clinic employees of this new kind of health worker. A mixed methods, pilot study was conducted using qualitative analysis; clinic, provider, and patient surveys; administrative data; and multivariate analysis. Qualitative analysis examined the emergence of the care guide role. Administrative data and surveys were used to examine patterns of interdependence between care guides, physicians, team members, and clinic staff; obtain physician evaluations of the care guide role; and evaluate the effect of care guides on patient perceptions of care coordination and follow-up. Evaluation of implementation of the care guide model showed that (a) the care guide scope of practice was clearly defined; (b) interdependent relationships between care guides and providers were formed; (c) relational triads consisting of patient, care guide, and physician were created; (d) patients and providers were supported in managing chronic disease; and (e) resistance to this model among traditional employees was minimized. The feasibility of implementing a new care model for chronic disease management in the primary care setting, identifying factors associated with a positive

  4. Primary care physician workforce and Medicare beneficiaries' health outcomes.

    PubMed

    Chang, Chiang-Hua; Stukel, Therese A; Flood, Ann Barry; Goodman, David C

    2011-05-25

    Despite a widespread interest in increasing the numbers of primary care physicians to improve care and to moderate costs, the relationship of the primary care physician workforce to patient-level outcomes remains poorly understood. To measure the association between the adult primary care physician workforce and individual patient outcomes. A cross-sectional analysis of the outcomes of a 2007 20% sample of fee-for-service Medicare beneficiaries aged 65 years or older (N = 5,132,936), which used 2 measures of adult primary care physicians (general internists and family physicians) across Primary Care Service Areas (N = 6542): (1) American Medical Association (AMA) Masterfile nonfederal, office-based physicians per total population and (2) office-based primary care clinical full-time equivalents (FTEs) per Medicare beneficiary derived from Medicare claims. Annual individual-level outcomes (mortality, ambulatory care sensitive condition [ACSC] hospitalizations, and Medicare program spending), adjusted for individual patient characteristics and geographic area variables. Marked variation was observed in the primary care physician workforce across areas, but low correlation was observed between the 2 primary care workforce measures (Spearman r = 0.056; P < .001). Compared with areas with the lowest quintile of primary care physician measure using AMA Masterfile counts, beneficiaries in the highest quintile had fewer ACSC hospitalizations (74.90 vs 79.61 per 1000 beneficiaries; relative rate [RR], 0.94; 95% confidence interval [CI], 0.93-0.95), lower mortality (5.38 vs 5.47 per 100 beneficiaries; RR, 0.98; 95% CI, 0.97-0.997), and no significant difference in total Medicare spending ($8722 vs $8765 per beneficiary; RR, 1.00; 95% CI, 0.99-1.00). Beneficiaries residing in areas with the highest quintile of primary care clinician FTEs compared with those in the lowest quintile had lower mortality (5.19 vs 5.49 per 100 beneficiaries; RR, 0.95; 95% CI, 0.93-0.96), fewer ACSC

  5. Racial/Ethnic Disparities in Primary Care Quality Among Type 2 Diabetes Patients, Medical Expenditure Panel Survey, 2012.

    PubMed

    Hu, Ruwei; Shi, Leiyu; Liang, Hailun; Haile, Geraldine Pierre; Lee, De-Chih

    2016-08-04

    Racial and ethnic disparities exist in diabetes prevalence, access to diabetes care, diabetes-related complications and mortality rates, and the quality of diabetes care among Americans. We explored racial and ethnic disparities in primary care quality among Americans with type 2 diabetes. We analyzed data on adults with type 2 diabetes derived from the household component of the 2012 Medical Expenditure Panel Survey. Multiple regression and multivariate logistic regressions were used to examine the association between race/ethnicity and primary care attributes related to first contact, longitudinality, comprehensiveness, and coordination, and clusters of confounding factors were added sequentially. Preliminary findings indicated differences in primary care quality between racial/ethnic minorities and whites across measures of first contact, longitudinality, comprehensiveness, and coordination. After controlling for confounding factors, these differences were no longer apparent; all racial/ethnic categories showed similar rates of primary care quality according to the 4 primary care domains of interest in the study. Results indicate equitable primary care quality for type 2 diabetes patients across 4 key domains of primary care after controlling for socioeconomic characteristics. Additional research is necessary to support these findings, particularly when considering smaller racial/ethnic groups and investigating outcomes related to diabetes.

  6. Primary health care reform, dilemmatic space and risk of burnout among health workers.

    PubMed

    Freeman, Toby; Baum, Fran; Labonté, Ronald; Javanparast, Sara; Lawless, Angela

    2018-05-01

    Health system changes may increase primary health care workers' dilemmatic space, created when reforms contravene professional values. Dilemmatic space may be a risk factor for burnout. This study partnered with six Australian primary health care services (in South Australia: four state government-managed services including one Aboriginal health team and one non-government organisation and in Northern Territory: one Aboriginal community-controlled service) during a period of change and examined workers' dilemmatic space and incidence of burnout. Dilemmatic space and burnout were assessed in a survey of 130 staff across the six services (58% response rate). Additionally, 63 interviews were conducted with practitioners, managers, regional executives and health department staff. Dilemmatic space occurred across all services and was associated with higher rates of self-reported burnout. Three conditions associated with dilemmatic space were (1) conditions inherent in comprehensive primary health care, (2) stemming from service provision for Aboriginal and Torres Strait Islander peoples and (3) changes wrought by reorientation to selective primary health care in South Australia. Responses to dilemmatic space included ignoring directives or doing work 'under the radar', undertaking alternative work congruent with primary health care values outside of hours, or leaving the organisation. The findings show that comprehensive primary health care was contested and political. Future health reform processes would benefit from considering alignment of changes with staff values to reduce negative effects of the reform and safeguard worker wellbeing.

  7. Identification of major cardiovascular events in patients with diabetes using primary care data.

    PubMed

    Pouwels, Koen Bernardus; Voorham, Jaco; Hak, Eelko; Denig, Petra

    2016-04-02

    Routine primary care data are increasingly being used for evaluation and research purposes but there are concerns about the completeness and accuracy of diagnoses and events captured in such databases. We evaluated how well patients with major cardiovascular disease (CVD) can be identified using primary care morbidity data and drug prescriptions. The study was conducted using data from 17,230 diabetes patients of the GIANTT database and Dutch Hospital Data register. To estimate the accuracy of the different measures, we analyzed the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) relative to hospitalizations and/or records with a diagnosis indicating major CVD, including ischaemic heart diseases and cerebrovascular events. Using primary care morbidity data, 43% of major CVD hospitalizations could be identified. Adding drug prescriptions to the search increased the sensitivity up to 94%. A proxy of at least one prescription of either a platelet aggregation inhibitor, vitamin k antagonist or nitrate could identify 85% of patients with a history of major CVD recorded in primary care, with an NPV of 97%. Using the same proxy, 57% of incident major CVD recorded in primary or hospital care could be identified, with an NPV of 99%. A substantial proportion of major CVD hospitalizations was not recorded in primary care morbidity data. Drug prescriptions can be used in addition to diagnosis codes to identify more patients with major CVD, and also to identify patients without a history of major CVD.

  8. Nursing contributions to chronic disease management in primary care.

    PubMed

    Lukewich, Julia; Edge, Dana S; VanDenKerkhof, Elizabeth; Tranmer, Joan

    2014-02-01

    As the prevalence of chronic diseases continues to increase, emphasis is being placed on the development of primary care strategies that enhance healthcare delivery. Innovations include interprofessional healthcare teams and chronic disease management strategies. To determine the roles of nurses working in primary care settings in Ontario and the extent to which chronic disease management strategies have been implemented. We conducted a cross-sectional survey of a random sample of primary care nurses, including registered practical nurses, registered nurses, and nurse practitioners, in Ontario between May and July 2011. Nurses in primary care reported engaging in chronic disease management activities but to different extents depending on their regulatory designation (licensure category). Chronic disease management strategy implementation was not uniform across primary care practices where the nurses worked. There is the potential to optimize and standardize the nursing role within primary care and improve the implementation of chronic disease management strategies.

  9. A national evaluation of homeless and nonhomeless veterans' experiences with primary care.

    PubMed

    Jones, Audrey L; Hausmann, Leslie R M; Haas, Gretchen L; Mor, Maria K; Cashy, John P; Schaefer, James H; Gordon, Adam J

    2017-05-01

    Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

  10. Teaching Primary Health Care: An Interdisciplinary Approach.

    ERIC Educational Resources Information Center

    Bezzina, Paul; Keogh, Johann J.; Keogh, Mariana

    1998-01-01

    Nursing and radiology students (n=15) at the University of Malta who completed an interdisciplinary module on primary health care reported they found the theoretical material applicable to practice; the module enabled them to learn about their potential role in primary health care. (SK)

  11. Which features of primary care affect unscheduled secondary care use? A systematic review

    PubMed Central

    Huntley, Alyson; Lasserson, Daniel; Wye, Lesley; Morris, Richard; Checkland, Kath; England, Helen; Salisbury, Chris; Purdy, Sarah

    2014-01-01

    Objectives To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. Setting Observational studies at primary care practice level. Participants Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. Primary and secondary outcome measures The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. Results 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. Conclusions The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions. PMID:24860000

  12. Across the divide: "Primary care departments working together to redesign care to achieve the Triple Aim".

    PubMed

    Koslov, Steven; Trowbridge, Elizabeth; Kamnetz, Sandra; Kraft, Sally; Grossman, Jeffrey; Pandhi, Nancy

    2016-09-01

    Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim. As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing. Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability. Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes. The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation. Copyright © 2015 Elsevier Inc. All rights reserved.

  13. Comparing homeless persons' care experiences in tailored versus nontailored primary care programs.

    PubMed

    Kertesz, Stefan G; Holt, Cheryl L; Steward, Jocelyn L; Jones, Richard N; Roth, David L; Stringfellow, Erin; Gordon, Adam J; Kim, Theresa W; Austin, Erika L; Henry, Stephen Randal; Kay Johnson, N; Shanette Granstaff, U; O'Connell, James J; Golden, Joya F; Young, Alexander S; Davis, Lori L; Pollio, David E

    2013-12-01

    We compared homeless patients' experiences of care in health care organizations that differed in their degree of primary care design service tailoring. We surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the "Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients. Mean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient-clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient-clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results. Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness.

  14. Provision of mental health care within primary care in Peru: A qualitative study exploring the perspectives of psychologists, primary health care providers, and patients

    PubMed Central

    Cavero, Victoria; Diez-Canseco, Francisco; Toyama, Mauricio; Flórez Salcedo, Gustavo; Ipince, Alessandra; Araya, Ricardo; Miranda, J. Jaime

    2018-01-01

    Background: This study aimed to understand the offer of mental health care at the primary care level, collecting the views of psychologists, primary health care providers (PHCPs), and patients, with a focus on health services in which patients attend regularly and who present a higher prevalence of mental disorders. Methods: A qualitative study was conducted in antenatal care, tuberculosis, HIV/AIDS, and chronic diseases services from six primary health care centers. Semi-structured interviews were conducted with psychologists, PHCPs, and patients working in or attending the selected facilities.  Results: A total of 4 psychologists, 22 PHCPs, and 37 patients were interviewed. A high perceived need for mental health care was noted. PHCPs acknowledged the emotional impact physical health conditions have on their patients and mentioned that referral to psychologists was reserved only for serious problems. Their approach to emotional problems was providing emotional support (includes listening, talk about their patients’ feelings, provide advice). PHCPs identified system-level barriers about the specialized mental health care, including a shortage of psychologists and an overwhelming demand, which results in brief consultations and lack in continuity of care. Psychologists focus their work on individual consultations; however, consultations were brief, did not follow a standardized model of care, and most patients attend only once. Psychologists also mentioned the lack of collaborative work among other healthcare providers. Despite these limitations, interviewed patients declared that they were willing to seek specialized care if advised and considered the psychologist's care provided as helpful; however, they recognized the stigmatization related to seeking mental health care. Conclusions: There is a perceived need of mental health care for primary care patients. To attend these needs, PHCPs provide emotional support and refer to psychology the most severe cases

  15. [Analysis of the influence of the process of care in primary health care on avoidable hospitalizations for heart failure].

    PubMed

    del Saz Moreno, Vicente; Alberquilla Menéndez-Asenjo, Ángel; Camacho Hernández, Ana M; Lora Pablos, David; Enríquez de Salamanca Lorente, Rafael; Magán Tapia, Purificación

    2016-02-01

    To determine if the process of care in primary health, affects the risk of avoidable hospitalizations for ambulatory care sensitive conditions (ACSH) for heart failure (HF). Case-control study analyzing the risk of hospitalization for HF. The exposure factor was the process of care for HF in primary health. Health area of the region of Madrid (n=466.901). There were included all adult patients (14 years or older) with a documented diagnosis of HF in the electronic medical record of primary health (n=3.277). The cases were patients who were hospitalized for HF while the controls did not require admission, during 2007. risk of ACSH for HF related to the process of care considered both overall and for each separate standard of appropiate care. Differences in clinical complexity of the groups were measured using the Adjusted Clinical Group (ACG) classification system. 227 cases and 3.050 controls. Clinical complexity was greater in cases. The standards of appropriate care were met to a greater degree in the control group, but none of the two groups met all the standards that would define a process of care as fully appropriate. A significantly lower risk of ACSH was seen for only two standards of appropriate care. For each additional standard of appropriate care not met, the probability of admission was significantly greater (OR: 1,33, 95% CI: 1,19-1,49). Higher quality in the process of care in primary health was associated with a lower risk of hospitalization for HF. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.

  16. Effectiveness and cost effectiveness of counselling in primary care.

    PubMed

    Bower, P; Rowland, N

    2006-07-19

    The prevalence of mental health and psychosocial problems in primary care is high. This review examines the clinical and cost-effectiveness of psychological therapies provided in primary care by counsellors. To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials for patients with psychological and psychosocial problems considered suitable for counselling. To update the review, the following electronic databases were searched on 25-10-2005: MEDLINE, EMBASE, PsycLIT, CINAHL, the Cochrane Controlled Trials register and the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers. All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2005 were included in the review. Data were extracted using a standardised data extraction sheet. Trials were rated for quality using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. Eight trials were included in the review. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials). Levels of satisfaction

  17. Access to primary health care services for Indigenous peoples: A framework synthesis.

    PubMed

    Davy, Carol; Harfield, Stephen; McArthur, Alexa; Munn, Zachary; Brown, Alex

    2016-09-30

    Indigenous peoples often find it difficult to access appropriate mainstream primary health care services. Securing access to primary health care services requires more than just services that are situated within easy reach. Ensuring the accessibility of health care for Indigenous peoples who are often faced with a vast array of additional barriers including experiences of discrimination and racism, can be complex. This framework synthesis aimed to identify issues that hindered Indigenous peoples from accessing primary health care and then explore how, if at all, these were addressed by Indigenous health care services. To be included in this framework synthesis papers must have presented findings focused on access to (factors relating to Indigenous peoples, their families and their communities) or accessibility of Indigenous primary health care services. Findings were imported into NVivo and a framework analysis undertaken whereby findings were coded to and then thematically analysed using Levesque and colleague's accessibility framework. Issues relating to the cultural and social determinants of health such as unemployment and low levels of education influenced whether Indigenous patients, their families and communities were able to access health care. Indigenous health care services addressed these issues in a number of ways including the provision of transport to and from appointments, a reduction in health care costs for people on low incomes and close consultation with, if not the direct involvement of, community members in identifying and then addressing health care needs. Indigenous health care services appear to be best placed to overcome both the social and cultural determinants of health which hamper Indigenous peoples from accessing health care. Findings of this synthesis also suggest that Levesque and colleague's accessibility framework should be broadened to include factors related to the health care system such as funding.

  18. A literature review: polypharmacy protocol for primary care.

    PubMed

    Skinner, Mary

    2015-01-01

    The purpose of this literature review is to critically evaluate published protocols on polypharmacy in adults ages 65 and older that are currently used in primary care settings that may potentially lead to fewer adverse drug events. A review of OVID, CINAHL, EBSCO, Cochrane Library, Medline, and PubMed databases was completed using the following key words: protocol, guideline, geriatrics, elderly, older adult, polypharmacy, and primary care. Inclusion criteria were: articles in medical, nursing, and pharmacology journals with an intervention, protocol, or guideline addressing polypharmacy that lead to fewer adverse drug events. Qualitative and quantitative studies were included. Exclusion criteria were: publications prior to the year 1992. A gap exists in the literature. No standardized protocol for addressing polypharmacy in the primary care setting was found. Mnemonics, algorithms, clinical practice guidelines, and clinical strategies for addressing polypharmacy in a variety of health care settings were found throughout the literature. Several screening instruments for use in primary care to assess potentially inappropriate prescription of medications in the elderly, such as the Beers Criteria and the STOPP screening tool, were identified. However, these screening instruments were not included in a standardized protocol to manage polypharmacy in primary care. Polypharmacy in the elderly is a critical problem that may result in adverse drug events such as falls, hospitalizations, and increased expenditures for both the patient and the health care system. No standardized protocols to address polypharmacy specific to the primary care setting were identified in this review of the literature. Given the growing population of elderly in this country and the high number of medications they consume, it is critical to focus on the utilization of a standardized protocol to address the potential harm of polypharmacy in the primary care setting and evaluate its effects on

  19. Environmental factors associated with primary care access among urban older adults.

    PubMed

    Ryvicker, Miriam; Gallo, William T; Fahs, Marianne C

    2012-09-01

    Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors - in particular, the primary care infrastructure - inform older adults' primary care use. Using geographic data on primary care physician supply and surveys from 1260 senior center attendees in New York City, we examined factors that facilitate and hinder primary care use for individuals living in service areas with different supply levels. Supply quartiles varied in primary care use (visit within the past 12 months), racial and socio-economic composition, and perceived neighborhood safety and social cohesion. Primary care use did not differ significantly after controlling for compositional factors. Individuals who used a community clinic or hospital outpatient department for most of their care were less likely to have had a primary care visit than those who used a private doctor's office. Stratified multivariate models showed that within the lowest-supply quartile, public transit users had a higher odds of primary care use than non-transit users. Moreover, a higher score on the perceived neighborhood social cohesion scale was associated with a higher odds of primary care use. Within the second-lowest quartile, nonwhites had a lower odds of primary care use compared to whites. Different patterns of disadvantage in primary care access exist that may be associated with - but not fully explained by - local primary care supply. In lower-supply areas, racial disparities and inadequate primary care infrastructure hinder access to care. However, accessibility and elder-friendliness of public transit, as well as efforts to improve social cohesion and support, may facilitate primary care access for individuals living in low-supply areas. Copyright © 2012 Elsevier Ltd. All rights reserved.

  20. The 10 Building Blocks of High-Performing Primary Care

    PubMed Central

    Bodenheimer, Thomas; Ghorob, Amireh; Willard-Grace, Rachel; Grumbach, Kevin

    2014-01-01

    Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements—engaged leadership, data-driven improvement, empanelment, and team-based care—that assist the implementation of the other 6 building blocks—patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement. PMID:24615313

  1. Practical Approaches for Achieving Integrated Behavioral Health Care in Primary Care Settings

    PubMed Central

    Ratzliff, Anna; Phillips, Kathryn E.; Sugarman, Jonathan R.; Unützer, Jürgen; Wagner, Edward H.

    2016-01-01

    Behavioral health problems are common, yet most patients do not receive effective treatment in primary care settings. Despite availability of effective models for integrating behavioral health care in primary care settings, uptake has been slow. The Behavioral Health Integration Implementation Guide provides practical guidance for adapting and implementing effective integrated behavioral health care into patient-centered medical homes. The authors gathered input from stakeholders involved in behavioral health integration efforts: safety net providers, subject matter experts in primary care and behavioral health, a behavioral health patient and peer specialist, and state and national policy makers. Stakeholder input informed development of the Behavioral Health Integration Implementation Guide and the GROW Pathway Planning Worksheet. The Behavioral Health Integration Implementation Guide is model neutral and allows organizations to take meaningful steps toward providing integrated care that achieves access and accountability. PMID:26698163

  2. Practical Approaches for Achieving Integrated Behavioral Health Care in Primary Care Settings.

    PubMed

    Ratzliff, Anna; Phillips, Kathryn E; Sugarman, Jonathan R; Unützer, Jürgen; Wagner, Edward H

    Behavioral health problems are common, yet most patients do not receive effective treatment in primary care settings. Despite availability of effective models for integrating behavioral health care in primary care settings, uptake has been slow. The Behavioral Health Integration Implementation Guide provides practical guidance for adapting and implementing effective integrated behavioral health care into patient-centered medical homes. The authors gathered input from stakeholders involved in behavioral health integration efforts: safety net providers, subject matter experts in primary care and behavioral health, a behavioral health patient and peer specialist, and state and national policy makers. Stakeholder input informed development of the Behavioral Health Integration Implementation Guide and the GROW Pathway Planning Worksheet. The Behavioral Health Integration Implementation Guide is model neutral and allows organizations to take meaningful steps toward providing integrated care that achieves access and accountability.

  3. Malpractice risk prevention for primary care physicians.

    PubMed

    Blackston, Joseph W; Bouldin, Marshall J; Brown, C Andrew; Duddleston, David N; Hicks, G Swink; Holman, Honey E

    2002-10-01

    The recent medical malpractice "crisis" has seen skyrocketing liability premiums and increasing fear of liability. Primary care physicians, especially family medicine and internal medicine physicians, have historically experienced low rates of malpractice claims, both in number and amount of payment. This can be attributed to several factors: the esteem held by internal medicine and family medicine physicians in their communities, relatively low numbers of invasive procedures, reluctance of patients to include "their" primary care physician in any potential litigation, and, probably most importantly, the atmosphere of mutual trust and communication between the internist or family physician and the patient. Recent years have seen this trend erased, as insurance industry data suggest primary care physicians presently face significant potential exposure for medical malpractice claims. It is imperative that primary care physicians take steps to insure they are adequately covered in case of a malpractice claim and that they practice aggressive but appropriate risk management to lessen the likelihood of a claim.

  4. Understanding health care communication preferences of veteran primary care users.

    PubMed

    LaVela, Sherri L; Schectman, Gordon; Gering, Jeffrey; Locatelli, Sara M; Gawron, Andrew; Weaver, Frances M

    2012-09-01

    To assess veterans' health communication preferences (in-person, telephone, or electronic) for primary care needs and the impact of computer use on preferences. Structured patient interviews (n=448). Bivariate analyses examined preferences for primary care by 'infrequent' vs. 'regular' computer users. Only 54% were regular computer users, nearly all of whom had ever used the internet. 'Telephone' was preferred for 6 of 10 reasons (general medical questions, medication questions and refills, preventive care reminders, scheduling, and test results); although telephone was preferred by markedly fewer regular computer users. 'In-person' was preferred for new/ongoing conditions/symptoms, treatment instructions, and next care steps; these preferences were unaffected by computer use frequency. Among regular computer users, 1/3 preferred 'electronic' for preventive reminders (37%), test results (34%), and refills (32%). For most primary care needs, telephone communication was preferred, although by a greater proportion of infrequent vs. regular computer users. In-person communication was preferred for reasons that may require an exam or visual instructions. About 1/3 of regular computer users prefer electronic communication for routine needs, e.g., preventive reminders, test results, and refills. These findings can be used to plan patient-centered care that is aligned with veterans' preferred health communication methods. Published by Elsevier Ireland Ltd.

  5. Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension.

    PubMed

    Ono, Sarah S; Crabtree, Benjamin F; Hemler, Jennifer R; Balasubramanian, Bijal A; Edwards, Samuel T; Green, Larry A; Kaufman, Arthur; Solberg, Leif I; Miller, William L; Woodson, Tanisha Tate; Sweeney, Shannon M; Cohen, Deborah J

    2018-02-01

    Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.

  6. Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension

    PubMed Central

    Ono, Sarah S.; Crabtree, Benjamin F.; Hemler, Jennifer R.; Balasubramanian, Bijal A.; Edwards, Samuel T.; Green, Larry A.; Kaufman, Arthur; Solberg, Leif I.; Miller, William L.; Woodson, Tanisha Tate; Sweeney, Shannon M.; Cohen, Deborah J.

    2018-01-01

    Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension—technological and quality improvement support, practice capacity building, and linking with community resources—to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services. PMID:29401016

  7. [Primary care in Belgium].

    PubMed

    Sánchez-Sagrado, T

    2017-09-01

    Belgium is an attractive country to work in, not just for doctors but for all Spanish workers, due to it having the headquarters of European Union. The health job allure is double; on the one hand, the opportunity to find a decent job, and on the other, because it is possible to develop their professional abilities with patients of the same nationality in a health system with a different way of working. The Belgium health care system is based on security social models. Health care is financed by the government, social security contributions, and voluntary private health insurance. Primary care in Belgium is very different to that in Spain. Citizens may freely choose their doctor (general practitioner or specialist) increasing the lack of coordination between primary and specialized care. This leads to serious patient safety problems and loss of efficiency within the system. Belgium is a European country with room to improve preventive coverage. General practitioners are self-employed professionals with free choice of setting, and their salary is linked to their professional activity. Ambulatory care is subjected to co-payment, and this fact leads to great inequities on access to care. The statistics say that there is universal coverage but, in 2010, 14% of the population did not seek medical contact due to economic problems. It takes 3 years to become a General Practitioner and continuing medical education is compulsory to be revalidated. In general, Belgian and Spaniards living and working in Belgium are happy with the functioning of the health care system. However, as doctors, we should be aware that it is a health care system in which access is constrained for some people, and preventive coverage could be improved. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

  8. Project DULCE: Strengthening Families through Enhanced Primary Care

    ERIC Educational Resources Information Center

    Sege, Robert; Kaplan-Sanof, Margot; Morton, Samantha J.; Velasco-Hodgson, M. Carolina; Preer, Genevieve; Morakinyo, Grace; DeVos, Ed; Krathen, Julie

    2014-01-01

    Project DULCE (Developmental understanding and legal Collaboration for everyone) integrated the Strengthening families approach to building family protective factors into routine health care visits for infants in a primary health care setting. The core collaborators--Boston medical Center pediatric primary care, the medical-legal partnership |…

  9. Iraqi primary care system in Kurdistan region: providers' perspectives on problems and opportunities for improvement.

    PubMed

    Shabila, Nazar P; Al-Tawil, Namir G; Al-Hadithi, Tariq S; Sondorp, Egbert; Vaughan, Kelsey

    2012-09-27

    As part of a comprehensive study on the primary health care system in Iraq, we sought to explore primary care providers' perspectives about the main problems influencing the provision of primary care services and opportunities to improve the system. A qualitative study based on four focus groups involving 40 primary care providers from 12 primary health care centres was conducted in Erbil governorate in the Iraqi Kurdistan region between July and October 2010. A topic guide was used to lead discussions and covered questions on positive aspects of and current problems with the primary care system in addition to the priority needs for its improvement. The discussions were fully transcribed and the qualitative data was analyzed by content analysis, followed by a thematic analysis. Problems facing the primary care system included inappropriate health service delivery (irrational use of health services, irrational treatment, poor referral system, poor infrastructure and poor hygiene), health workforce challenges (high number of specialists, uneven distribution of the health workforce, rapid turnover, lack of training and educational opportunities and discrepancies in the salary system), shortage in resources (shortage and low quality of medical supplies and shortage in financing), poor information technology and poor leadership/governance. The greatest emphasis was placed on poor organization of health services delivery, particularly the irrational use of health services and the related overcrowding and overload on primary care providers and health facilities. Suggestions for improving the system included application of a family medicine approach and ensuring effective planning and monitoring. This study has provided a comprehensive understanding of the factors that negatively affect the primary care system in Iraq's Kurdistan region from the perspective of primary care providers. From their experience, primary care providers have a role in informing the community and

  10. Primary care closed claims experience of Massachusetts malpractice insurers.

    PubMed

    Schiff, Gordon D; Puopolo, Ann Louise; Huben-Kearney, Anne; Yu, Winnie; Keohane, Carol; McDonough, Peggy; Ellis, Bonnie R; Bates, David W; Biondolillo, Madeleine

    Despite prior focus on high-impact inpatient cases, there are increasing data and awareness that malpractice in the outpatient setting, particularly in primary care, is a leading contributor to malpractice risk and claims. To study patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. Retrospective review of pooled closed claims data of 2 malpractice carriers covering most Massachusetts physicians during a 5-year period (January 1, 2005, through December 31, 2009). Data were harmonized between the 2 insurers using a standardized taxonomy. Primary care practices in Massachusetts. All malpractice claims that involved primary care practices insured by the 2 largest insurers in the state were screened. A total of 551 claims from primary care practices were identified for the analysis. Numbers and types of claims, including whether claims involved primary care physicians or practices; classification of alleged malpractice (eg, misdiagnosis or medication error); patient diagnosis; breakdown in care process; and claim outcome (dismissed, settled, verdict for plaintiff, or verdict for defendant). During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. Allegations were related to diagnosis in 397 (72.1%), medications in 68 (12.3%), other medical treatment in 41 (7.4%), communication in 15 (2.7%), patient rights in 11 (2.0%), and patient safety or security in 8 (1.5%). Leading diagnoses were cancer (n = 190), heart diseases (n = 43), blood vessel diseases (n = 27), infections (n = 22), and stroke (n = 16). Primary care cases were significantly more likely to be settled (35.2% vs 20.5%) or result in a verdict for the plaintiff (1.6% vs 0.9%) compared with non-general medical malpractice claims (P < .001). In Massachusetts, most primary care claims filed are related to alleged misdiagnosis. Compared with malpractice

  11. STRUCTURAL AND HIDDEN BARRIERS TO A LOCAL PRIMARY HEALTH CARE INFRASTRUCTURE: AUTONOMY, DECISIONS ABOUT PRIMARY HEALTH CARE, AND THE CENTRALITY AND SIGNIFICANCE OF POWER.

    PubMed

    Freed, Christopher R; Hansberry, Shantisha T; Arrieta, Martha I

    2013-09-01

    To examine a local primary health care infrastructure and the reality of primary health care from the perspective of residents of a small, urban community in the southern United States. Data derive from 13 semi-structured focus groups, plus three semi-structured interviews, and were analyzed inductively consistent with a grounded theory approach. Structural barriers to the local primary health care infrastructure include transportation, clinic and appointment wait time, and co-payments and health insurance. Hidden barriers consist of knowledge about local health care services, non-physician gatekeepers, and fear of medical care. Community residents have used home remedies and the emergency department at the local academic medical center to manage these structural and hidden barriers. Findings might not generalize to primary health care infrastructures in other communities, respondent perspectives can be biased, and the data are subject to various interpretations and conceptual and thematic frameworks. Nevertheless, the structural and hidden barriers to the local primary health care infrastructure have considerably diminished the autonomy community residents have been able to exercise over their decisions about primary health care, ultimately suggesting that efforts concerned with increasing the access of medically underserved groups to primary health care in local communities should recognize the centrality and significance of power. This study addresses a gap in the sociological literature regarding the impact of specific barriers to primary health care among medically underserved groups.

  12. Assessment of a primary care-based telemonitoring intervention for home care patients with heart failure and chronic lung disease. The TELBIL study

    PubMed Central

    2011-01-01

    Background Telemonitoring technology offers one of the most promising alternatives for the provision of health care services at the patient's home. The primary aim of this study is to evaluate the impact of a primary care-based telemonitoring intervention on the frequency of hospital admissions. Methods/design A primary care-based randomised controlled trial will be carried out to assess the impact of a telemonitoring intervention aimed at home care patients with heart failure (HF) and/or chronic lung disease (CLD). The results will be compared with those obtained with standard health care practice. The duration of the study will be of one year. Sixty patients will be recruited for the study. In-home patients, diagnosed with HF and/or CLD, aged 14 or above and with two or more hospital admissions in the previous year will be eligible. For the intervention group, telemonitoring will consist of daily patient self-measurements of respiratory-rate, heart-rate, blood pressure, oxygen saturation, weight and body temperature. Additionally, the patients will complete a qualitative symptom questionnaire daily using the telemonitoring system. Routine telephone contacts will be conducted every fortnight and additional telephone contacts will be carried out if the data received at the primary care centre are out of the established limits. The control group will receive usual care. The primary outcome measure is the number of hospital admissions due to any cause that occurred in a period of 12 months post-randomisation. The secondary outcome measures are: duration of hospital stay, hospital admissions due to HF or CLD, mortality rate, use of health care resources, quality of life, cost-effectiveness, compliance and patient and health care professional satisfaction with the new technology. Discussion The results of this study will shed some light on the effects of telemonitoring for the follow-up and management of chronic patients from a primary care setting. The study may

  13. Provider satisfaction in army primary care clinics.

    PubMed

    Byers, V L; Mays, M Z; Mark, D D

    1999-02-01

    The job satisfaction of physicians, nurse practitioners, and physician assistants was assessed during the course of a multicenter study of Army primary care clinics. All providers in nine clinics at three medical centers who were engaged in adult or family care were invited to participate in the study. Questionnaires on job satisfaction and other practice style variables were completed by 26 physicians, 19 nurse practitioners, and 13 physician assistants (46, 76, and 41% of eligible providers, respectively). Analysis revealed a broad range of job satisfaction in the sample. However, average levels of job satisfaction were not significantly different across the three groups of primary care providers. Autonomy and collaboration were significant predictors of job satisfaction. It is clear that changes in health care systems that reduce, or appear to reduce, the primary care provider's autonomy in clinical matters are likely to reduce provider satisfaction as well.

  14. Primary care assessment from a male population perspective.

    PubMed

    Silva, Abiúde Nadabe E; Silva, Simone Albino da; Silva, Ana Roberta Vilarouca da; Araújo, Telma Maria Evangelista de; Rebouças, Cristiana Brasil Almeida; Nogueira, Lídya Tolstenko

    2018-01-01

    to evaluate the quality of primary health care from the perspective of the male population. a cross-sectional descriptive-evaluative study conducted at the family health units of Teresina, Piauí, Brazil, with the male population being interviewed through the Primary Care Assessment Tool (PCAT). 301 participants with mean age of 51.34 years, married, incomplete elementary school and monthly income between one and two minimum wages. The evaluation was positive for the following care domains: utilization, information system and longitudinality. The features access, comprehensiveness of care, service available and service provided, family centeredness and community orientation obtained a negative evaluation. the features of primary care are unsatisfactory, indicating the need to expand access to services offered and to qualify care for male users.

  15. Primary care in Cuba: a public health approach.

    PubMed

    Swanson, K A; Swanson, J M; Gill, A E; Walter, C

    1995-01-01

    Cuba's primary health care model is presented. Unlike ambulatory care services, which are but one component of primary care, Cuba's model is a comprehensive public health approach that meets the World Health Organization's definition of primary care. The history of the development of Cuba's model is presented, including an update on the innovative neighborhood/home clinics. Achievements in health outcomes as a result of Cuba's model and the consequences for women's health care are discussed. Examples are presented of the effects on health care delivery of the economic hardship that Cuba has experienced since 1991 as a result of the loss of 85% of its trade with the former Soviet Union and the intensified U.S. embargo. A critique of Cuba's model concludes the article.

  16. Autism-Specific Primary Care Medical Home Intervention

    ERIC Educational Resources Information Center

    Golnik, Allison; Scal, Peter; Wey, Andrew; Gaillard, Philippe

    2012-01-01

    Forty-six subjects received primary medical care within an autism-specific medical home intervention (www.autismmedicalhome.com) and 157 controls received standard primary medical care. Subjects and controls had autism spectrum disorder diagnoses. Thirty-four subjects (74%) and 62 controls (40%) completed pre and post surveys. Controlling for…

  17. Cost-effectiveness of a program to prevent depression relapse in primary care.

    PubMed

    Simon, Gregory E; Von Korff, Michael; Ludman, Evette J; Katon, Wayne J; Rutter, Carolyn; Unützer, Jürgen; Lin, Elizabeth H B; Bush, Terry; Walker, Edward

    2002-10-01

    Evaluate the incremental cost-effectiveness of a depression relapse prevention program in primary care. Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks later. Those recovered from the current episode but at high risk for relapse (based on history of recurrent depression or dysthymia) were offered randomization to usual care or a relapse prevention intervention. The intervention included systematic patient education, two psychoeducational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and telephone and mail monitoring of medication adherence and depressive symptoms. Outcomes in both groups were assessed via blinded telephone assessments at 3, 6, 9, and 12 months and health plan claims and accounting data. Intervention patients experienced 13.9 additional depression-free days during a 12-month period (95% CI, -1.5 to 29.3). Incremental costs of the intervention were $273 (95% CI, $102 to $418) for depression treatment costs only and $160 (95% CI, -$173 to $512) for total outpatient costs. Incremental cost-effectiveness ratio was $24 per depression-free day (95% CI, -$59 to $496) for depression treatment costs only and $14 per depression-free day (95% CI, -$35 to $248) for total outpatient costs. A program to prevent depression relapse in primary care yields modest increases in days free of depression and modest increases in treatment costs. These modest differences reflect high rates of treatment in usual care. Along with other recent studies, these findings suggest that improved care of depression in primary care is a prudent investment of health care resources.

  18. The future: a primary care-led NHS.

    PubMed

    Cross, Sue

    2010-04-01

    The NHS is becoming increasingly primary care and community focused and the role of the community nurse is becoming more significant, not just in managing long-term conditions and end of life but in providing vital help and education. Helping people become more knowledgeable about maintaining both their own health and that of their families at home or within the community is vital - the desired end being less need for expensive hospital care. As the demand to implement more complex services grows, so the need for nurses to contribute to the planning and delivery of services becomes more important. Nurses in the community have the experience and practical knowledge and must use it to influence commissioning and engage proactively, and positively, with current policy agendas and with the people whose responsibility it is to implement them. Change in primary care is constant and increasingly it is the frontline deliverers of services that drive that change and help set the agenda. As more care and treatment is devolved from the secondary to primary care setting, there must be greater integration between general practice and the community nursing team, with each helping and informing the other to deliver a world class primary care service.

  19. Primary care practice organization influences colorectal cancer screening performance.

    PubMed

    Yano, Elizabeth M; Soban, Lynn M; Parkerton, Patricia H; Etzioni, David A

    2007-06-01

    To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors. Primary care director survey (1999-2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001). Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors. Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease. After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p<.03), and smaller size (p<.001). Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.

  20. Medical homes versus individual practice in primary care: impact on health care expenditures.

    PubMed

    Perelman, Julian; Roch, Isabelle; Heymans, Isabelle; Moureaux, Catherine; Lagasse, Raphael; Annemans, Lieven; Closon, Marie-Christine

    2013-08-01

    The medical home (MH) model has prompted increasing attention given its potential to improve quality of care while reducing health expenditures. We compare overall and specific health care expenditures in Belgium, from the third-party payer perspective (compulsory social insurance), between patients treated at individual practices (IP) and at MHs. We compare the sociodemographic profile of MH and IP users. This is a retrospective study using public insurance claims data. Generalized linear models estimate the impact on health expenditures of being treated at a MH versus IP, controlling for individual, and area-based sociodemographic characteristics. The choice of primary care setting is modeled using logistic regressions. A random sample of 43,678 persons followed during the year 2004. Third-party payer expenditures for primary care, secondary care consultations, pharmaceuticals, laboratory tests, acute and long-term inpatient care. Overall third-party payer expenditures do not differ significantly between MH and IP users (€+27). Third-party payer primary care expenditures are higher for MH than for IP users (€+129), but this difference is offset by lower expenditures for secondary care consultations (€-11), drugs (€-40), laboratory tests (€-5) and acute and long-term inpatient care (€-53). MHs attract younger and more underprivileged populations. MHs induce a shift in expenditures from secondary care, drugs, and laboratory tests to primary care, while treating a less economically favored population. Combined with positive results regarding quality, MH structures are a promising way to tackle the challenges of primary care.

  1. DSM-IV hypochondriasis in primary care.

    PubMed

    Escobar, J I; Gara, M; Waitzkin, H; Silver, R C; Holman, A; Compton, W

    1998-05-01

    The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impaired in their physical functioning than patients without the disorder. Of the various psychopathologies examined, major depressive syndromes were the most frequent among patients with hypochondriasis. Interestingly, unlike somatization disorder, hypochondriasis was not related to any demographic factor. Hypochondriasis is a relatively rare condition in primary care that is largely separable from somatization disorder but seems closely intertwined with the more severe depressive syndromes.

  2. Referral interventions from primary to specialist care: a systematic review of international evidence

    PubMed Central

    Blank, Lindsay; Baxter, Susan; Woods, Helen Buckley; Goyder, Elizabeth; Lee, Andrew; Payne, Nick; Rimmer, Melanie

    2014-01-01

    Background Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. Aim To review the international evidence on interventions to manage referral from primary to specialist care. Design and setting Systematic review. Method Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. Results The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no ‘magic bullet’ to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. Conclusions To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision. PMID:25452541

  3. Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff.

    PubMed

    Binswanger, Ingrid A; Koester, Stephen; Mueller, Shane R; Gardner, Edward M; Goddard, Kristin; Glanz, Jason M

    2015-12-01

    The rate of fatal unintentional pharmaceutical opioid poisonings has increased substantially since the late 1990s. Naloxone is an effective opioid antidote that can be prescribed to patients for bystander use in the event of an overdose. Primary care clinics represent settings in which large populations of patients prescribed opioids could be reached for overdose education and naloxone prescription. Our aim was to investigate the knowledge, attitudes and beliefs about overdose education and naloxone prescription among clinical staff in primary care. This was a qualitative study using focus groups to elucidate both clinic-level and provider-level barriers and facilitators. Ten primary care internal medicine, family medicine and infectious disease/HIV practices in three large Colorado health systems. A focus group guide was developed based on behavioral theory. Focus group transcripts were coded for manifest and latent meaning, and analyzed for themes using a recursive approach that included inductive and deductive analysis. Themes emerged in four content areas related to overdose education and naloxone prescription: knowledge, barriers, benefits and facilitators. Clinical staff (N = 56) demonstrated substantial knowledge gaps about naloxone and its use in outpatient settings. They expressed uncertainty about who to prescribe naloxone to, and identified a range of logistical barriers to its use in practice. Staff also described fears about offending patients and concerns about increased risk behaviors in patients prescribed naloxone. When considering naloxone, some providers reflected critically and with discomfort on their own opioid prescribing. These barriers were balanced by beliefs that prescribing naloxone could prevent death and result in safer opioid use behaviors. Findings from these qualitative focus groups may not be generalizable to other settings. In addition to evidence gaps, logistical and attitudinal barriers will need to be addressed to enhance

  4. Depression in primary care: assessing suicide risk

    PubMed Central

    Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping

    2017-01-01

    Major depression is a common condition seen in the primary care setting. This article describes the suicide risk assessment of a depressed patient, including practical aspects of history-taking, consideration of factors in deciding if a patient requires immediate transfer for inpatient care and measures to be taken if the patient is not hospitalised. It follows on our earlier article about the approach to management of depression in primary care. PMID:28210741

  5. Innovative approach to patient-centered care coordination in primary care practices.

    PubMed

    Clarke, Robin; Bharmal, Nazleen; Di Capua, Paul; Tseng, Chi-Hong; Mangione, Carol M; Mittman, Brian; Skootsky, Samuel A

    2015-09-01

    Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients. Matched case-control differences-in-differences. Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity. CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001). Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

  6. The CUPCIG (CAM-Use in Primary Care in Germany) Study:Part I-Pain. Study Protocol of a Pilot-trial to Assess Feasibility, Acceptability and Perceived Effectiveness of CAM in Pain Disorders in Primary Care.

    PubMed

    Schencking, Martin; Sönnichsen, Andreas; Bassüner, Susanne; Redaelli, Marcus

    2015-01-01

    There is limited valid data available on CAM procedures for chronic joint and neuropathic pain in primary care in Germany. Indiviual CAM qualifications of the general practitioners (GPs) and the potential of cost reduction through CAM treatment are almost unknown. The aim of this pilot trial preceding the main study is to examine the survey mode, to estimate the response rate by GPs with or without an additional qualification for CAM, and to identify the status quo in therapeutic approaches for chronic pain disorders in primary care. This is a cross-sectional study with an ex post facto design among German GPs consisting of 2 parts: In a first step, a pilot trial precedes the main study targeting 200 GPs with and 200 GPs without additional qualification in CAM in a selected region. The results of the CUPCIG study comprise the distribution of pain types treated in primary care practices, the GPs' attitude toward complementary pain therapy, pharmacological or CAM treatment, the estimate of cost reduction through CAM treatment of pain, the application of diverse CAM procedures, and biographical data. The CUPCIG study serves to compile pain therapy approaches in primary care in Germany with respect to the individual CAM expertise of the GPs. © 2015 S. Karger GmbH, Freiburg.

  7. Too Little? Too Much? Primary Care Physicians’ Views on US Health Care

    PubMed Central

    Sirovich, Brenda E.; Woloshin, Steven; Schwartz, Lisa M.

    2011-01-01

    Background Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians—the frontline of health care delivery—are not known. Methods Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n=627). Results Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community. Conclusions Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change. PMID:21949169

  8. Improving cardiovascular outcomes among Aboriginal Australians: Lessons from research for primary care

    PubMed Central

    Thompson, Sandra C; Haynes, Emma; Woods, John A; Bessarab, Dawn C; Dimer, Lynette A; Wood, Marianne M; Sanfilippo, Frank M; Hamilton, Sandra J; Katzenellenbogen, Judith M

    2016-01-01

    Background: The Aboriginal people of Australia have much poorer health and social indicators and a substantial life expectancy gap compared to other Australians, with premature cardiovascular disease a major contributor to poorer health. This article draws on research undertaken to examine cardiovascular disparities and focuses on ways in which primary care practitioners can contribute to reducing cardiovascular disparities and improving Aboriginal health. Methods: The overall research utilised mixed methods and included data analysis, interviews and group processes which included Aboriginal people, service providers and policymakers. Workshop discussions to identify barriers and what works were recorded by notes and on whiteboards, then distilled and circulated to participants and other stakeholders to refine and validate information. Additional engagement occurred through circulation of draft material and further discussions. This report distils the lessons for primary care practitioners to improve outcomes through management that is attentive to the needs of Aboriginal people. Results: Aspects of primordial, primary and secondary prevention are identified, with practical strategies for intervention summarised. The premature onset and high incidence of Aboriginal cardiovascular disease make prevention imperative and require that primary care practitioners understand and work to address the social underpinnings of poor health. Doctors are well placed to reinforce the importance of healthy lifestyle at all visits to involve the family and to reduce barriers which impede early care seeking. Ensuring better information for Aboriginal patients and better integrated care for patients who frequently have complex needs and multi-morbidities will also improve care outcomes. Conclusion: Primary care practitioners have an important role in improving Aboriginal cardiovascular care outcomes. It is essential that they recognise the special needs of their Aboriginal patients

  9. Improving cardiovascular outcomes among Aboriginal Australians: Lessons from research for primary care.

    PubMed

    Thompson, Sandra C; Haynes, Emma; Woods, John A; Bessarab, Dawn C; Dimer, Lynette A; Wood, Marianne M; Sanfilippo, Frank M; Hamilton, Sandra J; Katzenellenbogen, Judith M

    2016-01-01

    The Aboriginal people of Australia have much poorer health and social indicators and a substantial life expectancy gap compared to other Australians, with premature cardiovascular disease a major contributor to poorer health. This article draws on research undertaken to examine cardiovascular disparities and focuses on ways in which primary care practitioners can contribute to reducing cardiovascular disparities and improving Aboriginal health. The overall research utilised mixed methods and included data analysis, interviews and group processes which included Aboriginal people, service providers and policymakers. Workshop discussions to identify barriers and what works were recorded by notes and on whiteboards, then distilled and circulated to participants and other stakeholders to refine and validate information. Additional engagement occurred through circulation of draft material and further discussions. This report distils the lessons for primary care practitioners to improve outcomes through management that is attentive to the needs of Aboriginal people. Aspects of primordial, primary and secondary prevention are identified, with practical strategies for intervention summarised. The premature onset and high incidence of Aboriginal cardiovascular disease make prevention imperative and require that primary care practitioners understand and work to address the social underpinnings of poor health. Doctors are well placed to reinforce the importance of healthy lifestyle at all visits to involve the family and to reduce barriers which impede early care seeking. Ensuring better information for Aboriginal patients and better integrated care for patients who frequently have complex needs and multi-morbidities will also improve care outcomes. Primary care practitioners have an important role in improving Aboriginal cardiovascular care outcomes. It is essential that they recognise the special needs of their Aboriginal patients and work at multiple levels both outside and

  10. Colorectal cancer screening practices of primary care providers: results of a national survey in Malaysia.

    PubMed

    Norwati, Daud; Harmy, Mohamed Yusoff; Norhayati, Mohd Noor; Amry, Abdul Rahim

    2014-01-01

    The incidence of colorectal cancer has been increasing in many Asian countries including Malaysia during the past few decades. A physician recommendation has been shown to be a major factor that motivates patients to undergo screening. The present study objectives were to describe the practice of colorectal cancer screening by primary care providers in Malaysia and to determine the barriers for not following recommendations. In this cross sectional study involving 132 primary care providers from 44 Primary Care clinics in West Malaysia, self-administered questionnaires which consisted of demographic data, qualification, background on the primary care clinic, practices on colorectal cancer screening and barriers to colorectal cancer screening were distributed. A total of 116 primary care providers responded making a response rate of 87.9%. About 21% recommended faecal occult blood test (FOBT) in more than 50% of their patients who were eligible. The most common barrier was "unavailability of the test". The two most common patient factors are "patient in a hurry" and "poor patient awareness". This study indicates that colorectal cancer preventive activities among primary care providers are still poor in Malaysia. This may be related to the low availability of the test in the primary care setting and poor awareness and understanding of the importance of colorectal cancer screening among patients. More awareness programmes are required for the public. In addition, primary care providers should be kept abreast with the latest recommendations and policy makers need to improve colorectal cancer screening services in health clinics.

  11. Patients’ perceptions of access to primary care

    PubMed Central

    Premji, Kamila; Ryan, Bridget L.; Hogg, William E.; Wodchis, Walter P.

    2018-01-01

    Abstract Objective To gain a more comprehensive understanding of patients’ perceptions of access to their primary care practice and how these relate to patient characteristics. Design Cross-sectional study. Setting Ontario. Participants Adult primary care patients in Ontario (N = 1698) completing the Quality and Costs of Primary Care (QUALICOPC) Patient Experiences Survey. Main outcome measures Responses to 11 access-related survey items, analyzed both individually and as a Composite Access Score (CAS). Results The mean (SD) CAS was 1.78 (0.16) (the highest possible CAS was 2 and the lowest was 1). Most patients (68%) waited more than 1 day for their appointment. By far most (96%) stated that it was easy to obtain their appointment and that they obtained that appointment as soon as they wanted to (87%). There were no statistically significant relationships between CAS and sex, language fluency, income, education, frequency of emergency department use, or chronic disease status. A higher CAS was associated with being older and being born in Canada, better self-reported health, and increased frequency of visits to a doctor. Conclusion Despite criticisms of access to primary care, this study found that Ontario patients belonging to primary care practices have favourable impressions of their access. There were few statistically significant relationships between patient characteristics and access, and these relationships appeared to be weak. PMID:29540392

  12. Team-based primary care: The medical assistant perspective.

    PubMed

    Sheridan, Bethany; Chien, Alyna T; Peters, Antoinette S; Rosenthal, Meredith B; Brooks, Joanna Veazey; Singer, Sara J

    Team-based care has the potential to improve primary care quality and efficiency. In this model, medical assistants (MAs) take a more central role in patient care and population health management. MAs' traditionally low status may give them a unique view on changing organizational dynamics and teamwork. However, little empirical work exists on how team-based organizational designs affect the experiences of low-status health care workers like MAs. The aim of this study was to describe how team-based primary care affects the experiences of MAs. A secondary aim was to explore variation in these experiences. In late 2014, the authors interviewed 30 MAs from nine primary care practices transitioning to team-based care. Interviews addressed job responsibilities, teamwork, implementation, job satisfaction, and learning. Data were analyzed using a thematic networks approach. Interviews also included closed-ended questions about workload and job satisfaction. Most MAs reported both a higher workload (73%) and a greater job satisfaction (86%) under team-based primary care. Interview data surfaced four mechanisms for these results, which suggested more fulfilling work and greater respect for the MA role: (a) relationships with colleagues, (b) involvement with patients, (c) sense of control, and (d) sense of efficacy. Facilitators and barriers to these positive changes also emerged. Team-based care can provide low-status health care workers with more fulfilling work and strengthen relationships across status lines. The extent of this positive impact may depend on supporting factors at the organization, team, and individual worker levels. To maximize the benefits of team-based care, primary care leaders should recognize the larger role that MAs play under this model and support them as increasingly valuable team members. Contingent on organizational conditions, practices may find MAs who are willing to manage the increased workload that often accompanies team-based care.

  13. Sensemaking and the co-production of safety: a qualitative study of primary medical care patients.

    PubMed

    Rhodes, Penny; McDonald, Ruth; Campbell, Stephen; Daker-White, Gavin; Sanders, Caroline

    2016-02-01

    This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings. © 2015 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.

  14. Counselling for depression in primary care.

    PubMed

    Rowland, N; Bower, P; Mellor, C; Heywood, P; Godfrey, C

    2001-01-01

    There is wide clinician and patient support for counselling in primary care, particularly in the UK. This review examines the effectiveness and cost effectiveness of counselling for psychological and psychosocial problems in the primary care setting. To assess the effects of counselling in primary care by reviewing cost and outcome data for patients with psychological and psychosocial problems considered suitable for counselling. The search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned. Contact was made with subject experts and CCDAN members. Randomised and controlled patient preference trials comparing counselling in primary care with usual general practitioner care for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of April 1998 were included in the review. Trials were independently assessed by at least two reviewers for appropriateness of inclusion and methdological quality. Four trials, involving 678 participants, of whom 487 were followed up, were included. Data for psychological symptom levels (four trials) were pooled statistically. Patients receiving counselling had significantly better psychological symptom levels post intervention than patients receiving usual general practitioner care (standardised mean difference -0.30, 95% CI, (-0.49 to - 0.11). The effect remained statistically significant when the results from studies with less rigorous methodology were excluded in a sensitivity analysis. Patients who received counselling tended to be more satisfied with their treatment (three trials). Health service utilisation data were reported in all trials reviewed, but only one trial undertook a cost analysis. No clear cost advantage was

  15. Primary Care Practice Transformation Is Hard Work

    PubMed Central

    Crabtree, Benjamin F.; Nutting, Paul A.; Miller, William L.; McDaniel, Reuben R.; Stange, Kurt C.; Jaén, Carlos Roberto; Stewart, Elizabeth

    2010-01-01

    Background Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. Methods Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. Results A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with “agents” who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. Conclusions It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change. PMID:20856145

  16. Care interrupted: Poverty, in-migration, and primary care in rural resource towns.

    PubMed

    Rice, Kathleen; Webster, Fiona

    2017-10-01

    Internationally, rural people have poorer health outcomes relative to their urban counterparts, and primary care providers face particular challenges in rural and remote regions. Drawing on ethnographic fieldnotes and 14 open-ended qualitative interviews with care providers and chronic pain patients in two remote resource communities in Northern Ontario, Canada, this article examines the challenges involved in providing and receiving primary care for complex chronic conditions in these communities. Both towns struggle with high unemployment in the aftermath of industry closure, and are characterized by an abundance of affordable housing. Many of the challenges that care providers face and that patients experience are well-documented in Canadian and international literature on rural and remote health, and health care in resource towns (e.g. lack of specialized care, difficulty with recruitment and retention of care providers, heavy workload for existing care providers). However, our study also documents the recent in-migration of low-income, largely working-age people with complex chronic conditions who are drawn to the region by the low cost of housing. We discuss the ways in which the needs of these in-migrants compound existing challenges to rural primary care provision. To our knowledge, our study is the first to document both this migration trend, and the implications of this for primary care. In the interest of patient health and care provider well-being, existing health and social services will likely need to be expanded to meet the needs of these in-migrants. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

  17. Why primary care practices should become digital health information hubs for their patients.

    PubMed

    Baird, Aaron; Nowak, Samantha

    2014-11-25

    Two interesting health care trends are currently occurring: 1) patient-facing technologies, such as personal health records, patient portals, and mobile health apps, are being adopted at rapid rates, and 2) primary care, which includes family practice, is being promoted as essential to reducing health care costs and improving health care outcomes. While these trends are notable and commendable, both remain subject to significant fragmentation and incentive misalignments, which has resulted in significant data coordination and value generation challenges. In particular, patient-facing technologies designed to increase care coordination, often fall prey to the very digital fragmentation issues they are supposed to overcome. Additionally, primary care providers are treating patients that may have considerable health information histories, but generating a single view of such multi-source data is nearly impossible. We contribute to this debate by proposing that primary care practices become digital health information hubs for their patients. Such hubs would offer health data coordination in a medically professional setting with the benefits of expert, trustworthy advice coupled with active patient engagement. We acknowledge challenges including: costs, information quality and provenance, willingness-to-share information and records, willingness-to-use (by both providers and patients), primary care scope creep, and determinations of technical and process effectiveness. Even with such potential challenges, we strongly believe that more debate is needed on this topic prior to full implementation of various health information technology incentives and reform programs currently being designed and enacted throughout the world. Ultimately, if we do not provide a meaningful way for the full spectrum of health information to be used by both providers and patients, especially early in the health care continuum, effectively improving health outcomes may remain elusive. We view

  18. Relationship among team dynamics, care coordination and perception of safety culture in primary care.

    PubMed

    Blumenthal, Karen J; Chien, Alyna T; Singer, Sara J

    2018-05-18

    There remains a need to improve patient safety in primary care settings. Studies have demonstrated that creating high-performing teams can improve patient safety and encourage a safety culture within hospital settings, but little is known about this relationship in primary care. To examine how team dynamics relate to perceptions of safety culture in primary care and whether care coordination plays an intermediating role. This is a cross-sectional survey study with 63% response (n = 1082). The study participants were attending clinicians, resident physicians and other staff who interacted with patients from 19 primary care practices affiliated with Harvard Medical School. Three domains corresponding with our main measures: team dynamics, care coordination and safety culture. All items were measured on a 5-point Likert scale. We used linear regression clustered by practice site to assess the relationship between team dynamics and perceptions of safety culture. We also performed a mediation analysis to determine the extent to which care coordination explains the relationship between perceptions of team dynamics and of safety culture. For every 1-point increase in overall team dynamics, there was a 0.76-point increase in perception of safety culture [95% confidence interval (CI) 0.70-0.82, P < 0.001]. Care coordination mediated the relationship between team dynamics and the perception of safety culture. Our findings suggest there is a relationship between team dynamics, care coordination and perceptions of patient safety in a primary care setting. To make patients safer, we may need to pay more attention to how primary care providers work together to coordinate care.

  19. Comparing Homeless Persons’ Care Experiences in Tailored Versus Nontailored Primary Care Programs

    PubMed Central

    Holt, Cheryl L.; Steward, Jocelyn L.; Jones, Richard N.; Roth, David L.; Stringfellow, Erin; Gordon, Adam J.; Kim, Theresa W.; Austin, Erika L.; Henry, Stephen Randal; Kay Johnson, N.; Shanette Granstaff, U.; O’Connell, James J.; Golden, Joya F.; Young, Alexander S.; Davis, Lori L.; Pollio, David E.

    2013-01-01

    Objectives. We compared homeless patients’ experiences of care in health care organizations that differed in their degree of primary care design service tailoring. Methods. We surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the “Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients. Results. Mean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient–clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient–clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results. Conclusions. Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness. PMID:24148052

  20. Integration of basic dermatological care into primary health care services in Mali.

    PubMed Central

    Mahé, Antoine; Faye, Ousmane; N'Diaye, Hawa Thiam; Konaré, Habibatou Diawara; Coulibaly, Ibrahima; Kéita, Somita; Traoré, Abdel Kader; Hay, Roderick J.

    2005-01-01

    OBJECTIVE: To evaluate, in a developing country, the effect of a short training programme for general health care workers on the management of common skin diseases--a neglected component of primary health care in such regions. METHODS: We provided a one-day training programme on the management of the skin diseases to 400 health care workers who worked in primary health care centres in the Bamako area. We evaluated their knowledge and practice before and after training. FINDINGS: Before training, knowledge about skin diseases often was poor and practice inadequate. We found a marked improvement in both parameters after training. We analysed the registers of primary health care centres and found that the proportion of patients who presented with skin diseases who benefited from a clear diagnosis and appropriate treatment increased from 42% before the training to 81% after; this was associated with a 25% reduction in prescription costs. Improved levels of knowledge and practice persisted for up to 18 months after training. CONCLUSIONS: The training programme markedly improved the basic dermatological abilities of the health care workers targeted. Specific training may be a reasonable solution to a neglected component of primary health care in many developing countries. PMID:16462986

  1. Primary Care Physicians' Experience with Disease Management Programs

    PubMed Central

    Fernandez, Alicia; Grumbach, Kevin; Vranizan, Karen; Osmond, Dennis H; Bindman, Andrew B

    2001-01-01

    OBJECTIVE To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN Cross-sectional mailed survey. SETTING The 13 largest urban counties in California. PARTICIPANTS General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction. PMID:11318911

  2. Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

    PubMed

    Reddy, Ashok; Sessums, Laura; Gupta, Reshma; Jin, Janel; Day, Tim; Finke, Bruce; Bitton, Asaf

    2017-09-01

    Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services. © 2017 Annals of Family Medicine, Inc.

  3. Turning on the care coordination switch in rural primary care: voices from the practices--clinician champions, clinician partners, administrators, and nurse care managers.

    PubMed

    Fagnan, Lyle J; Dorr, David A; Davis, Melinda; McGinnis, Paul; Mahler, Jo; King, Molly McCarthy; Michaels, LeAnn

    2011-01-01

    This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.

  4. [Primary Health Care in the coordination of health care networks: an integrative review].

    PubMed

    Rodrigues, Ludmila Barbosa Bandeira; Silva, Patricia Costa Dos Santos; Peruhype, Rarianne Carvalho; Palha, Pedro Fredemir; Popolin, Marcela Paschoal; Crispim, Juliane de Almeida; Pinto, Ione Carvalho; Monroe, Aline Aparecida; Arcêncio, Ricardo Alexandre

    2014-02-01

    Health systems organized in health care networks and coordinated by Primary Health Care can contribute to an improvement in clinical quality with a positive impact on health outcomes and user satisfaction (by improving access and resolubility) and a reduction in the costs of local health systems. Thus, the scope of this paper is to analyze the scientific output about the evidence, potential, challenges and prospects of Primary Health Care in the coordination of Health Care Networks. To achieve this, the integrative review method was selected covering the period between 2000 and 2011. The databases selected were Medline (Medical Literature Analysis and Retrieval System online), Lilacs (Latin American Literature in Health Sciences) and SciELO (Scientific Electronic Library Online). Eighteen articles fulfilled the selection criteria. It was seen that the potential impacts of primary care services supersede the inherent weaknesses. However, the results revealed the need for research with a higher level of classification of the scientific evidence about the role of Primary Healh Care in the coordination of Health Care Networks.

  5. Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries.

    PubMed

    Schäfer, Willemijn L A; Boerma, Wienke G W; Kringos, Dionne S; De Ryck, Evelyne; Greß, Stefan; Heinemann, Stephanie; Murante, Anna Maria; Rotar-Pavlic, Danica; Schellevis, François G; Seghieri, Chiara; Van den Berg, Michael J; Westert, Gert P; Willems, Sara; Groenewegen, Peter P

    2013-01-01

    The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question 'How can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?' It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive at a set of appropriate questions for a broad international comparative study. The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). Based on the pilot survey, comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long. Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important, and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects (e.g. economic conditions) and care processes (e.g. comprehensiveness of services of primary care). The patient experiences questionnaire focused on the care processes and outcomes (e.g. how do patients experience access to care?). The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics. The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes

  6. Work-Related Depression in Primary Care Teams in Brazil.

    PubMed

    da Silva, Andréa Tenório Correia; Lopes, Claudia de Souza; Susser, Ezra; Menezes, Paulo Rossi

    2016-11-01

    To identify work-related factors associated with depressive symptoms and probable major depression in primary care teams. Cross-sectional study among primary care teams (community health workers, nursing assistants, nurses, and physicians) in the city of São Paulo, Brazil (2011-2012; n = 2940), to assess depressive symptoms and probable major depression and their associations with job strain and other work-related conditions. Community health workers presented higher prevalence of probable major depression (18%) than other primary care workers. Higher odds ratios for depressive symptoms or probable major depression were associated with longer duration of employment in primary care; having a passive, active, or high-strain job; lack of supervisor feedback regarding performance; and low social support from colleagues and supervisors. Observed levels of job-related depression can endanger the sustainability of primary care programs. Public Health implications. Strategies are needed to deliver care to primary care workers with depression, facilitating diagnosis and access to treatment, particularly in low- and middle-income countries. Preventive interventions can include training managers to provide feedback and creating strategies to increase job autonomy and social support at work.

  7. Stepped care for depression is easy to recommend, but harder to implement: results of an explorative study within primary care in the Netherlands.

    PubMed

    Hermens, Marleen L M; Muntingh, Anna; Franx, Gerdien; van Splunteren, Peter T; Nuyen, Jasper

    2014-01-09

    Depression is a common mental disorder with a high burden of disease which is mainly treated in primary care. It is unclear to what extent stepped care principles are applied in routine primary care. The first aim of this explorative study was to examine the gap between routine primary depression care and optimal care, as formulated in the depression guidelines. The second aim was to explore the facilitators and barriers that affect the provision of optimal care. Optimal care was operationalised by indicators covering the entire continuum of depression care: from prevention to chronic depression. Routine care was investigated by interviewing general practitioners (GPs) individually and together with other mental health care providers about the depression care they delivered collaboratively. Qualitative analysis of transcripts was performed using thematic coding. Additionally, the GPs completed a self-report questionnaire. Six GPs and 22 other (mostly primary) mental health care providers participated. The GPs and their primary care colleagues embraced a general stepped care approach. They offered psycho-education and counselling to mildly depressed patients. When the treatment effects were not satisfactory or patients were more severely depressed, the GPs offered, or referred to, psychotherapy or pharmacotherapy. Patients with a complex and severe depressive disorder were directly referred to specialised mental health care. However, GPs relied on their clinical judgment and rarely used instruments to assess and monitor the severity of depressive symptoms. Structured, evidence based interventions such as self-management and e-health were rarely offered to patients with depressive symptoms. Specific psychological interventions for relapse prevention or for chronically depressed patients were not available. A wide range of influencing factors for the provision of optimal depression care were put forward. Close collaboration with other mental health care professionals

  8. Genetic education for primary care providers

    PubMed Central

    Carroll, June C.; Rideout, Andrea L.; Wilson, Brenda J.; Allanson, Judith MD; Blaine, Sean M.; Esplen, Mary Jane; Farrell, Sandra A.; Graham, Gail E.; MacKenzie, Jennifer; Meschino, Wendy; Miller, Fiona; Prakash, Preeti; Shuman, Cheryl; Summers, Anne; Taylor, Sherry

    2009-01-01

    ABSTRACT OBJECTIVE To increase primary care providers’ awareness and use of genetic services; increase their knowledge of genetic issues; increase their confidence in core genetic competencies; change their attitudes toward genetic testing for hereditary diseases; and increase their confidence as primary care genetic resources. DESIGN Participants completed a workshop and 3 questionnaires: a baseline questionnaire, a survey that provided immediate feedback on the workshop itself, and a follow-up questionnaire 6 months later. SETTING Ontario. PARTICIPANTS Primary care providers suggested by deans of nursing, midwifery, family medicine, and obstetric programs, as well as coordinators of nurse practitioner programs, in Ontario and by the Ontario College of Family Physicians. INTERVENTION A complex educational intervention was developed, including an interactive workshop and PowerPoint educational modules on genetic topics for participants’ use (available at www.mtsinai.on.ca/FamMedGen/). MAIN OUTCOME MEASURES Awareness and use of genetic services, knowledge of genetics, confidence in core clinical genetic skills, attitudes toward genetic testing, and teaching activities related to genetics. RESULTS The workshop was attended by 29 participants; of those, 21 completed the baseline questionnaire and the 6-month follow-up questionnaire. There was no significant change found in awareness or reported use of genetic services. There was significant improvement in self-assessed knowledge of (P = .001) and confidence in (P = .005) skills related to adult-onset genetic disorders. There were significant increases in confidence in many core genetic competencies, including assessing risk of hereditary disorders (P = .033), deciding who should be offered referral for genetic counseling (P = .003), discussing prenatal testing options (P = .034), discussing benefits, risks, and limitations of genetic testing (P = .033), and describing what to expect at a genetic counseling session

  9. The Implementation of Integrated Behavioral Health Protocols In Primary Care Settings in Project Care.

    PubMed

    Padwa, Howard; Teruya, Cheryl; Tran, Elise; Lovinger, Katherine; Antonini, Valerie P; Overholt, Colleen; Urada, Darren

    2016-03-01

    The majority of adults with mental health (MH) and substance use (SU) disorders in the United States do not receive treatment. The Affordable Care Act will create incentives for primary care centers to begin providing behavioral health (MH and SU) services, thus promising to address the MH and SU treatment gaps. This paper examines the implementation of integrated care protocols by three primary care organizations. The Behavioral Health Integration in Medical Care (BHIMC) tool was used to evaluate the integrated care capacity of primary care organizations that chose to participate in the Kern County (California) Mental Health Department's Project Care annually for 3years. For a subsample of clinics, change over time was measured. Informed by the Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors, inner and outer contextual factors impacting implementation were identified and analyzed using multiple data sources and qualitative analytic methods. The primary care organizations all offered partially integrated (PI) services throughout the study period. At baseline, organizations offered minimally integrated/partially integrated (MI/PI) services in the Program Milieu, Clinical Process - Treatment, and Staffing domains of the BHIMC, and scores on all domains were at the partially integrated (PI) level or higher in the first and second follow-ups. Integrated care services emphasized the identification and management of MH more than SU in 52.2% of evaluated domains, but did not emphasize SU more than MH in any of them. Many of the gaps between MH and SU emphases were associated with limited capacities related to SU medications. Several outer (socio-political context, funding, leadership) and inner (organizational characteristics, individual adopter characteristics, leadership, innovation-values fit) contextual factors impacted the development of integrated care capacity. This study of a small sample of primary care organizations showed

  10. Tobacco use disorder treatment in primary care

    PubMed Central

    Kunyk, Diane; Els, Charl; Papadakis, Sophia; Selby, Peter

    2014-01-01

    Abstract Objective To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians. Design A prospective cohort study. Setting Sixty primary care sites in Alberta. Participants A convenience sample of 198 primary care physicians from the population of 2857. Main outcome measures Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians’ treatment intentions, and patient chart reviews examined changes in physicians’ consistency with the treatment algorithm. Results The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components. Conclusion Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians’ practices. PMID:25022640

  11. Classification Model That Predicts Medical Students' Choices of Primary Care or Non-Primary Care Specialties.

    ERIC Educational Resources Information Center

    Fincher, Ruth-Marie E.; And Others

    1992-01-01

    This study identified factors in graduating medical students' choice of primary versus nonprimary care specialty. Subjects were 509 students at the Medical College of Georgia in 1988-90. Students could be classified by such factors as desire for longitudinal patient care opportunities, monetary rewards, perception of lifestyle, and perception of…

  12. Primary school teacher as a primary health care worker.

    PubMed

    Nayar, S; Singh, D; Rao, N P; Choudhury, D R

    1990-01-01

    School children (1608) were examined for three items (nails, scalp hairs and teeth) relating to personal hygiene and relevant infective conditions from two sets of villages i.e. one set where primary school teacher was working as primary health care worker (Group I) and the other set where Community Health Volunteer (CHV) was delivering primary health care (Group II). The objective was to evaluate the efficiency of school teachers' role vis-a-vis CHVs' in imparting health education to school children. Out of 1608 school children, 801 belonged to Group I villages and the remaining 807 to Group II villages. From the results, it was evident that children of Group I villages were better with respect to all the items related to personal hygiene and infective conditions excepting scalp infections, where difference was not statistically significant, indicating teachers' superiority over the CHVs' in imparting health education to school children.

  13. Health Care Austerity Measures in Times of Crisis: The Perspectives of Primary Health Care Physicians in Madrid, Spain.

    PubMed

    Heras-Mosteiro, Julio; Sanz-Barbero, Belén; Otero-Garcia, Laura

    2016-01-01

    The current financial crisis has seen severe austerity measures imposed on the Spanish health care system, including reduced public spending, copayments, salary reductions, and reduced services for undocumented migrants. However, the impacts have not been well-documented. We present findings from a qualitative study that explores the perceptions of primary health care physicians in Madrid, Spain. This article discusses the effects of austerity measures implemented in the public health care system and their potential impacts on access and utilization of primary health care services. This is the first study, to our knowledge, exploring the health care experiences during the financial crisis of general practitioners in Madrid, Spain. The majority of participating physicians disapproved of austerity measures implemented in Spain. The findings of this study suggest that undocumented migrants should regain access to health care services; copayments should be minimized and removed for patients with low incomes; and health care professionals should receive additional help to avoid burnout. Failure to implement these measures could result in the quality of health care further deteriorating and could potentially have long-term negative consequences on population health. © The Author(s) 2016.

  14. Family-centred care delivery: comparing models of primary care service delivery in Ontario.

    PubMed

    Mayo-Bruinsma, Liesha; Hogg, William; Taljaard, Monica; Dahrouge, Simone

    2013-11-01

    To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC. Cross-sectional study. Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery. A total of 137 practices, 363 providers, and 5144 patients. Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations. Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural. Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.

  15. Primary care quality: community health center and health maintenance organization.

    PubMed

    Shi, Leiyu; Starfield, Barbara; Xu, Jiahong; Politzer, Robert; Regan, Jerrilyn

    2003-08-01

    This study compares the primary health care quality of community health centers (CHCs) and health maintenance organizations (HMOs) in South Carolina to elucidate the quality of CHC performance relative to mainstream settings such as the HMO. Mail surveys were used to obtain data from 350 randomly selected HMO users. Surveys with follow-up interviews were conducted to obtain data from 540 randomly selected CHC users. A validated adult primary care assessment tool was used in both surveys. Multivariate analyses were performed to assess the association of health care setting (HMO versus CHC) with primary care quality while controlling for sociodemographic and health care characteristics. After controlling for sociodemographic and health care use measures, CHC patients demonstrated higher scores in several primary care domains (ongoing care, coordination of service, comprehensiveness, and community orientation) as well as total primary care performance. Users of CHC are more likely than HMO users to rate their primary health care provider as good, except in the area of ease of first contact. The positive rating of the CHC is particularly impressive after taking into account that many CHC users have characteristics associated with poorer ratings of care.

  16. Fall Prevention in a Primary Care Setting.

    PubMed

    Siegrist, Monika; Freiberger, Ellen; Geilhof, Barbara; Salb, Johannes; Hentschke, Christian; Landendoerfer, Peter; Linde, Klause; Halle, Martin; Blank, Wolfgang A

    2016-05-27

    Falls and fall-related injuries are common in community-dwelling elderly people. Effective multifactorial fall prevention programs in the primary care setting may be a promising approach to reduce the incidence rate of falls. In a cluster randomized trial in 33 general practices 378 people living independently and at high risk of falling (65 to 94 years old; 285 women) were allocated to either a 16 week exercise-based fall prevention program including muscle strengthening and challenging balance training exercises, combined with a 12 week home-based exercise program (222 participants), or to usual care (156 participants). The main outcome was number of falls over a period of 12 months. Secondary outcomes were the number of fall-related injuries, physical function (Timed-Up-and-Go-Test, TUG, Chair-Stand-Test, CST, modified Romberg Test), and fear of falling. In the intervention group (n=222 patients in 17 general practices) 291 falls occurred, compared to 367 falls in the usual care group (n=156 patients in 16 general practices). We observed a lower incidence rate for falls in the intervention group (incidence rate ratio/IRR: 0.54; 95% confidence interval (CI): [0.35; 0.84], p=0.007) and for fall-related injuries (IRR: 0.66; [0.42; 0.94], p=0.033). Additionally, patients in the intervention group showed significant improvements in secondary endpoints (TUG: -2.39 s, [-3.91; -0.87], p=0.014; mRomberg: 1.70 s, [0.35; 3.04], p=0.037; fear of falling: -2.28 points, [-3.87; -0.69], p=0.022) compared to usual care. A complex falls prevention program in a primary care setting was effective in reducing falls and fall-related injuries in community dwelling older adults at risk.

  17. Mapping primary health care renewal in South America.

    PubMed

    Acosta Ramírez, Naydú; Giovanella, Ligia; Vega Romero, Roman; Tejerina Silva, Herland; de Almeida, Patty Fidelis; Ríos, Gilberto; Goede, Hedwig; Oliveira, Suelen

    2016-06-01

    Primary health care (PHC) renewal processes are currently ongoing in South America (SA), but their characteristics have not been systematically described. The study aimed to describe and contrast the PHC approaches being implemented in SA to provide knowledge of current conceptions, models and challenges. This multiple case study used a qualitative approach with technical visits to health ministries in order to apply key-informant interviews of 129 PHC national policy makers and 53 local managers, as well as field observation of 57 selected PHC providers and document analysis, using a common matrix for data collection and analysis. PHC approaches were analysed by triangulating sources using the following categories: PHC philosophy and conception, service provision organization, intersectoral collaboration and social participation. Primary health care models were identified in association with existing health system types and the dynamics of PHC renewal in each country. A neo-selective model was found in three countries where coverage is segmented by private and public regimes; here, individual and collective care are separated. A comprehensive approach similar to the Alma-Ata model was found in seven countries where the public sector predominates and individual, family and community care are coordinated under the responsibility of the same health care team. The process of implementing a renewed PHC approach is affected by how health systems are funded and organized. Both models face many obstacles. In addition, care system organization, intersectoral coordination and social participation are weak in most of the countries. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  18. The Harvard Medical School Academic Innovations Collaborative: transforming primary care practice and education.

    PubMed

    Bitton, Asaf; Ellner, Andrew; Pabo, Erika; Stout, Somava; Sugarman, Jonathan R; Sevin, Cory; Goodell, Kristen; Bassett, Jill S; Phillips, Russell S

    2014-09-01

    Academic medical centers (AMCs) need new approaches to delivering higher-quality care at lower costs, and engaging trainees in the work of high-functioning primary care practices. In 2012, the Harvard Medical School Center for Primary Care, in partnership with with local AMCs, established an Academic Innovations Collaborative (AIC) with the goal of transforming primary care education and practice. This novel two-year learning collaborative consisted of hospital- and community-based primary care teaching practices, committed to building highly functional teams, managing populations, and engaging patients. The AIC built on models developed by Qualis Health and the Institute for Healthcare Improvement, optimized for the local AMC context. Foundational elements included leadership engagement and development, application of rapid-cycle process improvement, and the creation of teams to care for defined patient populations. Nineteen practices across six AMCs participated, with nearly 260,000 patients and 450 resident learners. The collaborative offered three 1.5-day learning sessions each year featuring shared learning, practice coaches, and improvement measures, along with monthly data reporting, webinars, and site visits. Validated self-reports by transformation teams showed that practices made substantial improvement across all areas of change. Important factors for success included leadership development, practice-level resources, and engaging patients and trainees. The AIC model shows promise as a path for AMCs to catalyze health system transformation through primary care improvement. In addition to further evaluating the impact of practice transformation, expansion will require support from AMCs and payers, and the application of similar approaches on a broader scale.

  19. [Primary care evaluation of the hypertensive patient management in specialized care after derivation (DERIVA-2 Study)].

    PubMed

    Martell-Claros, Nieves; Galgo Nafría, Alberto; Abad-Cardiel, María; Álvarez-Álvarez, Beatriz; García Donaire, José Antonio; Márquez-Contreras, Emilio; Molino-González, Ángel

    2017-10-13

    To know the opinion/evaluation of the primary care physicians (PCPH) of the received information about patients that were attended in specialized care (SC). Cross-sectional study. Performed nationwide in primary care centers. Researchers from the primary care network. We used the SEH-LELHA derivation criteria guidelines, plus an ad hoc survey that included demographic and anthropometric data, blood pressure levels, and the main reason for derivation to SC at the baseline and final (post-derivation) visit. In addition, time deployed for the study of every patient, changes in diagnosis and treatment, type of follow-up, issues throughout the derivation process and assessment of the medical referred to the PCPH were evaluated. With participation of 578 researchers from primary, the study included 1715 patients aged 60.7±13.3years, 62.7% male. Patients were taking 2.3±1.2 (range 0-10) antihypertensive drugs pre-referral and 2.5±1.2 (0-9) after derivation. Blood pressure levels changed from 166±21.6 /97.7±12.6mmHg to 143±14.4 /85.5±10.5mmHg. The number of controlled patients (BP<140 and <90mmHg) increased from 5.8% to 32.2%. Time between pre- and post-derivation visit was 72±64days (median 57days, IQ26-99). The PCPH received a medical report in 80.3% of cases, 76.9% with an explanation of the results of the complementary tests, 75.8% with additional information or a reasoning of treatment and in 71% of cases information about the patient future management. 63% of PCPH were fully agreed with the management of the specialist, 29% agree and 2% strongly disagree. The derivation was evaluated as effective or very effective in 86% of patients and no effective in 9%. Communication between AE and SC in HTA is valued satisfactorily by MAP. However there is still room for improvement in the process. Copyright © 2017. Publicado por Elsevier España, S.L.U.

  20. Primary care research conducted in networks: getting down to business.

    PubMed

    Mold, James W

    2012-01-01

    This seventh annual practice-based research theme issue of the Journal of the American Board of Family Medicine highlights primary care research conducted in practice-based research networks (PBRNs). The issue includes discussion of (1) theoretical and methodological research, (2) health care research (studies addressing primary care processes), (3) clinical research (studies addressing the impact of primary care on patients), and (4) health systems research (studies of health system issues impacting primary care including the quality improvement process). We had a noticeable increase in submissions from PBRN collaborations, that is, studies that involved multiple networks. As PBRNs cooperate to recruit larger and more diverse patient samples, greater generalizability and applicability of findings lead to improved primary care processes.

  1. Gender Confirmation Surgery: An Update for the Primary Care Provider

    PubMed Central

    Schechter, Loren S.

    2016-01-01

    Abstract Increased advocacy efforts and expanded third-party insurance coverage have improved access to healthcare for transgender individuals. In conjunction with mental health and medical professionals, gender surgeries offer an important step in allowing individuals to realize their true selves. To provide quality multidisciplinary care, primary care doctors need to understand challenges facing transgender individuals and treatment options available to them. In this article, we will review the role of the surgeon and the goals of various gender confirming surgeries. In addition, we will provide an overview of the available surgical options. PMID:29159295

  2. Borderline personality disorder in the primary care setting.

    PubMed

    Dubovsky, Amelia N; Kiefer, Meghan M

    2014-09-01

    Borderline personality disorder is estimated to be present in approximately 6% of outpatient primary care settings. However, the time and energy spent on this population can greatly exceed what primary care doctors are able to spend. This article gives an overview of borderline personality disorder, including the clinical characteristics, epidemiology, and comorbidities, as well as pharmacologic and most important behavioral management. It is our hope that, with improved understanding of the disorder and skills for managing this population, caring for patients with the disorder can be more satisfying and less taxing for both primary care doctors and their patients. Copyright © 2014 Elsevier Inc. All rights reserved.

  3. Third sector primary health care in New Zealand.

    PubMed

    Crampton, P; Dowell, A C; Bowers, S

    2000-03-24

    To describe key organisational characteristics of selected third sector (non-profit and non-government) primary health care organisations. Data were collected, in 1997 and 1998, from 15 third sector primary care organisations that were members of a network of third sector primary care providers, Health Care Aotearoa (HCA). Data were collected by face-to-face interviews of managers and key informants using a semi-structured interview schedule, and from practice computer information systems. Overall the populations served were young: only 4% of patients were aged 65 years or older, and the ethnicity profile was highly atypical, with 21.8% European, 36% Maori, 22.7% Pacific Island, 12% other, and 7.5% not stated. Community services card holding rates were higher than recorded in other studies, and registered patients tended to live in highly deprived areas. HCA organisations had high patient to doctor ratios, in general over 2000:1, and there were significant differences in management structures between HCA practices and more traditional general practice. Third sector organisations provide services for populations that are disadvantaged in many respects. It is likely that New Zealand will continue to develop a diverse range of primary care organisational arrangements. Effort is now required to measure quality and effectiveness of services provided by different primary care organisations serving comparable populations.

  4. Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study.

    PubMed

    Mundt, Marlon P; Agneessens, Filip; Tuan, Wen-Jan; Zakletskaia, Larissa I; Kamnetz, Sandra A; Gilchrist, Valerie J

    2016-06-01

    Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care. To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes. A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling. 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013. Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (rate ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes. Primary care teams which relied on frequent daily face-to-face communication among more team members, and had a single RN communicating patient care

  5. Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study

    PubMed Central

    Mundt, Marlon P.; Agneessens, Filip; Tuan, Wen-Jan; Zakletskaia, Larissa I.; Kamnetz, Sandra A.; Gilchrist, Valerie J.

    2016-01-01

    Background Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care. Objective To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes. Methods A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling. Participants 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013. Results Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (Rate Ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds Ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes. Conclusions Primary care teams which relied on frequent daily face-to-face communication among more

  6. Identification of early childhood caries in primary care settings.

    PubMed

    Nicolae, Alexandra; Levin, Leo; Wong, Peter D; Dave, Malini G; Taras, Jillian; Mistry, Chetna; Ford-Jones, Elizabeth L; Wong, Michele; Schroth, Robert J

    2018-04-01

    Early childhood caries (ECC) is the most common chronic disease affecting young children in Canada. ECC may lead to pain and infection, compromised general health, decreased quality of life and increased risk for dental caries in primary and permanent teeth. A multidisciplinary approach to prevent and identify dental disease is recommended by dental and medical national organizations. Young children visit primary care providers at regular intervals from an early age. These encounters provide an ideal opportunity for primary care providers to educate clients about their children's oral health and its importance for general health. We designed an office-based oral health screening guide to help primary care providers identify ECC, a dental referral form to facilitate dental care access and an oral health education resource to raise parental awareness. These resources were reviewed and trialled with a small number of primary care providers.

  7. Reducing suicidal ideation in depressed older primary care patients.

    PubMed

    Unützer, Jürgen; Tang, Lingqi; Oishi, Sabine; Katon, Wayne; Williams, John W; Hunkeler, Enid; Hendrie, Hugh; Lin, Elizabeth H B; Levine, Stuart; Grypma, Lydia; Steffens, David C; Fields, Julie; Langston, Christopher

    2006-10-01

    To determine the effect of a primary care-based collaborative care program for depression on suicidal ideation in older adults. Randomized, controlled trial. Eighteen diverse primary care clinics. One thousand eight hundred one adults aged 60 and older with major depression or dysthymia. Participants randomized to collaborative care had access to a depression care manager who supported antidepressant medication management prescribed by their primary care physician and offered a course of Problem Solving Treatment in Primary Care for 12 months. Participants in the control arm received care as usual. Participants had independent assessments of depression and suicidal ideation at baseline and 3, 6, 12, 18, and 24 months. Depression was assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID). Suicidal ideation was determined using the SCID and the Hopkins Symptoms Checklist. At baseline, 139 (15.3%) intervention subjects and 119 (13.3%) controls reported thoughts of suicide. Intervention subjects had significantly lower rates of suicidal ideation than controls at 6 months (7.5% vs 12.1%) and 12 months (9.8% vs 15.5%) and even after intervention resources were no longer available at 18 months (8.0% vs 13.3%) and 24 months (10.1% vs 13.9%). There were no completed suicides in either group. Information on suicide attempts or hospitalization for suicidal ideation was not available. Primary care-based collaborative care programs for depression represent one strategy to reduce suicidal ideation and potentially the risk of suicide in older primary care patients.

  8. Across the Divide: “Primary Care Departments Working Together to Redesign Care to Achieve the Triple Aim”

    PubMed Central

    Koslov, Steven; Trowbridge, Elizabeth; Kamnetz, Sandra; Kraft, Sally; Grossman, Jeffrey; Pandhi, Nancy

    2016-01-01

    Background Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim. Methods As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing. Results Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability. Conclusions Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes. Implications The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation. PMID:27637827

  9. Socioeconomic status and geographical factors associated with active listing in primary care: a cross-sectional population study accounting for multimorbidity, age, sex and primary care

    PubMed Central

    Ranstad, Karin; Midlöv, Patrik; Halling, Anders

    2017-01-01

    Background Socioeconomic status and geographical factors are associated with health and use of healthcare. Well-performing primary care contributes to better health and more adequate healthcare. In a primary care system based on patient’s choice of practice, this choice (listing) is a key to understand the system. Objective To explore the relationship between population and practices in a primary care system based on listing. Methods Cross-sectional population-based study. Logistic regressions of the associations between active listing in primary care, income, education, distances to healthcare and geographical location, adjusting for multimorbidity, age, sex and type of primary care practice. Setting and subjects Population over 15 years (n=123 168) in a Swedish county, Blekinge (151 731 inhabitants), in year 2007, actively or passively listed in primary care. The proportion of actively listed was 68%. Main outcome measure Actively listed in primary care on 31 December 2007. Results Highest ORs for active listing in the model including all factors according to income had quartile two and three with OR 0.70 (95% CI 0.69 to 0.70), and those according to education less than 9 years of education had OR 0.70 (95% CI 0.68 to 0.70). Best odds for geographical factors in the same model had municipality C with OR 0.85 (95% CI 0.85 to 0.86) for active listing. Akaike’s Information Criterion (AIC) was 124 801 for a model including municipality, multimorbidity, age, sex and type of practice and including all factors gave AIC 123 934. Conclusions Higher income, shorter education, shorter distance to primary care or longer distance to hospital is associated with active listing in primary care. Multimorbidity, age, geographical location and type of primary care practice are more important to active listing in primary care than socioeconomic status and distance to healthcare. PMID:28601827

  10. Lung Cancer Screening with Low-Dose Computed Tomography for Primary Care Providers

    PubMed Central

    Richards, Thomas B.; White, Mary C.; Caraballo, Ralph S.

    2015-01-01

    This review provides an update on lung cancer screening with low-dose computed tomography (LDCT) and its implications for primary care providers. One of the unique features of lung cancer screening is the potential complexity in patient management if an LDCT scan reveals a small pulmonary nodule. Additional tests, consultation with multiple specialists, and follow-up evaluations may be needed to evaluate whether lung cancer is present. Primary care providers should know the resources available in their communities for lung cancer screening with LDCT and smoking cessation, and the key points to be addressed in informed and shared decision-making discussions with patients. PMID:24830610

  11. Curative procedures of oral health and structural characteristics of primary dental care.

    PubMed

    Baumgarten, Alexandre; Hugo, Fernando Neves; Bulgarelli, Alexandre Fávero; Hilgert, Juliana Balbinot

    2018-04-09

    To evaluate if the provision of clinical dental care, by means of the main curative procedures recommended in Primary Health Care, is associated with team structural characteristics, considering the presence of a minimum set of equipment, instrument, and supplies in Brazil's primary health care services. A cross-sectional exploratory study based on data collected from 18,114 primary healthcare services with dental health teams in Brazil, in 2014. The outcome was created from the confirmation of five clinical procedures performed by the dentist, accounting for the presence of minimum equipment, instrument, and supplies to carry them out. Covariables were related to structural characteristics. Poisson regression with robust variance was used to obtain crude and adjusted prevalence ratios, with 95% confidence intervals. A total of 1,190 (6.5%) dental health teams did not present the minimum equipment to provide clinical dental care and only 2,498 (14.8%) had all the instrument and supplies needed and provided the five curative procedures assessed. There was a positive association between the outcome and the composition of dental health teams, higher workload, performing analysis of health condition, and monitoring of oral health indicators. Additionally, the dental health teams that planned and programmed oral health actions with the primary care team monthly provided the procedures more frequently. Dentists with better employment status, career plans, graduation in public health or those who underwent permanent education activities provided the procedures more frequently. A relevant number of Primary Health Care services did not have the infrastructure to provide clinical dental care. However, better results were found in dental health teams with oral health technicians, with higher workload and that plan their activities, as well as in those that employed dentists with better working relationships, who had dentists with degrees in public health and who underwent

  12. Assessment of primary care services and perceived barriers to care in persons with disabilities.

    PubMed

    Harrington, Amanda L; Hirsch, Mark A; Hammond, Flora M; Norton, H James; Bockenek, William L

    2009-10-01

    To determine what percentage of persons with disabilities have a primary care provider, participate in routine screening and health maintenance examinations, and identify perceived physical or physician barriers to receiving care. A total of 344 surveys, consisting of 66 questions, were collected from adults with disabilities receiving care at an outpatient rehabilitation clinic. A total of 89.5% (95% CI 86.3%-92.8%) of participants reported having a primary care physician. Younger persons (P < 0.0001), men (P < 0.02), persons with brain injury (P < 0.05), or persons with amputations (P < 0.05) were less likely to have a primary care physician. Participant report of screening for alcohol, nonprescription drug use, and safety with relationships at home ranged from 26.6% to 37.5% compared with screening for depression, diet, exercise, and smoking (64.5%-70%). Completion rates of age- and gender-appropriate health maintenance examinations ranged from 42.4% to 90%. A total of 2.67% of participants reported problems with physical access at their physician's office, and 36.4% (95% CI 30.8%-42.1%) of participants reported having to teach their primary care physician about their disability. Most persons with disabilities have a primary care physician. In general, completion rates for routine screening and health maintenance examinations were high. Perceived deficits in primary care physicians' knowledge of disability issues seem more prevalent than physical barriers to care.

  13. Diverticular Disease in the Primary Care Setting.

    PubMed

    Wensaas, Knut-Arne; Hungin, Amrit Pali

    2016-10-01

    Diverticular disease is a chronic and common condition, and yet the impact of diverticular disease in primary care is largely unknown. The diagnosis of diverticular disease relies on the demonstration of diverticula in the colon, and the necessary investigations are often not available in primary care. The specificity and sensitivity of symptoms, clinical signs and laboratory tests alone are generally low and consequently the diagnostic process will be characterized by uncertainty. Also, the criteria for symptomatic uncomplicated diverticular disease in the absence of macroscopic inflammation are not clearly defined. Therefore both the prevalence of diverticular disease and the incidence of diverticulitis in primary care are unknown. Current recommendations for treatment and follow-up of patients with acute diverticulitis are based on studies where the diagnosis has been verified by computerized tomography. The results cannot be directly transferred to primary care where the diagnosis has to rely on the interpretation of symptoms and signs. Therefore, one must allow for greater diagnostic uncertainty, and safety netting in the event of unexpected development of the condition is an important aspect of the management of diverticulitis in primary care. The highest prevalence of diverticular disease is found among older patients, where multimorbidity and polypharmacy is common. The challenge is to remember the possible contribution of diverticular disease to the patient's overall condition and to foresee its implications in terms of advice and treatment in relation to other diseases.

  14. Multimorbidity, service organization and clinical decision making in primary care: a qualitative study.

    PubMed

    Bower, Peter; Macdonald, Wendy; Harkness, Elaine; Gask, Linda; Kendrick, Tony; Valderas, Jose M; Dickens, Chris; Blakeman, Tom; Sibbald, Bonnie

    2011-10-01

    Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses. Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions. Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.

  15. Time providing care outside visits in a home-based primary care program.

    PubMed

    Pedowitz, Elizabeth J; Ornstein, Katherine A; Farber, Jeffrey; DeCherrie, Linda V

    2014-06-01

    To assess how much time physicians in a large home-based primary care (HBPC) program spend providing care outside of home visits. Unreimbursed time and patient and provider-related factors that may contribute to that time were considered. Mount Sinai Visiting Doctors (MSVD) providers filled out research forms for every interaction involving care provision outside of home visits. Data collected included length of interaction, mode, nature, and with whom the interaction was for 3 weeks. MSVD, an academic home-visit program in Manhattan, New York. All primary care physicians (PCPs) in MSVD (n = 14) agreed to participate. Time data were analyzed using a comprehensive estimate and conservative estimates to quantify unbillable time. Data on 1,151 interactions for 537 patients were collected. An average 8.2 h/wk was spent providing nonhome visit care for a full-time provider. Using the most conservative estimates, 3.6 h/wk was estimated to be unreimbursed per full-time provider. No significant differences in interaction times were found between patients with and without dementia, new and established patients, and primary-panel and covered patients. Home-based primary care providers spend substantial time providing care outside home visits, much of which goes unrecognized in the current reimbursement system. These findings may help guide practice development and creation of new payment systems for HBPC and similar models of care. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

  16. Racial Disparities In Geographic Access To Primary Care In Philadelphia.

    PubMed

    Brown, Elizabeth J; Polsky, Daniel; Barbu, Corentin M; Seymour, Jane W; Grande, David

    2016-08-01

    Primary care is often thought of as the gateway to improved health outcomes and can lead to more efficient use of health care resources. Because of primary care's cardinal importance, adequate access is an important health policy priority. In densely populated urban areas, spatial access to primary care providers across neighborhoods is poorly understood. We examined spatial variation in primary care access in Philadelphia, Pennsylvania. We calculated ratios of adults per primary care provider for each census tract and included buffer zones based on prespecified drive times around each tract. We found that the average ratio was 1,073; the supply of primary care providers varied widely across census tracts, ranging from 105 to 10,321. We identified six areas of Philadelphia that have much lower spatial accessibility to primary care relative to the rest of the city. After adjustment for sociodemographic and insurance characteristics, the odds of being in a low-access area were twenty-eight times greater for census tracts with a high proportion of African Americans than in tracts with a low proportion of African Americans. Project HOPE—The People-to-People Health Foundation, Inc.

  17. Efficacy of self-help manuals for anxiety disorders in primary care: a systematic review.

    PubMed

    van Boeijen, Christine A; van Balkom, Anton J L M; van Oppen, Patricia; Blankenstein, Nettie; Cherpanath, Ammani; van Dyck, Richard

    2005-04-01

    The purpose of this study was to review effectiveness studies of self-help manuals for anxiety disorders in primary care. A systematic review of six identified randomized controlled trials was carried out. In addition to outcome, the articles were coded on quality variables. The studies included differed with respect to the methodological quality, measurements used and size of the study population. Despite these differences, global results suggest that a self-help manual is an effective treatment possibility for primary care patients with anxiety disorders. The more time that was spent on guidance on the use of the self-help manual the greater was its effectiveness. Treatment with a self-help manual for anxiety disorders may be effective in primary care. Data are lacking on the feasibility and cost-effectiveness of these manuals.

  18. Primary Health Care: care coordinator in regionalized networks?

    PubMed

    Almeida, Patty Fidelis de; Santos, Adriano Maia Dos

    2016-12-22

    To analyze the breadth of care coordination by Primary Health Care in three health regions. This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia. Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network. Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries. Analisar o alcance da coordenação do cuidado pela Atenção Primária à Saúde em três regiões de saúde. Trata-se de estudo de caso, com abordagem quantitativa e qualitativa. Foram realizadas 31 entrevistas semiestruturadas com gestores municipais, regionais e estaduais e estudo transversal com aplicação de questionários para médicos (74), enfermeiros (127) e amostra representativa de usuários (1.590) da Estratégia Saúde da Família em três municípios-sede de regiões de saúde do estado da Bahia. A função de porta de entrada preferencial pela Atenção Primária à Saúde deparava-se com forte concorrência de servi

  19. Using quality experts from manufacturing to transform primary care.

    PubMed

    Steiner, Rose M; Walsworth, David T

    2010-01-01

    Improving Performance in Practice (IPIP) is an initiative convened by the American Board of Medical Specialties. It investigates the efficacy of coaches in helping primary-care practices improve the care of patients with diabetes and asthma. Most IPIP states use coaches who have a health care background, and are trained in quality and process improvement. Michigan uses quality experts from the manufacturing industry who are educated regarding the health care environment, which enables them to perform as quality-improvement coaches (QICs) in primary-care practices. In this case study, ninety-six quality experts were trained to coach primary-care practices, with 53 currently assigned to offices, and others assisting as needed. Practice teams and QICs identify gaps in care and office practices with the use of assorted quality-improvement tools. Reports are made monthly to describe clinical and process measures and methods used. Michigan has 33 practices engaged, involving 205 physicians and 40 midlevel providers. The teaming of quality experts from the manufacturing industry with primary-care office providers and staff resulted in office efficiency, improved care provided, and progress toward attainment of a patient-centered medical home (PCMH). Quality experts from manufacturing volunteered to coach for improvements in primary care. The efforts of QICs have been successful. Because the QICs are volunteers, sustainability of the Michigan Improving Performance in Practice program is a challenge.

  20. Primary Care Practice Development: A Relationship-Centered Approach

    PubMed Central

    Miller, William L.; Crabtree, Benjamin F.; Nutting, Paul A.; Stange, Kurt C.; Jaén, Carlos Roberto

    2010-01-01

    PURPOSE Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to first-contact care, comprehensive care, coordination of care, and a personal relationship over time. METHODS Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians’ National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice. RESULTS Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice’s key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice’s internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fits with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations. CONCLUSIONS Successful practice development begins with changes that strengthen practices’ core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes. PMID:20530396

  1. Spatial Access to Primary Care Providers in Appalachia

    PubMed Central

    Donohoe, Joseph; Marshall, Vince; Tan, Xi; Camacho, Fabian T.; Anderson, Roger T.; Balkrishnan, Rajesh

    2016-01-01

    Purpose: The goal of this research was to examine spatial access to primary care physicians in Appalachia using both traditional access measures and the 2-step floating catchment area (2SFCA) method. Spatial access to care was compared between urban and rural regions of Appalachia. Methods: The study region included Appalachia counties of Pennsylvania, Ohio, Kentucky, and North Carolina. Primary care physicians during 2008 and total census block group populations were geocoded into GIS software. Ratios of county physicians to population, driving time to nearest primary care physician, and various 2SFCA approaches were compared. Results: Urban areas of the study region had shorter travel times to their closest primary care physician. Provider to population ratios produced results that varied widely from one county to another because of strict geographic boundaries. The 2SFCA method produced varied results depending on the distance decay weight and variable catchment size techniques chose. 2SFCA scores showed greater access to care in urban areas of Pennsylvania, Ohio, and North Carolina. Conclusion: The different parameters of the 2SFCA method—distance decay weights and variable catchment sizes—have a large impact on the resulting spatial access to primary care scores. The findings of this study suggest that using a relative 2SFCA approach, the spatial access ratio method, when detailed patient travel data are unavailable. The 2SFCA method shows promise for measuring access to care in Appalachia, but more research on patient travel preferences is needed to inform implementation. PMID:26906524

  2. Optimizing the Primary Prevention of Type-2 Diabetes in Primary Health Care

    ClinicalTrials.gov

    2017-08-18

    Interprofessional Relations; Primary Health Care/Organization & Administration; Diabetes Mellitus, Type 2/Prevention & Control; Primary Prevention/Methods; Risk Reduction Behavior; Randomized Controlled Trial; Life Style

  3. How to monitor patient safety in primary care? Healthcare professionals' views

    PubMed Central

    Samra, R; Car, J; Majeed, A; Vincent, C

    2016-01-01

    Summary Objective To identify patient safety monitoring strategies in primary care. Design Open-ended questionnaire survey. Participants A total of 113 healthcare professionals returned the survey from a group of 500 who were invited to participate achieving a response rate of 22.6%. Setting North-West London, United Kingdom. Method A paper-based and equivalent online survey was developed and subjected to multiple stages of piloting. Respondents were asked to suggest strategies for monitoring patient safety in primary care. These monitoring suggestions were then subjected to a content frequency analysis which was conducted by two researchers. Main Outcome measures Respondent-derived monitoring strategies. Results In total, respondents offered 188 suggestions for monitoring patient safety in primary care. The content analysis revealed that these could be condensed into 24 different future monitoring strategies with varying levels of support. Most commonly, respondents supported the suggestion that patient safety can only be monitored effectively in primary care with greater levels of staffing or with additional resources. Conclusion Approximately one-third of all responses were recommendations for strategies which addressed monitoring of the individual in the clinical practice environment (e.g. GP, practice nurse) to improve safety. There was a clear need for more staff and resource set aside to allow and encourage safety monitoring. Respondents recommended the dissemination of specific information for monitoring patient safety such as distributing the lessons of significant event audits amongst GP practices to enable shared learning. PMID:27540488

  4. Primary care nurses' performance in motivational interviewing: a quantitative descriptive study.

    PubMed

    Östlund, Ann-Sofi; Kristofferzon, Marja-Leena; Häggström, Elisabeth; Wadensten, Barbro

    2015-07-25

    Motivational interviewing is a collaborative conversational style intended to strengthen motivation to change. It has been shown to be effective in addressing many different lifestyle problems as well as in chronic disease management, and many disease prevention guidelines promote use of motivational interviewing. The aim of the present study was twofold: to assess to what extent the primary care nurses in the study perform motivational interviewing according to the Motivational Interviewing Treatment Integrity Code and to investigate how the participating primary care nurses rated their own performance in motivational interviewing. The study was based on twelve primary care nurses' audio-recorded motivational interviewing sessions with patients (total 32 sessions). After each session, the nurses completed a questionnaire regarding their experience of their own performance in motivational interviewing. The audio-recorded sessions were analyzed using Motivational Interviewing Integrity Code 3.1.1. None of the nurses achieved beginning proficiency in all parts of any motivational interviewing sessions and two nurses did not achieve beginning proficiency in any parts or sessions. Making more complex than simple reflections was the specific verbal behavior/summary score that most nurses achieved. Beginning proficiency/competency in "percent open questions" was the summary score that fewest achieved. Primary care nurses did not achieve beginning proficiency/competency in all aspects of motivational interviewing in their recorded sessions with patients, where lifestyle change was discussed. This indicates a need for improvement and thus additional training, feedback and supervision in clinical practice with motivational interviewing.

  5. Systematic review of the effectiveness of primary care nursing.

    PubMed

    Keleher, Helen; Parker, Rhian; Abdulwadud, Omar; Francis, Karen

    2009-02-01

    This paper reports on a systematic review that sought to answer the research question: What is the impact of the primary and community care nurse on patient health outcomes compared with usual doctor-led care in primary care settings? A range of pertinent text-words with medical subject headings were combined and electronic databases were searched. Because of the volume of published articles, the search was restricted to studies with high-level evidence. Overall, 31 relevant studies were identified and included in the review. We found modest international evidence that nurses in primary care settings can provide effective care and achieve positive health outcomes for patients similar to that provided by doctors. Nurses are effective in care management and achieve good patient compliance. Nurses are also effective in a more diverse range of roles including chronic disease management, illness prevention and health promotion. Nevertheless, there is insufficient evidence about primary care nurses' roles and impact on patient health outcomes.

  6. Physical Profiling Performance of Air Force Primary Care Providers

    DTIC Science & Technology

    2017-08-09

    AFRL-SA-WP-TR-2017-0014 Physical Profiling Performance of Air Force Primary Care Providers Anthony P. Tvaryanas1; William P...COVERED (From – To) September 2016 – January 2017 4. TITLE AND SUBTITLE Physical Profiling Performance of Air Force Primary Care Providers...encounter with their primary care team. An independent medical standards subject matter expert (SME) reviewed encounters in the electronic health record

  7. Contributions of graduate mental health workers in primary care.

    PubMed

    Schafer, Tim; Wrycraft, Nick

    Graduate primary care mental health workers are part of the NHS strategy for improving the mental health of the primary care population. This article describes the role and potential contribution of these health workers to patients' mental wellbeing in primary care. Readers are informed about the need for graduate worker, and some of the issues that arose on implementing this initiative in one English region.

  8. Managed care and the delivery of primary care to the elderly and the chronically ill.

    PubMed

    Wholey, D R; Burns, L R; Lavizzo-Mourey, R

    1998-06-01

    To analyze primary care staffing in HMOs and to review the literature on primary care organization and performance in managed care organizations, with an emphasis on the delivery of primary care to the elderly and chronically ill. Analysis of primary care staffing: InterStudy HMO census data on primary care (n = 1,956) and specialist (n = 1,777) physician staffing levels from 1991 through 1995. Primary care organization and performance for the chronically ill and elderly were analyzed using a review of published research. For the staffing-level models, the number of primary care and specialist physicians per 100,000 enrollees was regressed on HMO characteristics (HMO type [group, staff, network, mixed], HMO enrollment, federal qualification, profit status, national affiliation) and community characteristics (per capita income, population density, service area size, HMO competition). For the review of organization and performance, literature published was summarized in a tabular format. The analysis of physician staffing shows that group and staff HMOs have fewer primary care and specialist physicians per 100,000 enrollees than do network and mixed HMOs, which have fewer than IPAs. Larger HMOs use fewer physicians per 100,000 enrollees than smaller HMOs. Federally qualified HMOs have fewer primary care and specialist physicians per 100,000 enrollees. For-profit, nationally affiliated, and Blue Cross HMOs have more primary care and specialist physicians than do local HMOs. HMOs in areas with high per capita income have more PCPs per 100,000 and a greater proportion of PCPs in the panel. HMO penetration decreases the use of specialists, but the number of HMOs increases the use of primary care and specialist physicians in highly competitive markets. Under very competitive conditions, HMOs appear to compete by increasing access to both PCPs and specialists, with a greater emphasis on access to specialists. The review of research on HMO performance suggests that access

  9. Moving toward a United States strategic plan in primary care informatics: a White Paper of the Primary Care Informatics Working Group, American Medical Informatics Association.

    PubMed

    Little, David R; Zapp, John A; Mullins, Henry C; Zuckerman, Alan E; Teasdale, Sheila; Johnson, Kevin B

    2003-01-01

    The Primary Care Informatics Working Group (PCIWG) of the American Medical Informatics Association (AMIA) has identified the absence of a national strategy for primary care informatics. Under PCIWG leadership, major national and international societies have come together to create the National Alliance for Primary Care Informatics (NAPCI), to promote a connection between the informatics community and the organisations that support primary care. The PCIWG clinical practice subcommittee has recognised the necessity of a global needs assessment, and proposed work in point-of-care technology, clinical vocabularies, and ambulatory electronic medical record development. Educational needs include a consensus statement on informatics competencies, recommendations for curriculum and teaching methods, and methodologies to evaluate their effectiveness. The research subcommittee seeks to define a primary care informatics research agenda, and to support and disseminate informatics research throughout the primary care community. The AMIA board of directors has enthusiastically endorsed the conceptual basis for this White Paper.

  10. Spirometry in primary care: An analysis of spirometry test quality in a regional primary care asthma program

    PubMed Central

    Licskai, Christopher J; Sands, Todd W; Paolatto, Lisa; Nicoletti, Ivan; Ferrone, Madonna

    2012-01-01

    BACKGROUND: Primary care office spirometry can improve access to testing and concordance between clinical practice and asthma guidelines. Compliance with test quality standards is essential to implementation. OBJECTIVE: To evaluate the quality of spirometry performed onsite in a regional primary care asthma program (RAP) by health care professionals with limited training. METHODS: Asthma educators were trained to perform spirometry during two 2 h workshops and supervised during up to six patient encounters. Quality was analyzed using American Thoracic Society (ATS) 1994 and ATS/European Respiratory Society (ERS) 2003 (ATS/ERS) standards. These results were compared with two regional reference sites: a primary care group practice (Family Medical Centre [FMC], Windsor, Ontario) and a teaching hospital pulmonary function laboratory (London Health Sciences Centre [LHSC], London, Ontario). RESULTS: A total of 12,815 flow-volume loops (FVL) were evaluated: RAP – 1606 FVL in 472 patient sessions; reference sites – FMC 4013 FVL in 573 sessions; and LHSC – 7196 in 1151 sessions. RAP: There were three acceptable FVL in 392 of 472 (83%) sessions, two reproducible FVL according to ATS criteria in 428 of 469 (91%) sessions, and 395 of 469 (84%) according to ATS/ERS criteria. All quality criteria – minimum of three acceptable and two reproducible FVL according to ATS criteria in 361 of 472 (77%) sessions and according to ATS/ERS criteria in 337 of 472 (71%) sessions. RAP met ATS criteria more often than the FMC (388 of 573 [68%]); however, less often than LHSC (1050 of 1151 [91%]; P<0.001). CONCLUSIONS: Health care providers with limited training and experience operating within a simple quality program achieved ATS/ERS quality spirometry in the majority of sessions in a primary care setting. The quality performance approached pulmonary function laboratory standards. PMID:22891184

  11. Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users.

    PubMed

    Capp, Roberta; Misky, Gregory J; Lindrooth, Richard C; Honigman, Benjamin; Logan, Heather; Hardy, Rose; Nguyen, Dong Q; Wiler, Jennifer L

    2017-10-01

    Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities. Project HOPE—The People-to-People Health Foundation, Inc.

  12. Mental health care treatment initiation when mental health services are incorporated into primary care practice.

    PubMed

    Kessler, Rodger

    2012-01-01

    Most primary care patients with mental health issues are identified or treated in primary care rather than the specialty mental health system. Primary care physicians report that their patients do not have access to needed mental health care. When referrals are made to the specialty behavioral or mental health care system, rates of patients who initiate treatment are low. Collaborative care models, with mental health clinicians as part of the primary care medical staff, have been suggested as an alternative. The aim of this study is to examine rates of treatment startup in 2 collaborative care settings: a rural family medicine office and a suburban internal medicine office. In both practices referrals for mental health services are made within the practice. Referral data were drawn from 2 convenience samples of patients referred by primary care physicians for collaborative mental health treatment at Fletcher Allen Health Care in Vermont. The first sample consisted of 93 consecutively scheduled referrals in a family medicine office (sample A) between January 2006 and December 2007. The second sample consisted of 215 consecutive scheduled referrals at an internal medicine office (sample B) between January 2009 and December 2009. Referral data identified age, sex, and presenting mental health/medical problem. In sample A, 95.5% of those patients scheduling appointments began behavioral health treatment; in sample B this percentage was 82%. In sample B, 69% of all patients initially referred for mental health care both scheduled and initiated treatment. When referred to a mental health clinician who provides on-site access as part of a primary care mental health collaborative care model, a high percentage of patients referred scheduled care. Furthermore, of those who scheduled care, a high percentage of patients attend the scheduled appointment. Findings persist despite differences in practice type, populations, locations, and time frames of data collection. That the

  13. Integrating Social Determinants of Health into Primary Care Clinical and Informational Workflow during Care Transitions

    PubMed Central

    Hewner, Sharon; Casucci, Sabrina; Sullivan, Suzanne; Mistretta, Francine; Xue, Yuqing; Johnson, Barbara; Pratt, Rebekah; Lin, Li; Fox, Chester

    2017-01-01

    Context: Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. Case Description: The coordinating transitions intervention uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach. The intervention incorporates claims-based risk stratification to prioritize patients for follow-up and an assessment of social determinants of health using the Patient-centered Assessment Method (PCAM). Results from transitional care are stored and transmitted to qualified healthcare providers across the continuum. Findings: Reliance on tools that incorporated interoperability standards facilitated exchange of health information between the hospital and primary care. The PCAM was incorporated into both the clinical and informational workflow through the collaboration of clinical, industry, and academic partners. Health outcomes improved at the study practice over their baseline and in comparison with control practices and the regional Medicaid population. Major Themes: Current research supports the potential impact of systems approaches to care coordination in improving utilization value after discharge. The project demonstrated that flexibility in developing the informational and clinical workflow was critical in developing a solution that improved continuity during transitions. There is additional work needed in developing managerial continuity across settings such as shared comprehensive care plans. Conclusions: New clinical and informational workflows which incorporate social determinant of health data into standard practice transformed clinical practice and improved outcomes for patients.

  14. Assessment and management of suicide risk in primary care.

    PubMed

    Saini, Pooja; While, David; Chantler, Khatidja; Windfuhr, Kirsten; Kapur, Navneet

    2014-01-01

    Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services. To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide. Data collection from clinical proformas, case records, and semistructured face-to-face interviews with general practitioners. Primary and secondary care data were available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall κ = .127, p = .10). Depression, care setting (after discharge), suicidal ideation at last contact, and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices, and 33% of staff received training in suicide risk assessments. Risk is difficult to predict, but the variation in risk assessment between professional groups may reflect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care.

  15. Quality of asthma care under different primary care models in Canada: a population-based study.

    PubMed

    To, Teresa; Guan, Jun; Zhu, Jingqin; Lougheed, M Diane; Kaplan, Alan; Tamari, Itamar; Stanbrook, Matthew B; Simatovic, Jacqueline; Feldman, Laura; Gershon, Andrea S

    2015-02-14

    Previous research has shown variations in quality of care and patient outcomes under different primary care models. The objective of this study was to use previously validated, evidence-based performance indicators to measure quality of asthma care over time and to compare quality of care between different primary care models. Data were obtained for years 2006 to 2010 from the Ontario Asthma Surveillance Information System, which uses health administrative databases to track individuals with asthma living in the province of Ontario, Canada. Individuals with asthma (n=1,813,922) were divided into groups based on the practice model of their primary care provider (i.e., fee-for-service, blended fee-for-service, blended capitation). Quality of asthma care was measured using six validated, evidence-based asthma care performance indicators. All of the asthma performance indicators improved over time within each of the primary care models. Compared to the traditional fee-for-service model, the blended fee-for-service and blended capitation models had higher use of spirometry for asthma diagnosis and monitoring, higher rates of inhaled corticosteroid prescription, and lower outpatient claims. Emergency department visits were lowest in the blended fee-for-service group. Quality of asthma care improved over time within each of the primary care models. However, the amount by which they improved differed between the models. The newer primary care models (i.e., blended fee-for-service, blended capitation) appear to provide better quality of asthma care compared to the traditional fee-for-service model.

  16. The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review

    PubMed Central

    Stellefson, Michael; Stopka, Christine

    2013-01-01

    Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies. Results The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies. Conclusion CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. PMID:23428085

  17. Evidence-based practice among primary care physicians in Kuwait.

    PubMed

    Ahmad, Abeer S H; Al-Mutar, Nouf B E; Al-Hulabi, Fahad A S; Al-Rashidee, Eman S L; Doi, Suhail A R; Thalib, Lukman

    2009-12-01

    The level of evidence-based practice (EBP) and awareness has not been previously assessed among primary care physicians in Kuwait. The objectives of this study were to quantify the level of EBP and awareness in Kuwait and identify the factors related to EBP. We used a cross sectional study that enrolled 332 primary care physicians in 57 primary care centres randomly chosen in Kuwait. A self-administered questionnaire was used to collect the data with a response rate of about 93%. Although half of the physicians self reported that they use EBP most of the time, further analysis revealed that only about 24% of this group had a reasonable understanding of EBP. Most of the clinical practice in the Kuwaiti primary care system seems to be based on the clinician's own judgment or what they learned in the medical school and traditional text books, rather than evidence-based sources. None of the physicians had an Internet connection at their work place and a vast majority of them had no access to international journals nor were confident about critical appraisal of published evidence. Overall level of awareness of evidence-based medicine (EBM) among primary care physicians in Kuwait was considerably low. Training in the areas of EBM as well as making sure the Kuwaiti primary care centres have access to evidence-based sources are critically important if primary care in Kuwait were to become evidence based.

  18. Care pathways across the primary-hospital care continuum: using the multi-level framework in explaining care coordination

    PubMed Central

    2013-01-01

    Background Care pathways are widely used in hospitals for a structured and detailed planning of the care process. There is a growing interest in extending care pathways into primary care to improve quality of care by increasing care coordination. Evidence is sparse about the relationship between care pathways and care coordination. The multi-level framework explores care coordination across organizations and states that (inter)organizational mechanisms have an effect on the relationships between healthcare professionals, resulting in quality and efficiency of care. The aim of this study was to assess the extent to which care pathways support or create elements of the multi-level framework necessary to improve care coordination across the primary - hospital care continuum. Methods This study is an in-depth analysis of five existing local community projects located in four different regions in Flanders (Belgium) to determine whether the available empirical evidence supported or refuted the theoretical expectations from the multi-level framework. Data were gathered using mixed methods, including structured face-to-face interviews, participant observations, documentation and a focus group. Multiple cases were analyzed performing a cross case synthesis to strengthen the results. Results The development of a care pathway across the primary-hospital care continuum, supported by a step-by-step scenario, led to the use of existing and newly constructed structures, data monitoring and the development of information tools. The construction and use of these inter-organizational mechanisms had a positive effect on exchanging information, formulating and sharing goals, defining and knowing each other’s roles, expectations and competences and building qualitative relationships. Conclusion Care pathways across the primary-hospital care continuum enhance the components of care coordination. PMID:23919518

  19. Care pathways across the primary-hospital care continuum: using the multi-level framework in explaining care coordination.

    PubMed

    Van Houdt, Sabine; Heyrman, Jan; Vanhaecht, Kris; Sermeus, Walter; De Lepeleire, Jan

    2013-08-06

    Care pathways are widely used in hospitals for a structured and detailed planning of the care process. There is a growing interest in extending care pathways into primary care to improve quality of care by increasing care coordination. Evidence is sparse about the relationship between care pathways and care coordination.The multi-level framework explores care coordination across organizations and states that (inter)organizational mechanisms have an effect on the relationships between healthcare professionals, resulting in quality and efficiency of care.The aim of this study was to assess the extent to which care pathways support or create elements of the multi-level framework necessary to improve care coordination across the primary-hospital care continuum. This study is an in-depth analysis of five existing local community projects located in four different regions in Flanders (Belgium) to determine whether the available empirical evidence supported or refuted the theoretical expectations from the multi-level framework. Data were gathered using mixed methods, including structured face-to-face interviews, participant observations, documentation and a focus group. Multiple cases were analyzed performing a cross case synthesis to strengthen the results. The development of a care pathway across the primary-hospital care continuum, supported by a step-by-step scenario, led to the use of existing and newly constructed structures, data monitoring and the development of information tools. The construction and use of these inter-organizational mechanisms had a positive effect on exchanging information, formulating and sharing goals, defining and knowing each other's roles, expectations and competences and building qualitative relationships. Care pathways across the primary-hospital care continuum enhance the components of care coordination.

  20. Online medical care: the current state of "eVisits" in acute primary care delivery.

    PubMed

    Hickson, Ryan; Talbert, Jeffery; Thornbury, William C; Perin, Nathan R; Goodin, Amie J

    2015-02-01

    Online technologies offer the promise of an efficient, improved healthcare system. Patients benefit from increased access to care, physicians are afforded greater flexibility in care delivery, and the health system itself benefits from lower costs to provide such care. One method of incorporating online care into clinical practice, called electronic office visits or "eVisits," allows physicians to provide a consultation with patients online. We performed an analysis of the current published literature on eVisits as well as present emerging research describing the use of mobile platforms as the delivery model. We focused on the role of eVisits in acute primary care practice. A literature review was conducted using electronic databases with a variety of search terms related to the use of eVisits in primary care. Several advantages to eVisit utilization in the primary care setting were identified, namely, improvements in efficiency, continuity of care, quality of care, and access to care. Barriers to eVisit implementation were also identified, including challenges with incorporation into workflow, reimbursement, physician technological literacy, patient health literacy, overuse, security, confidentiality, and integration with existing medical technologies. Only one study of patient satisfaction with eVisit acute primary care services was identified, and this suggests that previous analyses of eVisit utilization are lacking this key component of healthcare service delivery evaluations. The delivery of primary care via eVisits on mobile platforms is still in adolescence, with few methodologically rigorous analyses of outcomes of efficiency, patient health, and satisfaction.

  1. Does setting up out of hours primary care cooperatives outside a hospital reduce demand for emergency care?

    PubMed

    van Uden, C J T; Crebolder, H F J M

    2004-11-01

    To investigate whether the reorganisation of out of hours primary care, from practice rotas to GP cooperatives, changed utilisation of primary and hospital emergency care. During a four week period before and a four week period after the reorganisation of out of hours primary care in a region in the south of the Netherlands all patient contacts with general practitioners and hospital accident and emergency (A&E) departments were analysed. A 10% increase was found in patient contacts with out of hours primary care, and a 9% decrease in patient contacts with out of hours emergency care. The number of self referrals at the A&E department was reduced by about 4%. The reorganisation of out of hours primary care has led to a shift in patient contacts from emergency care to primary care.

  2. Coordination of care by primary care practices: strategies, lessons and implications.

    PubMed

    O'Malley, Ann S; Tynan, Ann; Cohen, Genna R; Kemper, Nicole; Davis, Matthew M

    2009-04-01

    Despite calls from numerous organizations and payers to improve coordination of care, there are few published accounts of how care is coordinated in real-world primary care practices. This study by the Center for Studying Health System Change (HSC) documents strategies that a range of physician practices use to coordinate care for their patients. While there was no single recipe for coordination given the variety of patient, physician, practice and market factors, some cross-cutting lessons were identified, such as the value of a commitment to interpersonal continuity of care as a foundation for coordination. Respondents also identified the importance of system support for the standardization of office processes to foster care coordination. While larger practices may have more resources to invest, many of the innovations described could be scaled to smaller practices. Some coordination strategies resulted in improved efficiency over time for practices, but by and large, physician practices currently pursue these efforts at their own expense. In addition to sharing information on effective strategies among practices, the findings also provide policy makers with a snapshot of the current care coordination landscape and implications for initiatives to improve coordination. Efforts to provide technical support to practices to improve coordination, for example, through medical-home initiatives, need to consider the baseline more typical practices may be starting from and tailor their support to practices ranging widely in size, resources and presence of standardized care processes. If aligned with payment incentives, some of these strategies have the potential to increase quality and satisfaction among patients and providers by helping to move the health care delivery system toward better coordinated care.

  3. Understanding performance management in primary care.

    PubMed

    Rogan, Lisa; Boaden, Ruth

    2017-02-13

    Purpose Principal-agent theory (PAT) has been used to understand relationships among different professional groups and explain performance management between organisations, but is rarely used for research within primary care. The purpose of this paper is to explore whether PAT can be used to attain a better understanding of performance management in primary care. Design/methodology/approach Purposive sampling was used to identify a range of general practices in the North-west of England. Interviews were carried out with directors, managers and clinicians in commissioning and regional performance management organisations and within general practices, and the data analysed using matrix analysis techniques to produce a case study of performance management. Findings There are various elements of the principal-agent framework that can be applied in primary care. Goal alignment is relevant, but can only be achieved through clear, strategic direction and consistent interpretation of objectives at all levels. There is confusion between performance measurement and performance management and a tendency to focus on things that are easy to measure whilst omitting aspects of care that are more difficult to capture. Appropriate use of incentives, good communication, clinical engagement, ownership and trust affect the degree to which information asymmetry is overcome and goal alignment achieved. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation. Originality/value The principal-agent theoretical framework can be used to attain a better understanding of performance management in primary care; although it is likely that only partial goal alignment will be achieved, dependent on the extent and level of alignment of a range of factors.

  4. Primary care access for new patients on the eve of health care reform.

    PubMed

    Rhodes, Karin V; Kenney, Genevieve M; Friedman, Ari B; Saloner, Brendan; Lawson, Charlotte C; Chearo, David; Wissoker, Douglas; Polsky, Daniel

    2014-06-01

    Current measures of access to care have intrinsic limitations and may not accurately reflect the capacity of the primary care system to absorb new patients. To assess primary care appointment availability by state and insurance status. We conducted a simulated patient study. Trained field staff, randomly assigned to private insurance, Medicaid, or uninsured, called primary care offices requesting the first available appointment for either routine care or an urgent health concern. The study included a stratified random sample of primary care practices treating nonelderly adults within each of 10 states (Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas), selected for diversity along numerous dimensions. Collectively, these states comprise almost one-third of the US nonelderly, Medicaid, and currently uninsured populations. Sampling was based on enrollment by insurance type by county. Analyses were weighted to obtain population-based estimates for each state. The ability to schedule an appointment and number of days to the appointment. We also examined cost and payment required at the visit for the uninsured. Between November 13, 2012, and April 4, 2013, we made 12,907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to $75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern. Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Navigator programs

  5. Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers.

    PubMed

    Odusola, Aina O; Stronks, Karien; Hendriks, Marleen E; Schultsz, Constance; Akande, Tanimola; Osibogun, Akin; van Weert, Henk; Haafkens, Joke A

    2016-01-01

    Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques. Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider-insurer relationships; automated administration systems; and tailoring guidelines/patient education. By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.

  6. Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System.

    PubMed

    Vimalananda, Varsha G; Dvorin, Kelly; Fincke, B Graeme; Tardiff, Nicole; Bokhour, Barbara G

    Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.

  7. Socioeconomic status and geographical factors associated with active listing in primary care: a cross-sectional population study accounting for multimorbidity, age, sex and primary care.

    PubMed

    Ranstad, Karin; Midlöv, Patrik; Halling, Anders

    2017-06-09

    Socioeconomic status and geographical factors are associated with health and use of healthcare. Well-performing primary care contributes to better health and more adequate healthcare. In a primary care system based on patient's choice of practice, this choice (listing) is a key to understand the system. To explore the relationship between population and practices in a primary care system based on listing. Cross-sectional population-based study. Logistic regressions of the associations between active listing in primary care, income, education, distances to healthcare and geographical location, adjusting for multimorbidity, age, sex and type of primary care practice. Population over 15 years (n=123 168) in a Swedish county, Blekinge (151 731 inhabitants), in year 2007, actively or passively listed in primary care. The proportion of actively listed was 68%. Actively listed in primary care on 31 December 2007. Highest ORs for active listing in the model including all factors according to income had quartile two and three with OR 0.70 (95% CI 0.69 to 0.70), and those according to education less than 9 years of education had OR 0.70 (95% CI 0.68 to 0.70). Best odds for geographical factors in the same model had municipality C with OR 0.85 (95% CI 0.85 to 0.86) for active listing. Akaike's Information Criterion (AIC) was 124 801 for a model including municipality, multimorbidity, age, sex and type of practice and including all factors gave AIC 123 934. Higher income, shorter education, shorter distance to primary care or longer distance to hospital is associated with active listing in primary care.Multimorbidity, age, geographical location and type of primary care practice are more important to active listing in primary care than socioeconomic status and distance to healthcare. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  8. Which features of primary care affect unscheduled secondary care use? A systematic review.

    PubMed

    Huntley, Alyson; Lasserson, Daniel; Wye, Lesley; Morris, Richard; Checkland, Kath; England, Helen; Salisbury, Chris; Purdy, Sarah

    2014-05-23

    To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. Observational studies at primary care practice level. Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  9. Integrating Primary Care Providers in the Care of Cancer Survivors: Gaps in Evidence and Future Opportunities

    PubMed Central

    Nekhlyudov, Larissa; O’Malley, Denalee M.; Hudson, Shawna V.

    2017-01-01

    For over a decade since the release of the Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition, there has been a focus on providing coordinated, comprehensive care for cancer survivors that emphasized the role of primary care. Several models of care have been described which primarily focused on primary care providers (PCPs) as receivers of cancer survivors and specific types of information (e.g. survivorship care plans) from oncology based care, and not as active members of the cancer survivorship team. In this paper, we reviewed survivorship models that have been described in the literature, and specifically focused on strategies aiming to integrate primary care providers in caring for cancer survivors across different settings. We offer insights differentiating primary care providers’ level of expertise in cancer survivorship and how such expertise may be utilized. We provide recommendations for education, clinical practice, research and policy initiatives that may advance the integration of primary care providers in the care of cancer survivors in diverse clinical settings. PMID:28049575

  10. [Care concepts in mass casualty incidents and disasters. Concept for primary care clinic].

    PubMed

    Adams, H A; Flemming, A; Lange, C; Koppert, W; Krettek, C

    2015-02-01

    Patient care in mass casualty incidents and disaster strongly demand a joint approach of all preclinical and clinical forces. Special emphasis must be placed on immediate triage, establishment and preservation of transportability of high-risk patients and their clinical treatment as soon as possible. During limited mass casualties, the preclinical rescue station additionally serves as a buffer for patients, whereby in case of disaster, the focus on transportation of high-risk patients is imperative. Primary care hospitals are a decisive part in the chain of medical supply and are confronted with great challenges, which demand detailed emergency plans and also repeated exercises. In planning and exercises, special attention should be given to the cooperation with the fire department and other medical services.

  11. Patients' experiences of diabetes education teams integrated into primary care.

    PubMed

    Grohmann, Barbara; Espin, Sherry; Gucciardi, Enza

    2017-02-01

    To explore patients' perspectives on care received from diabetes education teams (a registered nurse and a registered dietitian) integrated into primary care. Qualitative study using semistructured, one-on-one interviews. Three diabetes education programs operating in 11 primary care sites in one region of Ontario. Twenty-three patients with diabetes. Purposeful sampling was used to recruit participants from each site for interviews. Educator teams invited patients with whom they had met at least once to participate in semistructured interviews. Data were analyzed using thematic analysis with NVivo 11 software. The diabetes education teams integrated into primary care exhibited many of the principles of person-centred care, as evidenced by the 2 overarching themes. The first is personalized care, with the subthemes care environment, shared decision making, and patient preference for one-on-one care. Participants described feeling included in partnerships with their health care providers, as they collaborated with physicians and diabetes educators to develop knowledge and set goals in the convenience and comfort of their usual primary care settings. Many participants also expressed a preference for one-on-one sessions. The second theme is patient-provider relationship, with the subthemes respect, supportive interaction, and facilitating patient engagement. Supportive environments created by the educators built trusting relationships, where patients expressed enhanced motivation to improve their self-care. Diabetes educators integrated into primary care can serve to enrich the experience of patients, provide key education to improve patient understanding, and support primary care physicians in providing timely and comprehensive clinical care. Diabetes patients appear to benefit from convenient access to interprofessional teams of educators in primary care to support diabetes self-management. Copyright© the College of Family Physicians of Canada.

  12. A typology of primary care workforce innovations in the United States since 2000.

    PubMed

    Friedman, Asia; Hahn, Karissa A; Etz, Rebecca; Rehwinkel-Morfe, Anna M; Miller, William L; Nutting, Paul A; Jaén, Carlos R; Shaw, Eric K; Crabtree, Benjamin F

    2014-02-01

    Innovative workforce models are being developed and implemented to meet the changing demands of primary care. A literature review was conducted to construct a typology of workforce models used by primary care practices. Ovid Medline, CINAHL, and PsycInfo were used to identify published descriptions of the primary care workforce that deviated from what would be expected in the typical practice in the year 2000. Expert consultants identified additional articles that would not show up in a regular computerized search. Full texts of relevant articles were read and matrices for sorting articles were developed. Each article was reviewed and assigned to one of 18 cells in the matrices. Articles within each cell were then read again to identify patterns and develop an understanding of the full spectrum of workforce innovation within each category. This synthesis led to the development of a typology of workforce innovations represented in the literature. Many workforce innovations added personnel to existing practices, whereas others sought to retrain existing personnel or even develop roles outside the traditional practice. Most of these sought to minimize the impact on the existing practice roles and functions, particularly that of physicians. The synthesis also identified recent innovations which attempted to fundamentally transform the existing practice, with transformation being defined as a change in practice members' governing variables or values in regard to their workforce role. Most conceptualizations of the primary care workforce described in the literature do not reflect the level of innovation needed to meet the needs of the burgeoning numbers of patients with complex health issues, the necessity for roles and identities of physicians to change, and the call for fundamentally redesigned practices. However, we identified 5 key workforce innovation concepts that emerged from the literature: team care, population focus, additional resource support, creating

  13. Primary Care Physicians’ Evaluation and Treatment of Depression

    PubMed Central

    Epstein, Steven A.; Hooper, Lisa M.; Weinfurt, Kevin P.; DePuy, Venita; Cooper, Lisa A.; Harless, William G.; Tracy, Cynthia M.

    2009-01-01

    Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics. PMID:18832109

  14. Describing the content of primary care: limitations of Canadian billing data.

    PubMed

    Katz, Alan; Halas, Gayle; Dillon, Michael; Sloshower, Jordan

    2012-02-15

    Primary health care systems are designed to provide comprehensive patient care. However, the ICD 9 coding system used for billing purposes in Canada neither characterizes nor captures the scope of clinical practice or complexity of physician-patient interactions. This study aims to describe the content of primary care clinical encounters and examine the limitations of using administrative data to capture the content of these visits. Although a number of U.S studies have described the content of primary care encounters, this is the first Canadian study to do so. Study-specific data collection forms were completed by 16 primary care physicians in community health and family practice clinics in Winnipeg, Manitoba, Canada. The data collection forms were completed immediately following the patient encounter and included patient and visit characteristics, such as primary reason for visit, topics discussed, actions taken, degree of complexity as well as diagnosis and ICD-9 codes. Data was collected for 760 patient encounters. The diagnostic codes often did not reflect the dominant topic of the visit or the topic requiring the most amount of time. Physicians often address multiple problems and provide numerous services thus increasing the complexity of care. This is one of the first Canadian studies to critically analyze the content of primary care clinical encounters. The data allowed a greater understanding of primary care clinical encounters and attests to the deficiencies of singular ICD-9 coding which fails to capture the comprehensiveness and complexity of the primary care encounter. As primary care reform initiatives in the U.S and Canada attempt to transform the way family physicians deliver care, it becomes increasingly important that other tools for structuring primary care data are considered in order to help physicians, researchers and policy makers understand the breadth and complexity of primary care.

  15. Does quality influence utilization of primary health care? Evidence from Haiti.

    PubMed

    Gage, Anna D; Leslie, Hannah H; Bitton, Asaf; Jerome, J Gregory; Joseph, Jean Paul; Thermidor, Roody; Kruk, Margaret E

    2018-06-20

    Expanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti. We constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery. Facilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure. Poor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.

  16. Mental health care roles of non-medical primary health and social care services.

    PubMed

    Mitchell, Penny

    2009-02-01

    Changes in patterns of delivery of mental health care over several decades are putting pressure on primary health and social care services to increase their involvement. Mental health policy in countries like the UK, Australia and New Zealand recognises the need for these services to make a greater contribution and calls for increased intersectoral collaboration. In Australia, most investment to date has focused on the development and integration of specialist mental health services and primary medical care, and evaluation research suggests some progress. Substantial inadequacies remain, however, in the comprehensiveness and continuity of care received by people affected by mental health problems, particularly in relation to social and psychosocial interventions. Very little research has examined the nature of the roles that non-medical primary health and social care services actually or potentially play in mental health care. Lack of information about these roles could have inhibited development of service improvement initiatives targeting these services. The present paper reports the results of an exploratory study that examined the mental health care roles of 41 diverse non-medical primary health and social care services in the state of Victoria, Australia. Data were collected in 2004 using a purposive sampling strategy. A novel method of surveying providers was employed whereby respondents within each agency worked as a group to complete a structured survey that collected quantitative and qualitative data simultaneously. This paper reports results of quantitative analyses including a tentative principal components analysis that examined the structure of roles. Non-medical primary health and social care services are currently performing a wide variety of mental health care roles and they aspire to increase their involvement in this work. However, these providers do not favour approaches involving selective targeting of clients with mental disorders.

  17. Curing and Caring: The Work of Primary Care Physicians With Dementia Patients

    PubMed Central

    CarolinaApesoa-Varano, Ester; Barker, Judith C.; Hinton, Ladson

    2013-01-01

    The symbolic framework guiding primary care physicians’ (PCPs) practice is crucial in shaping the quality of care for those with degenerative dementia. Examining the relationship between the cure and care models in primary care offers a unique opportunity for exploring change toward a more holistic approach to health care. The aims of this study were to (a) explore how PCPs approach the care of patients with Alzheimer’s disease (AD), and (b) describe how this care unfolds from the physicians’ perspectives. This was a cross-sectional study of 40 PCPs who completed semistructured interviews as part of a dementia caregiving study. Findings show that PCPs recognize the limits of the cure paradigm and articulate a caring, more holistic model that addresses the psychosocial needs of dementia patients. However, caring is difficult to uphold because of time constraints, emotional burden, and jurisdictional issues. Thus, the care model remains secondary and temporary. PMID:21685311

  18. Experiences of primary care physicians and staff following lean workflow redesign.

    PubMed

    Hung, Dorothy Y; Harrison, Michael I; Truong, Quan; Du, Xue

    2018-04-10

    In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members. The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses. We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign. Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement

  19. Factors shaping intersectoral action in primary health care services.

    PubMed

    Anaf, Julia; Baum, Fran; Freeman, Toby; Labonte, Ron; Javanparast, Sara; Jolley, Gwyn; Lawless, Angela; Bentley, Michael

    2014-12-01

    To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action. © 2014 Public Health Association of Australia.

  20. Time providing care outside visits in a home-based primary care program

    PubMed Central

    Pedowitz, Elizabeth J.; Ornstein, Katherine A.; Farber, Jeffrey; DeCherrie, Linda V.

    2016-01-01

    Background/Objectives Homebound elderly patients with chronic medical illnesses face multiple barriers to care. Primary care physicians (PCPs) devote a significant amount of time to care apart from actual office visits, but there is little quantification of such time by physicians who provide primary care in the home. This article assesses exactly how much time physicians in a large home based primary care (HBPC) program spend providing care outside of home visits. Unreimbursed time, as well as patient and provider-related factors that may contribute to that increased time, are considered. Design Mount Sinai Visiting Doctors (MSVD) providers filled out research forms for every interaction involving care provision outside of home visits. Data collected included: length of interaction, mode, nature, and whom the interaction was with for 3 weeks. Setting/Participants MSVD is an academic home-visit program in Manhattan, NY. All PCPs in MSVD (n=14) agreed to participate. Measurements Time data were analyzed using a comprehensive estimate and conservative estimates to quantify unbillable time. Results Data on 1151 interactions for 537 patients were collected. An average 8.2 hours/week were spent providing non-home visit care for a full-time provider. Using the most conservative estimates, 3.6 hours/week was estimated to be unreimbursed per full-time provider. No significant differences in interaction times were found among dementia vs. non-dementia patients, new vs. non-new patients, and primary-panel vs. covered patients. Conclusion Findings suggest that HBPC providers spend substantial time providing care outside home visits, much of which goes unrecognized in the current reimbursement system. These findings may help guide practice development and creation of new payment systems for HBPC and similar models of care. PMID:24802078

  1. Moral sensitivity in Primary Health Care nurses.

    PubMed

    Nora, Carlise Rigon Dalla; Zoboli, Elma Lourdes Campos Pavone; Vieira, Margarida M

    2017-04-01

    to characterize the profile and describe the moral sensitivity of primary health care nurses. this is a quantitative, transversal, exploratory, descriptive study. The data were collected through the Moral Sensitivity Questionnaire translated and adapted to Brazil. 100 primary health care nurses participated, from Rio Grande do Sul, Brazil. The data collection took place during the months of March and July 2016, in an online form. The analysis of the data occurred through descriptive statistical analysis. the nurses had an average moral sensitivity of 4.5 (out of 7). The dimensions with the greatest moral sensitivity were: interpersonal orientation, professional knowledge, moral conflict and moral meaning. the nurses of Rio Grande do Sul have a moderate moral sensitivity, which may contribute to a lower quality in Primary Health Care.

  2. Men's Preconception Health: A Primary Health-Care Viewpoint.

    PubMed

    O'Brien, Anthony Paul; Hurley, John; Linsley, Paul; McNeil, Karen Anne; Fletcher, Richard; Aitken, John Robert

    2018-05-01

    The purpose of this article is to theoretically explore men's preconception health as a mechanism to enhance fertility, as well as the health and well-being of the subject and his descendants. Premorbid risk factors and behaviors associated with stress, environmental toxins, excessive alcohol consumption, smoking, lack of exercise/obesity, and the use of illicit drugs are all known to affect fecundity. While there are many health clinics available to women, where advice in areas such as postnatal care of the newborn, family planning, and couples fertility is provided, there are few, if any, equivalent health clinics available to men. Additionally, getting men to attend primary health-care services has also been continuously problematic, even in the context of there being a clearly discernible need for treatment. It is argued in this article that an impetus is required to encourage men to focus on and improve their preconception health and to utilize primary health-care services to take action. An assertive men's preconception health outlook can positively influence the conjugal relationship, fathering, male self-esteem, and continued good health. Using the sometimes complex concept of preconception health as a motivating factor for healthy lifestyle adaptation has the potential to improve male fertility outcomes and general health and well-being, as well as the health of future generations.

  3. Managed care and the delivery of primary care to the elderly and the chronically ill.

    PubMed Central

    Wholey, D R; Burns, L R; Lavizzo-Mourey, R

    1998-01-01

    OBJECTIVE: To analyze primary care staffing in HMOs and to review the literature on primary care organization and performance in managed care organizations, with an emphasis on the delivery of primary care to the elderly and chronically ill. DATA SOURCES/STUDY SETTING: Analysis of primary care staffing: InterStudy HMO census data on primary care (n = 1,956) and specialist (n = 1,777) physician staffing levels from 1991 through 1995. Primary care organization and performance for the chronically ill and elderly were analyzed using a review of published research. STUDY DESIGN: For the staffing-level models, the number of primary care and specialist physicians per 100,000 enrollees was regressed on HMO characteristics (HMO type [group, staff, network, mixed], HMO enrollment, federal qualification, profit status, national affiliation) and community characteristics (per capita income, population density, service area size, HMO competition). For the review of organization and performance, literature published was summarized in a tabular format. PRINCIPAL FINDINGS: The analysis of physician staffing shows that group and staff HMOs have fewer primary care and specialist physicians per 100,000 enrollees than do network and mixed HMOs, which have fewer than IPAs. Larger HMOs use fewer physicians per 100,000 enrollees than smaller HMOs. Federally qualified HMOs have fewer primary care and specialist physicians per 100,000 enrollees. For-profit, nationally affiliated, and Blue Cross HMOs have more primary care and specialist physicians than do local HMOs. HMOs in areas with high per capita income have more PCPs per 100,000 and a greater proportion of PCPs in the panel. HMO penetration decreases the use of specialists, but the number of HMOs increases the use of primary care and specialist physicians in highly competitive markets. Under very competitive conditions, HMOs appear to compete by increasing access to both PCPs and specialists, with a greater emphasis on access to

  4. Role of Geography and Nurse Practitioner Scope-of-Practice in Efforts to Expand Primary Care System Capacity: Health Reform and the Primary Care Workforce.

    PubMed

    Graves, John A; Mishra, Pranita; Dittus, Robert S; Parikh, Ravi; Perloff, Jennifer; Buerhaus, Peter I

    2016-01-01

    Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians--particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured. We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws. An observational study. 2013 Area Health Resource File (AHRF) and US Census Bureau county travel data. The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC. We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations. Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.

  5. Advancing primary care to promote equitable health: implications for China

    PubMed Central

    2012-01-01

    China is a country with vast regional differences and uneven economic development, which have led to widening gaps between the rich and poor in terms of access to healthcare, quality of care, and health outcomes. China's healthcare reform efforts must be tailored to the needs and resources of each region and community. Building and strengthening primary care within the Chinese health care system is one way to effectively address health challenges. This paper begins by outlining the concept of primary care, including key definitions and measurements. Next, results from a number of studies will demonstrate that primary care characteristics are associated with savings in medical costs, improvements in health outcomes and reductions in health disparities. This paper concludes with recommendations for China on successfully incorporating a primary care model into its national health policy, including bolstering the primary care workforce, addressing medical financing structures, recognizing the importance of evidence-based medicine, and looking to case studies from countries that have successfully implemented health reform. PMID:22264309

  6. Primary Health Care That Works: The Costa Rican Experience.

    PubMed

    Pesec, Madeline; Ratcliffe, Hannah L; Karlage, Ami; Hirschhorn, Lisa R; Gawande, Atul; Bitton, Asaf

    2017-03-01

    Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented. Project HOPE—The People-to-People Health Foundation, Inc.

  7. Chinese primary care physicians and work attitudes.

    PubMed

    Shi, Leiyu; Hung, Li-Mei; Song, Kuimeng; Rane, Sarika; Tsai, Jenna; Sun, Xiaojie; Li, Hui; Meng, Qingyue

    2013-01-01

    China passed a landmark health care reform in 2009, aimed at improving health care for all citizens by strengthening the primary care system, largely through improvements to infrastructure. However, research has shown that the work attitudes of primary care physicians (PCPs) can greatly affect the stability of the overall workforce and the quality and delivery of health care. The purpose of this study is to investigate the relationship between reported work attitudes of PCPs and their personal, work, and educational characteristics. A multi-stage, complex sampling design was employed to select a sample of 434 PCPs practicing in urban and rural primary care settings, and a survey questionnaire was administered by researchers with sponsorship from the Ministry of Health. Four outcome measures describing work attitudes were used, as well as a number of personal-, work-, and practice-related factors. Findings showed that although most PCPs considered their work as important, a substantial number also reported large workloads, job pressure, and turnover intentions. Findings suggest that policymakers should focus on training and educational opportunities for PCPs and consider ways to ease workload pressures and improve salaries. These policy improvements must accompany reform efforts that are already underway before positive changes in reduced disparities and improved health outcomes can be realized in China.

  8. Evaluation of clinical pharmacy interventions in a Veterans Affairs medical center primary care clinic.

    PubMed

    Hough, Augustus; Vartan, Christine M; Groppi, Julie A; Reyes, Sonia; Beckey, Nick P

    2013-07-01

    The development of an electronic tool to quantify and characterize the interventions made by clinical pharmacy specialists (CPSs) in a primary care setting is described. An electronic clinical tool was developed to document the clinical pharmacy interventions made by CPSs at the Veterans Affairs Medical Center in West Palm Beach, Florida. The tool, embedded into the electronic medical record, utilizes a novel reminder dialogue to complete pharmacotherapy visit encounters and allows CPSs to document interventions made during patient care visits. Interventions are documented using specific electronic health factors so that the type and number of interventions made for both disease-specific and other pharmacotherapy interventions can be tracked. These interventions were assessed and analyzed to evaluate the impact of CPSs in the primary care setting. From February 2011 through January 2012, a total of 16,494 pharmacotherapy interventions (therapeutic changes and goals attained) were recorded. The average numbers of interventions documented per patient encounter were 0.96 for the management of diabetes mellitus, hypertension, dyslipidemia, and heart failure and 1.36 for non-disease-specific interventions, independent of those interventions being made by the primary physician or other members of the primary care team. A clinical reminder tool developed to quantify and characterize the interventions provided by CPSs found that for every visit with a CPS, approximately one disease-specific intervention and one additional pharmacotherapy intervention were made, independent of those interventions being made by the primary physician or other members of the primary care team.

  9. Do female primary care physicians practise preventive care differently from their male colleagues?

    PubMed Central

    Woodward, C. A.; Hutchison, B. G.; Abelson, J.; Norman, G.

    1996-01-01

    OBJECTIVE: To assess whether female primary care physicians' reported coverage of patients eligible for certain preventive care strategies differs from male physicians' reported coverage. DESIGN: A mailed survey. SETTING: Primary care practices in southern Ontario. PARTICIPANTS: All primary care physicians who graduated between 1972 and 1988 and practised in a defined geographic area of Ontario were selected from the Canadian Medical Association's physician resource database. Response rate was 50%. MAIN OUTCOME MEASURES: Answers to questions on sociodemographic and practice characteristics, attitudes toward preventive care, and perceptions about preventive care behaviour and practices. RESULTS: In general, reported coverage for Canadian Task Force on the Periodic Health Examination's (CTFPHE) A and B class recommendations was low. However, more female than male physicians reported high coverage of women patients for female-specific preventive care measures (i.e., Pap smears, breast examinations, and mammography) and for blood pressure measurement. Female physicians appeared to question more patients about a greater number of health risks. Often, sex of physician was the most salient factor affecting whether preventive care services thought effective by the CTFPHE were offered. However, when evidence for effectiveness of preventive services was equivocal or lacking, male and female physicians reported similar levels of coverage. CONCLUSION: Female primary care physicians are more likely than their male colleagues to report that their patients eligible for preventive health measures as recommended by the CTFPHE take advantage of these measures. PMID:8969856

  10. [Primary care: A definition of the field to develop research].

    PubMed

    Verga-Gérard, A

    2018-03-01

    Research in the field of primary care has dramatically increased in France in recent years, especially since 2013 with the introduction of primary care as a thematic priority for research proposals launched by the Ministry of Health (Direction générale de l'offre de soins). The RECaP (Research in Clinical Epidemiology and Public Health) network is a French research network supported by Inserm, which recently implemented a specific working group focusing on research in primary care, based on a multidisciplinary approach. Researchers from different specialties participate in this group. The first aim of the group was to reach a common definition of the perimeter and of the panel of healthcare professionals and structures potentially involved in the field of primary care. For this purpose, a selection of different data sets of sources defining primary care was analyzed by the group, each participant collecting a set of sources, from which a synthesis was made and discussed. A definition of primary care at different levels (international, European and French) was summarized. A special attention was given to the French context in order to adapt the perimeter to the characteristics of the French healthcare system, notably by illustrating the different key elements of the definition with the inclusion of primary care actors and the type of practice premises. In conclusion, this work illustrates the diversity of primary care in France and the potential offered for research purposes. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

  11. Primary Care Providers' HIV Prevention Practices Among Older Adults

    PubMed Central

    Davis, Tracy; Teaster, Pamela B.; Thornton, Alice; Watkins, John F.; Alexander, Linda; Zanjani, Faika

    2016-01-01

    Purpose To explore primary care providers' HIV prevention practices for older adults. Primary care providers' perceptions and awareness were explored to understand factors that affect their provision of HIV prevention materials and HIV screening for older adults. Design and Method Data were collected through 24 semistructured interviews with primary care providers (i.e., physicians, physician assistants, and nurse practitioners) who see patients older than 50 years. Results Results reveal facilitators and barriers of HIV prevention for older adults among primary care providers and understanding of providers' HIV prevention practices and behaviors. Individual, patient, institutional, and societal factors influenced HIV prevention practices among participants, for example, provider training and work experience, lack of time, discomfort in discussing HIV/AIDS with older adults, stigma, and ageism were contributing factors. Furthermore, factors specific to primary and secondary HIV prevention were identified, for instance, the presence of sexually transmitted infections influenced providers' secondary prevention practices. Implications HIV disease, while preventable, is increasing among older adults. These findings inform future research and interventions aimed at increasing HIV prevention practices in primary care settings for patients older than 50. PMID:25736425

  12. Traveller gypsies and primary care.

    PubMed Central

    Feder, G

    1989-01-01

    Traveller gypsies have resided in the British Isles for over 500 years, making them one of our oldest ethnic minorities. They experience widespread prejudice and discrimination from the settled population. In the sphere of health care the marginalization of traveller gypsies has resulted in poor access to services and relative neglect of their health needs. In this paper the health of traveller gypsies is reviewed from the perspective of primary care, and the role of general practitioners in improving health care for this community is discussed. PMID:2560026

  13. Incorporating Spirituality in Primary Care.

    PubMed

    Isaac, Kathleen S; Hay, Jennifer L; Lubetkin, Erica I

    2016-06-01

    Addressing cultural competency in health care involves recognizing the diverse characteristics of the patient population and understanding how they impact patient care. Spirituality is an aspect of cultural identity that has become increasingly recognized for its potential to impact health behaviors and healthcare decision-making. We consider the complex relationship between spirituality and health, exploring the role of spirituality in primary care, and consider the inclusion of spirituality in existing models of health promotion. We discuss the feasibility of incorporating spirituality into clinical practice, offering suggestions for physicians.

  14. [The Articulator of Primary Health Care Program: an innovative proposal for qualification of Primary Health Care].

    PubMed

    Doricci, Giovanna Cabral; Guanaes-Lorenzi, Carla; Pereira, Maria José Bistafa

    2017-06-01

    In 2009, the Secretary of State for Health of Sao Paulo created a Program with a view to qualify the primary care in the state. This proposal includes a new job function, namely the articulator of primary care. Due to the scarcity of information about the practice of these new professionals in the scientific literature, this article seeks to analyze how articulators interpret their function and how they describe their daily routines. Thirteen articulators were interviewed. The interviews were duly analyzed by qualitative delineation. The results describe three themes: 1)Roles of the articulator: technical communicator and political advisor; 2) Activities performed to comply with the expected roles, examples being diagnosis of the municipalities, negotiation of proposals, participation in meetings, visits to municipalities; and 3) Challenges of the role, which are configured as challenges to the health reform process, examples being the lack of physical and human resources, activities of professionals in the medical-centered model, among others. The conclusion drawn is that the Program has great potential to provide input for the development and enhancement of Primary Care. Nevertheless, there are a series of challenges to be overcome, namely challenges to the context per se.

  15. Development of the Primary Care Quality-Homeless (PCQ-H) Instrument: A Practical Survey of Patients' Experiences in Primary Care

    PubMed Central

    Kertesz, Stefan. G.; Pollio, David E.; Jones, Richard N.; Steward, Jocelyn; Stringfellow, Erin J.; Gordon, Adam J.; Johnson, Nancy K.; Kim, Theresa A.; Granstaff, Unita; Austin, Erika L.; Young, Alexander S.; Golden, Joya; Davis, Lori L.; Roth, David L.; Holt, Cheryl L.

    2015-01-01

    Background Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients' priorities and concerns. Objectives This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients and (b) the methods utilized in its development. Methods Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA Health Care for the Homeless Program. Using Item Response Theory, we examined Test Information Function curves to eliminate less informative items and devise plausibly distinct subscales. Results The resulting 33-item instrument (Primary Care Quality-Homeless, PCQ-H) has four subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items) and Homeless-Specific Needs (4 items). Evidence for divergent and convergent validity is provided. Test Information Function (TIF) graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (alpha=0.75) and patients frequently reported problems in this aspect of care. Conclusions Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development. PMID:25023918

  16. Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers

    PubMed Central

    Odusola, Aina O.; Stronks, Karien; Hendriks, Marleen E.; Schultsz, Constance; Akande, Tanimola; Osibogun, Akin; van Weert, Henk; Haafkens, Joke A.

    2016-01-01

    Background Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. Objective We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. Design Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques. Results Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider–insurer relationships; automated administration systems; and tailoring guidelines/patient education. Conclusions By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA. PMID:26880152

  17. [Relations with emergency medical care and primary care doctor, home health care].

    PubMed

    Azuma, Kazunari; Ohta, Shoichi

    2016-02-01

    Medical care for an ultra-aging society has been shifted from hospital-centered to local community-based. This shift has yielded the so-called Integrated Community Care System. In the system, emergency medical care is considered important, as primary care doctors and home health care providers play a crucial role in coordinating with the department of emergency medicine. Since the patients move depending on their physical condition, a hospital and a community should collaborate in providing a circulating service. The revision of the medical payment system in 2014 clearly states the importance of "functional differentiation and strengthen and coordination of medical institutions, improvement of home health care". As part of the revision, the subacute care unit has been integrated into the community care unit, which is expected to have more than one role in community coordination. The medical fee has been set for the purpose of promoting the home medical care visit, and enhancing the capability of family doctors. In the section of end-of-life care for the elderly, there have been many issues such as reduction of the readmission rate and endorsement of a patient's decision-making, and judgment for active emergency medical care for patient admission. The concept of frailty as an indicator of prognosis has been introduced, which might be applied to the future of emergency medicine. As described above, the importance of a primary doctor and a family doctor should be identified more in the future; thereby it becomes essential for doctors to closely work with the hospital. Advancing the cooperation between a hospital and a community for seamless patient-centered care, the emergency medicine as an integrated community care will further develop by adapting to an ultra-aging society.

  18. Designing payment for Collaborative Care for Depression in primary care.

    PubMed

    Bao, Yuhua; Casalino, Lawrence P; Ettner, Susan L; Bruce, Martha L; Solberg, Leif I; Unützer, Jürgen

    2011-10-01

    To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care. A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients. We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models. Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design. Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives. © Health Research and Educational Trust.

  19. Improving Quality of Care in Primary Health-Care Facilities in Rural Nigeria

    PubMed Central

    Ugo, Okoli; Ezinne, Eze-Ajoku; Modupe, Oludipe; Nicole, Spieker; Kelechi, Ohiri

    2016-01-01

    Background: Nigeria has a high population density but a weak health-care system. To improve the quality of care, 3 organizations carried out a quality improvement pilot intervention at the primary health-care level in selected rural areas. Objective: To assess the change in quality of care in primary health-care facilities in rural Nigeria following the provision of technical governance support and to document the successes and challenges encountered. Method: A total of 6 states were selected across the 6 geopolitical zones of the country. However, assessments were carried out in 40 facilities in only 5 states. Selection was based on location, coverage, and minimum services offered. The facilities were divided randomly into 2 groups. The treatment group received quality-of-care assessment, continuous feedback, and improvement support, whereas the control group received quality assessment and no other support. Data were collected using the SafeCare Healthcare Standards and managed on the SafeCare Data Management System—AfriDB. Eight core areas were assessed at baseline and end line, and compliance to quality health-care standards was compared. Result: Outcomes from 40 facilities were accepted and analyzed. Overall scores increased in the treatment facilities compared to the control facilities, with strong evidence of improvement (t = 5.28, P = .0004) and 11% average improvement, but no clear pattern of improvement emerged in the control group. Conclusion: The study demonstrated governance support and active community involvement offered potential for quality improvement in primary health-care facilities. PMID:28462280

  20. Improving home-based providers' communication to primary care providers to enhance care coordination.

    PubMed

    Gum, Amber M; Dautovich, Natalie D; Greene, Jennifer; Hirsch, Anne; Schonfeld, Lawrence

    2015-01-01

    Health care system fragmentation is a pervasive problem. Research has not delineated concrete behavioral strategies to guide providers to communicate with personnel in other organizations to coordinate care. We addressed this gap within a particular context: home-based providers delivering depression care management (DCM) to older adults requiring coordination with primary care personnel. Our objective was to pilot test a communication protocol ('BRIDGE - BRinging Inter-Disciplinary Guidelines to Elders') in conjunction with DCM. In an open pilot trial (N = 7), home-based providers delivered DCM to participants. Following the BRIDGE protocol, home-based providers made scripted telephone calls and sent structured progress reports to personnel in participants' primary care practices with concise information and requests for assistance. Home-based providers documented visits with participants, contacts to and responses from primary care personnel. A research interviewer assessed participant outcomes [Symptom Checklist-20 (depressive symptoms), World Health Organization Disability Assessment Schedule-12, satisfaction] at baseline, three months, and six months. Over 12 months, home-based providers made 2.4 telephone calls and sent 6.3 faxes to other personnel, on average per participant. Primary care personnel responded to 18 of 22 requests (81.8%; 2 requests dropped, 2 ongoing), with at least one response per participant. Participants' depressive symptoms and disability improved significantly at both post-tests with large effect sizes (d ranged 0.73-2.3). Participants were satisfied. Using BRIDGE, home-based providers expended a small amount of effort to communicate with primary care personnel, who responded to almost all requests. Larger scale research is needed to confirm findings and potentially extend BRIDGE to other client problems, professions, and service sectors.

  1. Explaining the de-prioritization of primary prevention: Physicians' perceptions of their role in the delivery of primary care

    PubMed Central

    Mirand, Amy L; Beehler, Gregory P; Kuo, Christina L; Mahoney, Martin C

    2003-01-01

    Background While physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery. Methods A focus group with regional primary care physician (PCP) Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine) participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology. Results The PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care. Conclusions The secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration. PMID:12729463

  2. A Competition between Care Teams Improved Recording of Diagnoses in Primary Dental Care: A Longitudinal Follow-Up Study.

    PubMed

    Kallio, Jouko; Kauppila, Timo; Suominen, Lasse; Heikkinen, Anna Maria

    2017-01-01

    A playful competition was launched in a primary dental health care system to improve the recording of diagnoses into an electronic patient chart system and to study what diagnoses were used in primary dental care. This was a longitudinal follow-up study with public sector primary dental care practices in a Finnish city. A one-year-lasting playful competition between the dental care teams was launched and the monthly percentage of dentists' visits with recorded diagnosis before, during, and after the intervention was recorded. The assessed diagnoses were recorded with the International Classification of Diseases (ICD-10). Before the competition, the level of diagnosis recordings was practically zero. At the end of this intervention, about 25% of the visits had a recorded diagnosis. Two years after the competition, this percentage was 35% without any additional measures. The most frequent diagnoses were dental caries (K02, 38.6%), other diseases of hard tissues of teeth (K03, 14.8%), and diseases of pulp and periapical tissues (K04, 11.4%). Commitment to the idea that recording of diagnoses was beneficial improved the recording of dental diagnoses. However, the diagnoses obtained did not accurately reflect the reputed prevalence of oral diseases in the Finnish population.

  3. Primary Palliative Care for the General Internist: Integrating Goals of Care Discussions into the Outpatient Setting

    PubMed Central

    Ahia, Chad L.; Blais, Christopher M.

    2014-01-01

    Background Primary palliative care consists of the palliative care competencies required of all primary care clinicians. Included in these competencies is the ability to assist patients and their families in establishing appropriate goals of care. Goals of care help patients and their families understand the patient's illness and its trajectory and facilitate medical care decisions consistent with the patient's values and goals. General internists and family medicine physicians in primary care are central to getting patients to articulate their goals of care and to have these documented in the medical record. Case Report Here we present the case of a 71-year-old male patient with chronic obstructive pulmonary disorder, congestive heart failure, and newly diagnosed Alzheimer dementia to model pertinent end-of-life care communication and discuss practical tips on how to incorporate it into practice. Conclusion General internists and family medicine practitioners in primary care are central to eliciting patients' goals of care and achieving optimal end-of-life outcomes for their patients. PMID:25598737

  4. Primary health care registered nurses' types in implementation of health promotion practices.

    PubMed

    Maijala, Virpi; Tossavainen, Kerttu; Turunen, Hannele

    2016-09-01

    Aim This study aimed to identify and reach consensus among primary health care participants [registered nurses (RNs) who receive clients, directors of nursing, senior physicians, health promotion officers, and local councillors] on the types of service provider that RNs who receive clients represent in the implementation of health promotion practices in primary health care in Eastern Finland. There is an increasing focus on public health thinking in many countries as the population ages. To meet the growing needs of the health promotion practices of populations, advance practice has been recognized as effective in the primary health care setting. The advance practice nurses share many common features, such as being RNs with additional education, possessing competencies to work independently, treating clients in both acute and primary care settings, and applying a variety of health promotion practices into nursing. The two-stage modified Delphi method was applied. In round one, semi-structured interviews were conducted among primary health care participants (n=42) in 11 health centres in Eastern Finland. In round two, a questionnaire survey was conducted in the same health centres. The questionnaire was answered by 64% of those surveyed (n=56). For data analysis, content analysis and descriptive statistics were used. Findings This study resulted in four types of service provider that RNs who receive clients represented in the implementation of health promotion practices in the primary health care setting in Eastern Finland. First, the client-oriented health promoter demonstrated four dimensions, which reached consensus levels ranging between 82.1 and 89.3%. Second, the developer of health promotion practices comprised four dimensions, which reached consensus levels between 71.4 and 85.7%. Third, the member of multi-professional teams of health promotion practices representing three dimensions, with consensus levels between 69.6 and 82.1%. Fourth, the type who showed

  5. Integrating care coordination home telehealth and home based primary care in rural Oklahoma: a pilot study.

    PubMed

    Sorocco, Kristen H; Bratkovich, Kristi L; Wingo, Rita; Qureshi, Saleem M; Mason, Patrick J

    2013-08-01

    The purpose of this program was to evaluate the benefits of integrating VA Care Coordination Home Telehealth and Telemental health within HBPC. A case study design was used to determine quality assurance and quality improvement of incorporating additional home telehealth equipment within Home Based Primary Care (HBPC). Veterans with complex medical conditions and their caregivers living in rural Oklahoma were enrolled. Veterans received the same care other HBPC patients received with the addition of home telehealth equipment. Members from the interdisciplinary treatment team were certified to use the telehealth equipment. Veterans and their caregivers were trained on use of the equipment in their homes. Standard HBPC program measures were used to assess the program success. Assessments from all disciplines on the HBPC team were at baseline, 3, and 6 months, and participants provided satisfaction and interview data to assess the benefits of integrating technology into standard care delivery within an HBPC program. Six veterans were enrolled (mean age = 72 yrs) with a range of physical health conditions including: chronic obstructive pulmonary disease, cerebrovascular accident, spinal cord injury, diabetes, hypertension, and syncope. Primary mental health conditions included depression, dementia, anxiety, and PTSD. Scores on the Mini-Mental State Examination ranged from 18 to 30. Over a 6-month period, case studies indicated improvements in strength, social functioning, decreased caregiver burden, and compliance with treatment plan. This integration of CCHT and HBPC served previously underserved rural veterans having complex medical conditions and appears both feasible and clinically beneficial to veterans and their caregivers. PsycINFO Database Record (c) 2013 APA, all rights reserved.

  6. A Comprehensive Primary Health Care Delivery Model.

    ERIC Educational Resources Information Center

    Pullen, Carol; And Others

    1994-01-01

    This primary health care model is based on four assumptions: emphasis on collective, not individual, needs; coordination of preventive/episodic care with secondary/tertiary care; comprehensive, holistic approach; and partnership and equality among professional disciplines and community members. Stakeholders involved are medical, nursing, and…

  7. Providing primary health care with non-physicians.

    PubMed

    Chen, P C

    1984-04-01

    The definition of primary health care is basically the same, but the wide variety of concepts as to the form and type of worker required is largely due to variations in economic, demographic, socio-cultural and political factors. Whatever form it takes, in many parts of the developing world, it is increasingly clear that primary health care must be provided by non-physicians. The reasons for this trend are compelling, yet it is surprisingly opposed by the medical profession in many a developing country. Nonetheless, numerous field trials are being conducted in a variety of situations in several countries around the world. Non-physician primary health care workers vary from medical assistants and nurse practitioners to aide-level workers called village mobilizers, village volunteers, village aides and a variety of other names. The functions, limitations and training of such workers will need to be defined, so that an optimal combination of skills, knowledge and attitudes best suited to produce the desired effect on local health problems may be attained. The supervision of such workers by the physician and other health professionals will need to be developed in the spirit of the health team. An example of the use of non-physicians in providing primary health care in Sarawak is outlined.

  8. Management of postmenopausal osteoporosis for primary care.

    PubMed

    Miller, P; Lukert, B; Broy, S; Civitelli, R; Fleischmann, R; Gagel, R; Khosla, S; Lucas, M; Maricic, M; Pacifici, R; Recker, R; Sarran, H S; Short, B; Short, M J

    1998-01-01

    The shift in health care delivery from a subspecialty to primary care system has transferred the responsibility of preventing osteoporotic fractures from specialists in metabolic bone disease to the web of physicians--family practitioners, general internists, pediatricians, and gynecologists--who provide the bulk of primary care. The challenge for this group of physicians is to decrease the rising prevalence of osteoporotic hip and vertebral fractures while operating within the cost parameters. It is the goal of this brief summary to provide primary practitioners with focused guidelines for the management of postmenopausal osteoporosis based on new and exciting developments. Prevention and treatment will change rapidly over the next decade and these advances will require changes in these recommendations. We identified patients at risk for osteoporosis and provided indications for bone mass measurement, criteria for diagnosis of osteoporosis, therapeutic interventions, and biochemical markers of the disease. Prevention and treatment are discussed, including hormone replacement therapy and use of calcitonin, sodium fluoride, bisphosphonates, and serum estrogen receptor modulators. Postmenopausal osteoporosis should no longer be an accepted process of aging. It is both preventable and treatable. Primary care physicians must proactively prevent and treat osteoporosis in their daily practice, and combination therapies are suggested.

  9. 2001 survey on primary medical care in Singapore.

    PubMed

    Emmanuel, S C; Phua, H P; Cheong, P Y

    2004-05-01

    The 2001 survey on primary medical care was undertaken to compare updated primary healthcare practices such as workload and working hours in the public and private sectors; determine private and public sector market shares in primary medical care provision; and gather the biographical profile and morbidity profile of patients seeking primary medical care from both sectors in Singapore. This is the third survey in its series, the earlier two having been carried out in 1988 and 1993, respectively. The survey questionnaire was sent out to all the 1480 family doctors in private primary health outpatient practice, the 89 community-based paediatricians in the private sector who were registered with the Singapore Medical Council and also to all 152 family doctors working in the public sector primary medical care clinics. The latter comprised the polyclinics under the two health clusters in Singapore, namely the Singapore Health Services and National Healthcare Group, and to a very much smaller extent, the School Health Service's (SHS) outpatient clinics. The survey was conducted on 21 August 2001, and repeated on 25 September 2001 to enable those who had not responded to the original survey date to participate. Subjects consisted of all outpatients who sought treatment at the private family practice clinics (including the clinics of the community-based paediatricians), and the public sector primary medical care clinics, on the survey day. The response rate from the family doctors in private practice was 36 percent. Owing to the structured administrative organisation of the polyclinics and SHS outpatient clinics, all returns were completed and submitted to the respective headquarters. Response from the community-based paediatricians was poor, so their findings were omitted in the survey analysis. The survey showed that the average daily patient-load of a family doctor in private practice was 33 patients per day, which was lower than the 40 patients a day recorded in 1993

  10. Pulmonary rehabilitation in COPD - available resources and utilization in Swedish primary and secondary care.

    PubMed

    Sundh, Josefin; Lindgren, Helena; Hasselgren, Mikael; Montgomery, Scott; Janson, Christer; Ställberg, Björn; Lisspers, Karin

    2017-01-01

    Pulmonary rehabilitation is effective in all stages of COPD. The availability and utilization of pulmonary rehabilitation resources, and the characteristics of COPD patients receiving rehabilitation, were investigated in primary and secondary care in central Sweden. Data on available pulmonary rehabilitation resources were collected using questionnaires, to 14 hospitals and 54 primary health care centers, and information on utilization of different rehabilitation professionals was obtained from questionnaires completed by 1,329 COPD patients from the same centers. Multivariable logistic regression examined associations with having received rehabilitation in the previous year. In primary care, nurse-based asthma/COPD clinics were common (87%), with additional separate access to other rehabilitation professionals. In secondary care, rehabilitation was more often offered as part of a multidisciplinary teamwork (71%). In total, 36% of the patients met an asthma/COPD nurse in the previous year. Utilization was lower in primary than in secondary care for physiotherapists (7% vs 16%), occupational therapists (3% vs 10%), nutritionists (5% vs 13%), and counselors (1% vs 4%). A higher COPD Assessment Test score and frequent exacerbations were associated with higher utilization of all rehabilitation professionals. Pulmonary rehabilitation resources are available but underutilized, and receiving rehabilitation is more common in severe COPD. Treatment recommendations need to be better implemented, especially in mild and moderate COPD.

  11. A Strength Training Program for Primary Care Patients, Central Pennsylvania, 2012

    PubMed Central

    Patel, Vijay A.; Kraschnewski, Jennifer L.; Rovniak, Liza S.; Messina, Dino A.; Stuckey, Heather L.; Curry, William J.; Chuang, Cynthia H.; Sherwood, Lisa L.; Hess, Stacy L.

    2014-01-01

    Introduction Primary care providers can recommend strength training programs to use “Exercise as Medicine,” yet few studies have examined the interest of primary care patients in these programs. Methods We conducted a cross-sectional survey of primary care patients in central Pennsylvania. Interest in participating in free group-based strength training and weight control programs was assessed, in addition to patient demographics, medical history, and quality of life. Results Among 414 patients, most (61.0%) were aged 54 or older, and 64.0% were female. More patients were interested in a strength training program (55.3%) than in a weight control program (45.4%). Nearly three-quarters (72.8%) of those reporting 10 or more days of poor physical health were interested in a strength training program compared with 49.5% of those reporting no days of poor physical health. After adjusting for potential confounders, those reporting poorer physical health had 2.7 greater odds (95% confidence interval, 1.4–5.1) of being interested in a strength training program compared with those reporting better physical health. Patients with hypertension, diabetes, or high cholesterol were not more interested in a strength training program than those without these conditions. Conclusion Primary care practices may consider offering or referring patients to community-based strength training programs. This study observed high levels of interest in these widely available programs. Practices may also consider screening and referring those with poorer physical health, as they may be the most interested and have the most to gain from participating. PMID:24967829

  12. Integrating mental health into primary care in Sverdlovsk

    PubMed Central

    2009-01-01

    Introduction Mental disorders occur as frequently in Russia as elsewhere, but the common mental disorders, especially depression, have gone largely unrecognised and undiagnosed by policlinic staff and area doctors. Methods This paper describes the impact and sustainability of a multi-component programme to facilitate the integration of mental health into primary care, by situation appraisal, policy dialogue, development of educational materials, provision of a training programme and the publication of standards and good practice guidelines to improve the primary care of mental disorders in the Sverdlovsk region of the Russian Federation. Results The multi-component programme has resulted in sustainable training about common mental disorders, not only of family doctors but also of other cadres and levels of professionals, and it has been well integrated with Sverdlovsk's overall programme of health sector reforms. Conclusion It is possible to facilitate the sustainable integration of mental health into primary care within the Russian context. While careful adaptation will be needed, the approach adopted here may also hold useful lessons for policy makers seeking to integrate mental health within primary care in other contexts and settings. PMID:22477885

  13. Uncommon Caring: Primary Males and Implicit Judgments.

    ERIC Educational Resources Information Center

    King, James R.

    The caring and nurturing of children, which characterize primary education culture, have tended to shape a public perception of primary teaching as "women's work." Several social factors influence men's underrepresentation in the profession of primary education, such as parents not wanting their children exposed to "soft"…

  14. Influence of Primary Care Use on Population Delivery of Colorectal Cancer Screening

    PubMed Central

    Fenton, Joshua J.; Reid, Robert J.; Baldwin, Laura-Mae; Elmore, Joann G.; Buist, Diana S.M.; Franks, Peter

    2009-01-01

    Objective Colorectal cancer (CRC) screening is commonly initiated during primary care visits. Thus, at the population level, limited primary care attendance may constitute a substantial barrier to CRC screening uptake. Within a defined population, we quantified the percent of CRC screening underuse that is potentially explained by low use of primary care visits. Methods Among 48,712 adults aged 50-78 years eligible for CRC screening within a Washington state health plan, we estimated the degree to which a lack of CRC screening in 2002-2003 (fecal occult blood testing, sigmoidoscopy, or colonoscopy) was attributable to low primary care use, expressed as the population attributable risk percent (PAR%) associated with 0 to 3 primary care visits during the two-year period. Results In analyses adjusted for age, comorbidity, non-primary care visit use, and prior preventive service use, low primary care use in 2002-2003 was strongly associated with a lack of CRC screening among both women and men. However, a majority of unscreened women and men had >=4 primary care visits. Thus, whether low primary care use was defined as 0, 0 to 1, 0 to 2, or 0 to 3 primary care visits, the PAR% associated with low primary care use was large in neither women (range: 3.0-6.8%) nor men (range: 5.6-11.5%). Conclusions Health plan outreach efforts to encourage primary care attendance would be unlikely to substantially increase population uptake of CRC screening. In similar settings, resources might be more fruitfully devoted to the optimization of screening delivery during primary care visits that patients already attend. PMID:19190140

  15. Medical ethics in the primary care setting.

    PubMed

    Smith, H L

    1987-01-01

    Much popular and professional understanding of 'medical ethics' is nowadays located in quandary ethics, exotic life-and-death decision-making, and tertiary care settings. Medical ethics in the primary care setting is concerned with very different matters. Among these are issues having to do with basic self-understandings of health professionals and patients and their fiduciary relationships; with fundamental social, political and economic notions which will and do shape the allocation and distribution of health care resources; with the goals and purposes appropriate to medical interventions of various sorts; and with the care of the whole person rather than the limited attention to a particular illness or disease syndrome. The commitments of primary care medicine challenge in radical ways some cherished claims of modern liberal societies by questioning the limits of autonomous individualism and by affirming the indispensability of social justice.

  16. Free establishment of primary health care providers: effects on geographical equity.

    PubMed

    Isaksson, David; Blomqvist, Paula; Winblad, Ulrika

    2016-01-23

    A reform in 2010 in Swedish primary care made it possible for private primary care providers to establish themselves freely in the country. In the former, publicly planned system, location was strictly regulated by local authorities. The goal of the new reform was to increase access and quality of health care. Critical arguments were raised that the reform could have detrimental effects on equity if the new primary health care providers chose to establish foremost in socioeconomically prosperous areas. The aim of this study is to examine how the primary care choice reform has affected geographical equity by analysing patterns of establishment on the part of new private providers. The basis of the design was to analyse socio-economic data on individuals who reside in the same electoral areas in which the 1411 primary health care centres in Sweden are established. Since the primary health care centres are located within 21 different county councils with different reimbursement schemes, we controlled for possible cluster effects utilizing generalized estimating equations modelling. The empirical material used in the analysis is a cross-sectional data set containing socio-economic data of the geographical areas in which all primary health care centres are established. When controlling for the effects of the county council regulation, primary health care centres established after the primary care choice reform were found to be located in areas with significantly fewer older adults living alone as well as fewer single parents - groups which generally have lower socio-economic status and high health care needs. However, no significant effects were observed for other socio-economic variables such as mean income, percentage of immigrants, education, unemployment, and children <5 years. The primary care choice reform seems to have had some negative effects on geographical equity, even though these seem relatively minor.

  17. Improving Communication About Serious Illness in Primary Care: A Review.

    PubMed

    Lakin, Joshua R; Block, Susan D; Billings, J Andrew; Koritsanszky, Luca A; Cunningham, Rebecca; Wichmann, Lisa; Harvey, Doreen; Lamey, Jan; Bernacki, Rachelle E

    2016-09-01

    The Institute of Medicine recently called for systematic improvements in clinician-led conversations about goals, values, and care preferences for patients with serious and life-threatening illnesses. Studies suggest that these conversations are associated with improved outcomes for patients and their families, enhanced clinician satisfaction, and lower health care costs; however, the role of primary care clinicians in driving conversations about goals and priorities in serious illness is not well defined. To present a review of a structured search of the evidence base about communication in serious illness in primary care. MEDLINE was searched, via PubMed, on January 19, 2016, finding 911 articles; 126 articles were reviewed and selected titles were added from bibliography searches. Review of the literature informed 2 major topic areas: the role of primary care in communication about serious illness and clinician barriers and system failures that interfere with effective communication. Literature regarding the role that primary care plays in communication focused primarily on the ambiguity about whether primary care clinicians or specialists are responsible for initiating conversations, the benefits of primary care clinicians and specialists conducting conversations, and the quantity and quality of discussions. Timely and effective communication about serious illness in primary care is hampered by key clinician barriers, which include deficits in knowledge, skills, and attitudes; discomfort with prognostication; and lack of clarity about the appropriate timing and initiation of conversations. Finally, system failures in coordination, documentation, feedback, and quality improvement contribute to lack of conversations. Clinician and system barriers will challenge primary care clinicians and institutions to meet the needs of patients with serious illness. Ensuring that conversations about goals and values occur at the appropriate time for seriously ill patients will

  18. New Roles for Medical Assistants in Innovative Primary Care Practices.

    PubMed

    Chapman, Susan A; Blash, Lisel K

    2017-02-01

    To identify and describe new roles for medical assistants (MAs) in innovative care models that improve care while providing training and career advancement opportunities for MAs. Primary data collected at 15 case study sites; 173 key informant interviews and de-identified secondary data on staffing, wages, patient satisfaction, and health outcomes. Researchers used snowball sampling and screening calls to identify 15 organizations using MAs in new roles. Conducted site visits from 2010 to 2012 and updated information in 2014. Thematic analysis explored key topics: factors driving MA role innovation, role description, training required, and wage gains. Categorized outcome data in patient and staff satisfaction, quality of care, and efficiency. New MA roles included health coach, medical scribe, dual role translator, health navigator, panel manager, cross-trained flexible role, and supervisor. Implementation of new roles required extensive training. MA incentives and enhanced compensation varied by role type. New MA roles are part of a larger attempt to reform workflow and relieve primary care providers. Despite some evidence of success, spread has been limited. Key challenges to adoption included leadership and provider resistance to change, cost of additional MA training, and lack of reimbursement for nonbillable services. © Health Research and Educational Trust.

  19. Health system challenges to integration of mental health delivery in primary care in Kenya--perspectives of primary care health workers.

    PubMed

    Jenkins, Rachel; Othieno, Caleb; Okeyo, Stephen; Aruwa, Julyan; Kingora, James; Jenkins, Ben

    2013-09-30

    Health system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness. Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training). These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other

  20. The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care.

    PubMed

    Reddy, Ashok; Pollack, Craig E; Asch, David A; Canamucio, Anne; Werner, Rachel M

    2015-07-01

    Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326,374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184,501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, -5.3; 95% CI, -6.0 to -4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, -1.1; 95% CI, -2.1 to -0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, -1.44; 95% CI, -2.2 to -0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no

  1. Career Choice and Primary Care in the United Arab Emirates

    PubMed Central

    Schiess, Nicoline; Ibrahim, Halah; Shaban, Sami; Perez, Maria Nichole; Nair, Satish Chandrasekhar

    2015-01-01

    Background  The low number of medical trainees entering primary care is contributing to the lack of access to primary care services in many countries. Despite the need for primary care physicians in the Middle East, there is limited information regarding trainees' career choices, a critical determinant in the supply of primary care physicians. Objective  We analyzed the career choices of medical students in the United Arab Emirates (UAE), with a larger goal of reforming postgraduate training in the region and enhancing the focus on primary care. Methods  We conducted a cross-sectional survey of applicants to a large established internal medicine residency program in the UAE. We calculated data for demographics, subspecialty choice, and factors affecting subspecialty choice, and we also reported descriptive statistics. Results  Our response rate was 86% (183 of 212). Only 25% of applicants (n = 46) were interested in general internal medicine. The majority of respondents (n = 126, 69%) indicated a desire to pursue subspecialty training, and the remainder chose careers in research or administration. A majority of respondents (73%) were women, unmarried, and childless. Educational debt or lifestyle were not indicated as important factors in career choice. Conclusions  Low interest in primary care was similar to that in many Western countries, despite a much higher percentage of female applicants and a reduced emphasis on lifestyle or income factors in career decisions. Reasons for the reduced interest in primary care deserve further exploration, as do tests of interventions to increase interest, such as improving the primary care clerkship experience. PMID:26692983

  2. Effectiveness and cost effectiveness of counselling in primary care.

    PubMed

    Bower, P; Rowland, N; Mellor, C l; Heywood, P; Godfrey, C; Hardy, R

    2002-01-01

    % confidence intervals. Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. In view of the diversity of counselling services in primary care (the range of treatments, patients and practitioners) tests of heterogeneity were done to assess the feasibility of aggregating measures of outcome from trials. Sensitivity analyses were undertaken to test the robustness of the results. Seven trials were included in the review. The main analyses showed significantly greater clinical effectiveness in the counselling group compared with 'usual care' in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n=772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n=475, 4 trials). Levels of satisfaction with counselling were high. Four studies reported similar total costs associated with counselling and usual care over the long-term. However, the economic analyses were likely to be underpowered. Counselling is associated with modest improvement in short-term outcome compared to 'usual care', but provides no additional advantages in the long-term. Patients are satisfied with counselling, and it may not be associated with increased costs.

  3. Primary Care Practice Transformation and the Rise of Consumerism.

    PubMed

    Shrank, William H

    2017-04-01

    Americans are increasingly demanding the same level of service in healthcare that they receive in other services and products that they buy. This rise in consumerism poses challenges for primary care physicians as they attempt to transform their practices to succeed in a value-based reimbursement landscape, where they are rewarded for managing costs and improving the health of populations. In this paper, three examples of consumer-riven trends are described: retail healthcare, direct and concierge care, and home-based diagnostics and care. For each, the intersection of consumer-driven care and the goals of value-based primary care are explored. If the correct payment and connectivity enablers are in place, some examples of consumer-driven care are well-positioned to support primary care physicians in their mission to deliver high-quality, efficient care for the populations they serve. However, concerns about access and equity make other trends less consistent with that mission.

  4. Primary care physicians in underserved areas. Family physicians dominate.

    PubMed Central

    Burnett, W H; Mark, D H; Midtling, J E; Zellner, B B

    1995-01-01

    Using the definitions of "medically underserved areas" developed by the California Health Manpower Policy Commission and data on physician location derived from a survey of California physicians applying for licensure or relicensure between 1984 and 1986, we examined the extent to which different kinds of primary care physicians located in underserved areas. Among physicians completing postgraduate medical education after 1974, board-certified family physicians were 3 times more likely to locate in medically underserved rural communities than were other primary care physicians. Non-board-certified family and general physicians were 1.6 times more likely than other non-board-certified primary care physicians to locate in rural underserved areas. Family and general practice physicians also showed a slightly greater likelihood than other primary care physicians of being located in urban underserved areas. PMID:8553635

  5. Kansas Primary Care Weighs In: A Pilot Randomized Trial of a Chronic Care Model Program for Obesity in 3 Rural Kansas Primary Care Practices

    ERIC Educational Resources Information Center

    Ely, Andrea C.; Banitt, Angela; Befort, Christie; Hou, Qing; Rhode, Paula C.; Grund, Chrysanne; Greiner, Allen; Jeffries, Shawn; Ellerbeck, Edward

    2008-01-01

    Context: Obesity is a chronic disease of epidemic proportions in the United States. Primary care providers are critical to timely diagnosis and treatment of obesity, and need better tools to deliver effective obesity care. Purpose: To conduct a pilot randomized trial of a chronic care model (CCM) program for obesity care in rural Kansas primary…

  6. Improving primary care for persons with spinal cord injury: Development of a toolkit to guide care.

    PubMed

    Milligan, James; Lee, Joseph; Hillier, Loretta M; Slonim, Karen; Craven, Catharine

    2018-05-07

    To identify a set of essential components for primary care for patients with spinal cord injury (SCI) for inclusion in a point-of-practice toolkit for primary care practitioners (PCP) and identification of the essential elements of SCI care that are required in primary care and those that should be the focus of specialist care. Modified Delphi consensus process; survey methodology. Primary care. Three family physicians, six specialist physicians, and five inter-disciplinary health professionals completed surveys. Importance of care elements for inclusion in the toolkit (9-point scale: 1 = lowest level of importance, 9 = greatest level of importance) and identification of most responsible physician (family physician, specialist) for completing key categories of care. Open-ended comments were solicited. There was consensus between the respondent groups on the level of importance of various care elements. Mean importance scores were highest for autonomic dysreflexia, pain, and skin care and lowest for preventive care, social issues, and vital signs. Although, there was agreement across all respondents that family physicians should assume responsibility for assessing mental health, there was variability in who should be responsible for other care categories. Comments were related to the need for shared care approaches and capacity building and lack of knowledge and specialized equipment as barriers to optimal care. This study identified important components of SCI care to be included in a point-of-practice toolkit to facilitate primary care for persons with SCI.

  7. Improving Primary Care Provider Practices in Youth Concussion Management.

    PubMed

    Arbogast, Kristy B; Curry, Allison E; Metzger, Kristina B; Kessler, Ronni S; Bell, Jeneita M; Haarbauer-Krupa, Juliet; Zonfrillo, Mark R; Breiding, Matthew J; Master, Christina L

    2017-08-01

    Primary care providers are increasingly providing youth concussion care but report insufficient time and training, limiting adoption of best practices. We implemented a primary care-based intervention including an electronic health record-based clinical decision support tool ("SmartSet") and in-person training. We evaluated consequent improvement in 2 key concussion management practices: (1) performance of a vestibular oculomotor examination and (2) discussion of return-to-learn/return-to-play (RTL/RTP) guidelines. Data were included from 7284 primary care patients aged 0 to 17 years with initial concussion visits between July 2010 and June 2014. We compared proportions of visits pre- and post-intervention in which the examination was performed or RTL/RTP guidelines provided. Examinations and RTL/RTP were documented for 1.8% and 19.0% of visits pre-intervention, respectively, compared with 71.1% and 72.9% post-intervention. A total of 95% of post-intervention examinations were documented within the SmartSet. An electronic clinical decision support tool, plus in-person training, may be key to changing primary care provider behavior around concussion care.

  8. [Renewing primary health care in the Americas].

    PubMed

    Macinko, James; Montenegro, Hernán; Nebot Adell, Carme; Etienne, Carissa

    2007-01-01

    At the 2003 meeting of the Directing Council of the Pan American Health Organization (PAHO), the PAHO Member States issued a mandate to strengthen primary health care (Resolution CD44. R6). The mandate led in 2005 to the document "Renewing Primary Health Care in the Americas. A Position Paper of the Pan American Health Organization/WHO [World Health Organization]," and it culminated in the Declaration of Montevideo, an agreement among the governments of the Region of the Americas to renew their commitment to primary health care (PHC). Scientific data have shown that PHC, regarded as the basis of all the health systems in the Region, is a key component of effective health systems and can be adapted to the range of diverse social, cultural, and economic conditions that exist. The new, global health paradigm has given rise to changes in the population's health care needs. Health services and systems must adapt to address these changes. Building on the legacy of the International Conference on Primary Health Care, held in 1978 in Alma-Ata (Kazakhstan, Union of Soviet Socialist Republics), PAHO proposes a group of strategies critical to adopting PHC-based health care systems based on the principles of equity, solidarity, and the right to the highest possible standard of health. The main objective of the strategies is to develop and/or strengthen PHC-based health systems in the entire Region of the Americas. A substantial effort will be required on the part of health professionals, citizens, governments, associations, and agencies. This document explains the strategies that must be employed at the national, subregional, Regional, and global levels.

  9. Integration of depression and primary care: barriers to adoption.

    PubMed

    Grazier, Kyle L; Smith, Judith E; Song, Jean; Smiley, Mary L

    2014-01-01

    Despite the prevailing consensus as to its value, the adoption of integrated care models is not widespread. Thus, the objective of this article it to examine the barriers to the adoption of depression and primary care models in the United States. A literature search focused on peer-reviewed journal literature in Medline and PsycInfo. The search strategy focused on barriers to integrated mental health care services in primary care, and was based on previously existing searches. The search included: MeSH terms combined with targeted keywords; iterative citation searches in Scopus; searches for grey literature (literature not traditionally indexed by commercial publishers) in Google and organization websites, examination of reference lists, and discussions with researchers. Integration of depression care and primary care faces multiple barriers. Patients and families face numerous barriers, linked inextricably to create challenges not easily remedied by any one party, including the following: vulnerable populations with special needs, patient and family factors, medical and mental health comorbidities, provider supply and culture, financing and costs, and organizational issues. An analysis of barriers impeding integration of depression and primary care presents information for future implementation of services.

  10. Primary Care Attributes and Care for Depression Among Low-Income African American Women

    PubMed Central

    O’Malley, Ann S.; Forrest, Christopher B.; Miranda, Jeanne

    2003-01-01

    Objectives. We examined the association between attributes of primary care providers and care for depression, from a patients’ perspective, among a sample of predominantly low-income African American women. Methods. Computer-assisted telephone interviews were conducted among a population-based sample of 1202 women residing in Washington, DC. Results. Respondents whose primary care physicians provided more comprehensive medical services were more likely to be asked about and treated for depressive symptoms than women whose providers were less medically comprehensive. Women who rated their providers as having more respect for them also were more likely to be asked about and treated for depression. Conclusions. More comprehensive primary care delivery and a physician–patient relationship focused on mutual respect are associated with greater rates of physician inquiry about and treatment for depression among vulnerable women. PMID:12893623

  11. Pediatric Primary Care Providers' Relationships with Mental Health Care Providers: Survey Results

    ERIC Educational Resources Information Center

    Pidano, Anne E.; Honigfeld, Lisa; Bar-Halpern, Miri; Vivian, James E.

    2014-01-01

    Background: As many as 20 % of children have diagnosable mental health conditions and nearly all of them receive pediatric primary health care. However, most children with serious mental health concerns do not receive mental health services. This study tested hypotheses that pediatric primary care providers (PPCPs) in relationships with mental…

  12. Improving substance abuse screening and intervention in a primary care clinic.

    PubMed

    Neushotz, Lori A; Fitzpatrick, Joyce J

    2008-04-01

    Despite recent efforts to educate primary care providers in the identification and management of patients presenting with substance abuse problems, many opportunities to identify and intervene with these patients are overlooked. This project was designed to identify factors that interfere with rates of screening and brief intervention (SBI) of substance abuse problems in a primary care clinic in a major academic medical center in New York City. Six informants representing the disciplines of medicine, nursing, and social work in the primary care clinic provided information regarding SBI. Analysis was focused on substantiation of the need for enhanced diffusion of knowledge related to screening for substance abuse problems to improve rates of SBI in primary care. Recommendations for improvement included continued promotion of SBI by influential role models and opinion leaders, improvement in primary care providers' perceptions of the perceived characteristics of SBI to improve rates of adoption, implementation of interdisciplinary educational initiatives toward the goal of improving rates of SBI in the primary care clinic, and initiation of translational research at the clinic supporting SBI in primary care.

  13. Electrocardiogram interpretation and arrhythmia management: a primary and secondary care survey.

    PubMed

    Begg, Gordon; Willan, Kathryn; Tyndall, Keith; Pepper, Chris; Tayebjee, Muzahir

    2016-05-01

    There is increasing desire among service commissioners to treat arrhythmia in primary care. Accurate interpretation of the electrocardiogram (ECG) is fundamental to this. ECG interpretation has previously been shown to vary widely but there is little recent data. To examine the interpretation of ECGs in primary and secondary care. A cross-sectional survey of participants' interpretation of six ECGs and hypothetical management of patients based on those ECGs, at primary care educational events, and a cardiology department in Leeds. A total of 262 primary care clinicians and 20 cardiology clinicians were surveyed via questionnaire. Answers were compared with expert electrophysiologist opinion. In primary care, abnormal ECGs were interpreted as normal by 23% of responders. ST elevation and prolonged QT were incorrectly interpreted as normal by 1% and 22%, respectively. In cardiology, abnormal ECGs were interpreted as normal by 3%. ECG provision and interpretation remains inconsistent in both primary and secondary care. Primary care practitioners are less experienced and less confident with ECG interpretation than cardiologists, and require support in this area. © British Journal of General Practice 2016.

  14. Implementation strategy for advanced practice nursing in primary health care in Latin America and the Caribbean.

    PubMed

    Oldenburger, David; De Bortoli Cassiani, Silvia Helena; Bryant-Lukosius, Denise; Valaitis, Ruta Kristina; Baumann, Andrea; Pulcini, Joyce; Martin-Misener, Ruth

    2017-06-08

    SYNOPSIS Advanced practice nursing (APN) is a term used to describe a variety of possible nursing roles operating at an advanced level of practice. Historically, APN roles haves evolved informally, out of the need to improve access to health care services for at-risk and disadvantaged populations and for those living in underserved rural and remote communities. To address health needs, especially ones related to primary health care, nurses acquired additional skills through practice experience, and over time they developed an expanded scope of practice. More recently, APN roles have been developed more formally through the establishment of graduate education programs to meet agreed-upon competencies and standards for practice. The introduction of APN roles is expected to advance primary health care throughout Latin America and the Caribbean, where few such roles exist. The purpose of the paper is to outline an implementation strategy to guide and support the introduction of primary health care APN roles in Latin America and the Caribbean. The strategy includes the adaptation of an existing framework, utilization of recent research evidence, and application of knowledge from experts on APN and primary health care. The strategy consists of nine steps. Each step includes a national perspective that focuses on direct country involvement in health workforce planning and development and on implementation. In addition, each step incorporates an international perspective on encouraging countries that have established APN programs and positions to collaborate in health workforce development with nations without advanced practice nursing.

  15. [Primary care in maternal-child health].

    PubMed

    Pedreira Massa, J L

    1986-07-01

    The theoretical and methodological elements of primary health care (PHC) include a philosophy of work and an epistemological focus toward the processes of health and illness, as well as a practical medical anthropological knowledge of the culture-specific aspects of disease. The work methodology of PHC requires care of the individual as a bio-psycho-socio-affective being integrated into a particular environment; none of the aspects of being should be neglected or given priority. Care should also be integrated in the sense of providing preventive health care as well as curative and rehabilitative services, in all phases from training of health personnel to record keeping. The primary health care team is multidisciplinary in constitution and interdisciplinary in function. PHC assumes that health care will be accessible to users and that continuity of care will be provided. The need for community participation in all phases of health care has been reiterated in several international health declarations. A well-functioning PHC system will require new types of pre- and postgraduate health education in a changing social and professional system and continuing education under adequate supervision for health workers. Research capability for identifying community health problems, a rigorous evaluation system, and epidemiologic surveillance are also needed. All of these elements are applicable to the field of maternal and child health as well as to PHC. The most appropriate place to intervene in order to correct existing imbalances in access to health care for mothers and children is in the PHC system. Examples of areas that should be stressed include vaccinations, nutrition, psychomotor development, early diagnosis and treatment for handicapped children, prevention of childhood accidents, school health and absenteeism, all aspects of health education, adoption and alternatives to abandonment of children, alcoholism and addiction, adolescent pregnancy and family planning

  16. Root Doctors as Providers of Primary Care

    PubMed Central

    Stitt, Van J.

    1983-01-01

    Physicians in primary care recognize that as many as 65 percent of the patients seen in their offices are there for psychological reasons. In any southern town with a moderate population of blacks, there are at least two “root doctors.” These root doctors have mastered the power of autosuggestion and are treating these patients with various forms of medication and psychological counseling. This paper updates the practicing physician on root doctors who practice primary care. PMID:6887277

  17. Managing obesity in primary care.

    PubMed

    Goldie, Christine; Brown, Jenny

    Obesity is a complex problem and often difficult to tackle in primary care. A year-long pilot of a practice nurse-led scheme that used a holistic approach towards self-care in obesity management was set up to reduce the cardiovascular risk of patients who were obese and improve their quality of life. This person-centred approach may offer an important tool in the management of these patients in the GP surgery.

  18. Primary Care Physicians' Dementia Care Practices: Evidence of Geographic Variation

    ERIC Educational Resources Information Center

    Fortinsky, Richard H.; Zlateva, Ianita; Delaney, Colleen; Kleppinger, Alison

    2010-01-01

    Purpose: This article explores primary care physicians' (PCPs) self-reported approaches and barriers to management of patients with dementia, with a focus on comparisons in dementia care practices between PCPs in 2 states. Design and Methods: In this cross-sectional study, questionnaires were mailed to 600 randomly selected licensed PCPs in…

  19. Breathlessness in the primary care setting.

    PubMed

    Baxter, Noel

    2017-09-01

    Breathlessness is a high-volume problem with 10% of adults experiencing the symptom daily placing a heavy burden on the health and wider economy. As it worsens, they enter the specialist and hospital-based symptom services where costs quickly escalate and people may find themselves in a place not of their choosing. For many, their care will be delivered by a disease or organ specialist and can find themselves passing between physicians without coordination for symptom support. General practitioners (GPs) will be familiar with this scenario and can often feel out of their depth. Recent advances in our thinking about breathlessness symptom management can offer opportunities and a sense of hope when the GP is faced with this situation. Original research, reviews and other findings over the last 12-18 months that pertain to the value that general practice and the wider primary care system can add, include opportunities to help people recognize they have a problem that can be treated. We present systems that support decisions made by primary healthcare professionals and an increasingly strong case that a solution is required in primary care for an ageing and frail population where breathlessness will be common. Primary care practitioners and leaders must start to realize the importance of recognizing and acting early in the life course of the person with breathlessness because its impact is enormous. They will need to work closely with public health colleagues and learn from specialists who have been doing this work usually with people near to the end of life translating the skills and knowledge further upstream to allow people to live well and remain near home and in their communities.

  20. Suicidal ideations, plans and attempts in primary care: cross-sectional study of consultants at primary health care system in Morocco.

    PubMed

    Oneib, Bouchra; Sabir, Maria; Otheman, Yassine; Abda, Naima; Ouanass, Abderrazzak

    2016-01-01

    The aim of the study is to estimate the prevalence of suicidal ideation among Moroccan consultants in primary health care system. We conducted a cross sectional survey in three health care centers in two cities of Morocco to estimate the prevalence of suicidal ideation, plan and suicide attempts among 396 consultants in the primary health care system, using the Mini International neuropsychiatric interview. Patients were 18 years and older, without known psychiatric or chronic somatic disease. Statistical analysis was performed by the SPSS 13.0 software. The prevalence of suicidal ideation was 5.3%, and 2.7% of the patients planned their suicide and 1.2% tried to commit suicide. The multivariate analysis did not demonstrate significant association. Suicidal ideation, plan and suicide attempts are prevalent in primary health care patients, but they are still under diagnosed. An adequate training of physicians and the establishment of education programs is essential to reduce the rate of suicide.

  1. The next phase of Title VII funding for training primary care physicians for America's health care needs.

    PubMed

    Phillips, Robert L; Turner, Barbara J

    2012-01-01

    Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section 747 of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and ultimately to improve the responsiveness of teaching hospitals to community needs. To accomplish these goals, Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk.

  2. Physicians' accounts of frontline tensions when implementing pilot projects to improve primary care.

    PubMed

    Mansfield, Elizabeth; Bhattacharyya, Onil; Christian, Jennifer; Naglie, Gary; Steriopoulos, Vicky; Webster, Fiona

    2018-03-19

    Purpose Canada's primary care system has been described as "a culture of pilot projects" with little evidence of converting successful initiatives into funded, permanent programs or sharing project outcomes and insights across jurisdictions. Health services pilot projects are advocated as an effective strategy for identifying promising models of care and building integrated care partnerships in local settings. In the qualitative study reported here, the purpose of this paper is to investigate the strengths and challenges of this approach. Design/methodology/approach Semi-structured interviews were conducted with 34 primary care physicians who discussed their experiences as pilot project leads. Following thematic analysis methods, broad system issues were captured as well as individual project information. Findings While participants often portrayed themselves as advocates for vulnerable patients, mobilizing healthcare organizations and providers to support new models of care was discussed as challenging. Competition between local healthcare providers and initiatives could impact pilot project success. Participants also reported tensions between their clinical, project management and research roles with additional time demands and skill requirements interfering with the work of implementing and evaluating service innovations. Originality/value Study findings highlight the complexity of pilot project implementation, which encompasses physician commitment to addressing care for vulnerable populations through to the need for additional skill set requirements and the impact of local project environments. The current pilot project approach could be strengthened by including more multidisciplinary collaboration and providing infrastructure supports to enhance the design, implementation and evaluation of health services improvement initiatives.

  3. Primary Care and the Hypertension Care Continuum in Brazil.

    PubMed

    Macinko, James; Leventhal, Daniel G P; Lima-Costa, Maria Fernanda

    This study provides estimates of hypertension prevalence, awareness, treatment, and control in Brazil and assesses how well different modes of primary care delivery achieve each of these outcomes. Over one-third of the Brazilian adult population had measured hypertension or prior diagnosis. Nearly 90% of these had recent contact with the health system, but only 65% were aware of their condition. Only 62% of these regularly sought care for hypertension, but of these 92% received treatment. Hypertension control was 33% overall, but increased to 57% among those who received all levels of care.

  4. Frequent users of rural primary care: comparisons with randomly selected users.

    PubMed

    Mehl-Madrona, L E

    1998-01-01

    Frequent users of primary care have not been adequately characterized. The unique characteristics of this population was sought--why they come so often, what their care costs, and whether psychosocial factors play a role in their high utilization of health care. The billing system of a rural primary care clinic was used to find the frequency of visits for all patients attending the clinic for the previous 12 months. The 211 most frequent visitors were selected. A comparison group of 250 patients was drawn from the billing records using a random number generator. Charts were reviewed to compare diagnoses (by frequency), number of procedures, amount billed for care, amount received from those billings, number of psychotropic medications prescribed, and response to medication. A subgroup of each group was interviewed to confirm chart review findings and to inquire about personal reasons for coming to the clinic. Compared with patients who were random users, patients who were frequent users were more likely to come from the younger and older age groups, they averaged significantly more emergency department visits and visits to other specialists (P < 0.0001), and they had more mental health problems diagnosed (P < 0.01). Significantly more frequent users were insured by Medicaid and fewer were insured by Medicare. They had more detailed office visits and more laboratory tests. They received twice as much psychotherapy and had a higher percentage of problem-focused office visits. Chart audits and interviews of selected patients revealed that many nonmedical reasons were related to visits in addition to psychosocial stressors. Nonmedical factors are important among the most frequent users of a primary care clinic. Proposals to improve care for frequent users should consider the psychosocial needs of this population.

  5. Primary care renewal: regional faculty development and organizational change.

    PubMed

    Quirk, Mark E; Haley, Heather-Lyn; Hatem, David; Starr, Susan; Philbin, Mary

    2005-03-01

    Many reports, including the Future of Family Medicine, have called for change in primary care, but few have defined, implemented, and evaluated mechanisms to address such change. The regional, interdisciplinary Primary Care Renewal Project was designed to address problems in primary care practice and teaching related to practice management, compensation, increasing responsibility for teaching, and faculty development. Twelve northeastern US medical schools assembled a conference attended by teams of key stakeholders representing both clinical and educational missions. Teams developed and implemented an institutional plan to address identified needs. Outcome data was collected during, and for 1 year after, the conference. Findings demonstrate novel ways of improving learning experiences, coordinating and centralizing planning efforts, and addressing faculty needs. The magnitude of organizational change ranged from establishing new administrative units with significant institutional authority (eg, restructuring dean's office) to enhancing the strategic planning process and refining mission statements to reflect emphasis on primary care. A well-planned, regional interdisciplinary effort that fosters the development of concrete plans can be associated with significant change in medical education. A central theme emerged--that primary care medicine will survive only if institutions align their educational and clinical missions and foster system-wide change.

  6. The Primary Care Physician Workforce: Ethical and Policy Implications

    PubMed Central

    Starfield, Barbara; Fryer, George E.

    2007-01-01

    PURPOSE We undertook a study to examine the characteristics of countries exporting physicians to the United States according to their relative contribution to the primary care supply in the United States. METHODS We used data from the World Health Organization and from the American Medical Association Physician Masterfile to gather sociodemographic, health system, and health characteristics of countries and the number of international medical graduates (IMGs) for the countries, according to the specialty of their practice in the United States. RESULTS Countries whose medical school graduates added a relatively greater percentage of the primary care physicians than the overall percentage of primary care physicians in the United States (31%) were poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates than countries contributing relatively more specialists to the US physician workforce. CONCLUSION The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply. The ethical aspects of depending on foreign medical graduates is an important issue, especially when it deprives disadvantaged countries of their graduates to buttress a declining US primary care physician supply. PMID:18025485

  7. Retail clinics versus traditional primary care: Employee satisfaction guaranteed?

    PubMed

    Lelli, Vanessa R; Hickman, Ronald L; Savrin, Carol L; Peterson, Rachel A

    2015-09-01

    To examine if differences exist in the levels of autonomy and job satisfaction among primary care nurse practitioners (NPs) employed in retail clinics versus traditional primary care settings. Data were collected from 310 primary care NPs who attended the American Association of NP's 28th Annual Conference in June 2013. Participants completed a demographic form, the Misener NP Job Satisfaction Scale, and the Dempster Practice Behavior Scale. Overall, there were no differences in job satisfaction or autonomy among NPs by practice setting. Retail NPs felt less valued and were less satisfied with social interaction, but more satisfied with benefits compared to NPs in traditional settings. NPs working in retail clinics were less likely to have intentions to leave current position compared to NPs in traditional practice settings. The results of this study enhance our current understanding of the linkages between levels of autonomy, job satisfaction, and practice setting among primary care NPs. The findings of this descriptive study offer valuable insights for stakeholders devoted to the development of the primary care workforce and identify modifiable factors that may influence retention and turnover rates among NPs. ©2015 American Association of Nurse Practitioners.

  8. The contribution of dietitians to the primary health care workforce.

    PubMed

    Howatson, Alexandra; Wall, Clare R; Turner-Benny, Petrina

    2015-12-01

    Dietetic intervention is effective in the management of nutrition-related conditions and their comorbidities. New Zealand has an increasing need for primary and preventive health care to reduce the burden of non-communicable disease. To review the recent evidence of effectiveness of dietetic intervention in primary health care on health and wider economic outcomes. Health benefits and cost benefits of employing dietitians to perform nutrition intervention in the primary health care setting are evaluated in the areas of obesity in conjunction with diabetes and cardiovascular disease, and malnutrition in older adults. An electronic literature search of four scientific databases, websites of major dietetic associations and high-impact nutrition and dietetic journals was conducted. Randomised controlled trials and non-randomised studies conducted from 2000 to 2014 were included. Dietetic intervention demonstrates statistically and clinically significant impacts on health outcomes in the areas of obesity, cardiovascular disease, diabetes, and malnutrition in older adults, when compared to usual care. Dietitians working in primary health care can also have significant economic benefits, potentially saving the health care system NZ$5.50-$99 for every NZ$1 spent on dietetic intervention. New Zealand must look to new models of health care provision that are not only patient-centred but are also cost-effective. This review demonstrates that dietitians in primary health care can improve patients' health and quality of life. Increasing the number of dietitians working in primary health care has the potential to make quality nutrition care accessible and affordable for more New Zealanders.

  9. Psychiatric treatment received by primary care patients with panic disorder with and without agoraphobia

    PubMed Central

    Marcks, Brook A.; Weisberg, Risa B.; Keller, Martin B.

    2013-01-01

    Objective Although the majority of individuals with panic disorder first present to the primary care setting, little is known about the psychiatric treatment primary care patients with the disorder typically receive. The purpose of the current study was to explore characteristics of treatment received by those with panic disorder with and without agoraphobia, examine demographic and clinical predictors of receiving treatment, and explore treatment barriers. Methods This study uses data from the Primary Care Anxiety Project (PCAP), which is a naturalistic, longitudinal study of anxiety disorders in primary care patients. This study presents data on 235 PCAP participants diagnosed with panic disorder with (N=150) or without agoraphobia (N=85) at the study intake assessment. Results Many patients with panic disorder were not receiving psychiatric treatment at study intake, with those without agoraphobia being less likely to receive treatment. Psychotropic medications were the treatment of choice, with SSRIs/SNRIs being the most commonly received class of medications. Only 39% of those with panic disorder with agoraphobia and 24% of those without agoraphobia were receiving psychotherapy, and use of empirically supported interventions was rare. The most common treatment barriers were: not believing in utilizing medication/therapy for emotional problems and not receiving a treatment recommendation from one’s provider. Conclusions The findings suggest a need for better treatment dissemination, in addition to making interventions more accessible and/or adapting them to the particular needs of primary care patients. PMID:19487354

  10. Culture-bound syndromes in Hispanic primary care patients.

    PubMed

    Bayles, Bryan P; Katerndahl, David A

    2009-01-01

    We sought to document Hispanic primary care patients' knowledge and experience of five culture-bound syndromes (CBS), as well as the basic socio-cultural correlates of these disorders. A convenience sample of 100 adult Hispanic patients presenting in an urban South Texas primary care clinic was recruited to complete a brief cross-sectional survey, presented in an oral format. Interviews sought information concerning five culture-bound syndromes--susto, empacho, nervios, mal de ojo, and ataques de nervios. Additional demographic, socio-economic, and acculturation data was collected. Descriptive and bivariate statistics (chi square, Fisher's) were used to assess relationships among variables and experience with each CBS. A multivariate logistic analysis was conducted to determine the possible contributions of age, gender, acculturation, and education to the personal experience of a culture-bound syndrome. Results indicate that 77% of respondents had knowledge of all five syndromes, with 42% reporting having personally experienced at least one CBS. Nervios was the most commonly suffered disorder, being reported by 30 respondents. This was followed, in declining order ofprevalence, by susto, mal de ojo, empacho, and ataques de nervios. Multivariate logistic regression analysis found that higher education beyond high school was associated with a slightly decreased likelihood of reporting having suffered from any culture-bound syndrome. While co-occurrence among these disorders occurred, the patterns of predictors suggest that the co-occurrence is not a reflection of mislabeling of one common syndrome. Knowledge of and experience with culture-bound syndromes is common among Hispanic primary care patients in South Texas. Healthcare providers ought to consider discussing these illnesses in a non-judgmental manner with patients who present with symptoms that are consistent with these syndromes. Future studies, with larger sample sizes, are warranted to elucidate the nature

  11. [Evaluative study of medical-care costs in primary care].

    PubMed

    Brotons Cuixart, Carlos; Moral Peláez, Irene; Pitarch Salgado, Marc; Sellarès Sallas, Jaume; Bohigas Santasusagna, Lluís; da Pena Alvarez, José Manuel

    2007-09-01

    To estimate the real costs of medical care by diagnostic groups at a primary care centre. Descriptive, retrospective study, based on the review of computerized medical records. Urban primary care centre (PCC). All patients who attended the PCC during 2005. Mean medical care cost per visit in euros, broken down for health professionals, diagnostic procedures and drugs costs, and stratified by diagnostic groups. The most frequent visits were for pulmonary, locomotor, cardiovascular, and gastro-intestinal conditions. The mean number of visits per patient attended was 8.7 (SD, 9.4); and per patient registered at the centre, 5.9 (8.7). The highest costs were for cardiovascular (18.96%; 95% CI, 18.93%-18.99%), locomotor (11.21%; 95% CI, 11.18%-11.23%), psychological (10.69%, 95% CI, 10.66%-10.71%), pulmonary (10.20%; 95% CI, 10.17%-10.22%) and endocrinal-nutritional (9.61%; 95% CI, 9.58%-9.63%) problems. Drugs expenditure accounted for 65% of the total cost; visits to health professionals, for 33%; and procedures, for 2%. Overall cost per inhabitant was 239.1 (493.6) euros, and per patient attended was 349.5 (563.5). Cardiovascular disease conditions are much the most costly ones in terms of overall medical cost. Psychological conditions are located in second place in terms of pharmaceutical cost; and in third place, in terms of overall medical-care cost.

  12. Effective communication with primary care providers.

    PubMed

    Smith, Karen

    2014-08-01

    Effective communication requires direct interaction between the hospitalist and the primary care provider using a standardized method of information exchange with the opportunity to ask questions and assign accountability for follow-up roles. The discharge summary is part of the process but does not provide the important aspects of handoff, such as closed loop communication and role assignments. Hospital discharge is a significant safety risk for patients, with more than half of discharged patients experiencing at least one error. Hospitalist and primary care providers need to collaborate to develop a standardized system to communicate about shared patients that meets handoff requirements. Copyright © 2014 Elsevier Inc. All rights reserved.

  13. Using knowledge as the basis for evidence-based practice in primary care nurses.

    PubMed

    Bennasar-Veny, M; Gonzalez-Torrente, S; De Pedro-Gomez, J; Morales-Asencio, J M; Pericas-Beltran, J

    2016-06-01

    The aim of this study was to explore the perception of primary care nurses regarding the need and use of knowledge from research, as a basis for evidence-based practice in their workplace. Additionally, the study aimed to determine which factors might hinder or enable implementation into daily practice. Evidence-based practice involves integrating best results in research with clinical experience, which enables us to provide a higher quality of care, as well as to optimize the care given. International studies show that nurses feel that there are still many barriers that hinder their doing research and incorporating new findings into clinical practice; although in the field of primary care, few studies have been carried out. This descriptive qualitative study design used focus groups to collect data. This study was carried out in Spanish primary care centres. Forty-six registered nurses took part in this study and were divided into five focus groups. Three significant themes emerged: awareness of the need to use research, nurses as knowledge-generation agents and motivation to use research despite barriers. A limited number of participants and a convenience sample were used. Nurses recognize that professional health care must be based on evidence obtained from daily work - both originated by their colleagues and by themselves - and they are willing to work on it although they perceive a lack of competence for this purpose and demand support from their institutions. Primary care institutions should empower nursing coordinators as leaders of evidence-based practice and implicate clinical nurses from the beginning on the implementation of guidelines. © 2016 International Council of Nurses.

  14. Shared Care: A Quality Improvement Initiative to Optimize Primary Care Management of Constipation

    PubMed Central

    Vernacchio, Louis; Trudell, Emily; Antonelli, Richard; Nurko, Samuel; Leichtner, Alan M.; Lightdale, Jenifer R.

    2015-01-01

    BACKGROUND: Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children’s Hospital and the Pediatric Physician’s Organization at Children’s (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. METHODS: We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children’s Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. RESULTS: Fewer active patients in the sample were referred after implementation (61/27 365 [0.22%] vs 90/27 792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals. CONCLUSIONS: A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration. PMID:25896837

  15. Measurement tools and process indicators of patient safety culture in primary care. A mixed methods study by the LINNEAUS collaboration on patient safety in primary care.

    PubMed

    Parker, Dianne; Wensing, Michel; Esmail, Aneez; Valderas, Jose M

    2015-09-01

    There is little guidance available to healthcare practitioners about what tools they might use to assess the patient safety culture. To identify useful tools for assessing patient safety culture in primary care organizations in Europe; to identify those aspects of performance that should be assessed when investigating the relationship between safety culture and performance in primary care. Two consensus-based studies were carried out, in which subject matter experts and primary healthcare professionals from several EU states rated (a) the applicability to their healthcare system of several existing safety culture assessment tools and (b) the appropriateness and usefulness of a range of potential indicators of a positive patient safety culture to primary care settings. The safety culture tools were field-tested in four countries to ascertain any challenges and issues arising when used in primary care. The two existing tools that received the most favourable ratings were the Manchester patient safety framework (MaPsAF primary care version) and the Agency for healthcare research and quality survey (medical office version). Several potential safety culture process indicators were identified. The one that emerged as offering the best combination of appropriateness and usefulness related to the collection of data on adverse patient events. Two tools, one quantitative and one qualitative, were identified as applicable and useful in assessing patient safety culture in primary care settings in Europe. Safety culture indicators in primary care should focus on the processes rather than the outcomes of care.

  16. Health psychology in primary care: recent research and future directions.

    PubMed

    Thielke, Stephen; Thompson, Alexander; Stuart, Richard

    2011-01-01

    Over the last decade, research about health psychology in primary care has reiterated its contributions to mental and physical health promotion, and its role in addressing gaps in mental health service delivery. Recent meta-analyses have generated mixed results about the effectiveness and cost-effectiveness of health psychology interventions. There have been few studies of health psychology interventions in real-world treatment settings. Several key challenges exist: determining the degree of penetration of health psychology into primary care settings; clarifying the specific roles of health psychologists in integrated care; resolving reimbursement issues; and adapting to the increased prescription of psychotropic medications. Identifying and exploring these issues can help health psychologists and primary care providers to develop the most effective ways of applying psychological principles in primary care settings. In a changing health care landscape, health psychologists must continue to articulate the theories and techniques of health psychology and integrated care, to put their beliefs into practice, and to measure the outcomes of their work.

  17. Race, gender, and language concordance in the primary care setting.

    PubMed

    Martin, Brian C; Shi, Leiyu; Ward, Ryan D

    2009-01-01

    The purpose of this paper is to examine race, gender and language concordance in terms of importance to primary care. The 2003 Medical Expenditure Panel Survey Household Component (MEPS) was used. Four distinguishing primary care attributes and selected measures were operationalized primarily from a sample subset that identified a usual source of care (USC): accessibility to USC; interface between primary care and specialist services; treatment decisions; and preventive services received from the USC. Bivariate and multivariate results are reported. Adjusting for covariates, the following items remained statistically significant: race--choosing primary care physician as USC, USC having office hours, and going to USC for new health problems; gender--choosing primary care physician as USC and USC having office hours; and language--lack of difficulty contacting the USC after hours. However, these items appear to be isolated cases rather than indicators that concordance plays a key role in determining primary care quality. Language barriers/communication issues are the only areas where improvement appears warranted. While the study has strong accessibility and interpersonal relationship measures, service coordination and comprehensiveness indicators are limited. The analyses' cross-sectional nature also poses a problem in drawing causal relationships and conclusive findings. Finally, sample size limitations preclude stratified analyses across racial/ethnic groups, an important consideration as the relationships between concordance and quality may vary across groups. This study indicates that more research is needed in this area to determine future resource allocation and policy direction. The unique contribution of the study is to suggest that race and gender concordance may not accurately predict primary health care quality.

  18. Integrating GDM management in primary care: Gulf Cooperation Council (GCC) perspective.

    PubMed

    Anjum, Qudsia; Mumtaz, Shadma

    2016-09-01

    Diabetes is prevailing universally and Gulf Cooperation Council (GCC) is no exception. Pregnancies associated with gestational diabetes place women at high risk of natal complications. Statistics from GCC gives variable figures for GDM. Family Physicians are the first level health care providers and their role in management of GDM can be promising. This has been evident from a focused group study where patients prefer screening for GDM in primary care settings. Strengthening of primary care is important universally. Government should have mandatory primary care registration to be referred to secondary level for obstetric follow up and management. An important issue needing attention is presence of multiple criteria for diagnosing and screening GDM. There is need for a single guideline globally to avoid confusion for primary care providers.10 Primary care centers can better be utilized to screen for GDM at early stages. This will decrease the load on secondary and tertiary care centers and can also maintain continuity of care.

  19. Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review

    PubMed Central

    Hone, Thomas; Lee, John Tayu; Majeed, Azeem; Conteh, Lesong; Millett, Christopher

    2017-01-01

    Abstract Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients. PMID:28453713

  20. Counselling for mental health and psychosocial problems in primary care.

    PubMed

    Bower, Peter; Knowles, Sarah; Coventry, Peter A; Rowland, Nancy

    2011-09-07

    The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care. To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care. To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011). Randomised controlled trials of counselling for mental health and psychosocial problems in primary care. Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events. Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the

  1. Using Geographic Information Systems (GIS) to understand a community's primary care needs.

    PubMed

    Dulin, Michael F; Ludden, Thomas M; Tapp, Hazel; Blackwell, Joshua; de Hernandez, Brisa Urquieta; Smith, Heather A; Furuseth, Owen J

    2010-01-01

    A key element for reducing health care costs and improving community health is increased access to primary care and preventative health services. Geographic information systems (GIS) have the potential to assess patterns of health care utilization and community-level attributes to identify geographic regions most in need of primary care access. GIS, analytical hierarchy process, and multiattribute assessment and evaluation techniques were used to examine attributes describing primary care need and identify areas that would benefit from increased access to primary care services. Attributes were identified by a collaborative partnership working within a practice-based research network using tenets of community-based participatory research. Maps were created based on socioeconomic status, population density, insurance status, and emergency department and primary care safety-net utilization. Individual and composite maps identified areas in our community with the greatest need for increased access to primary care services. Applying GIS to commonly available community- and patient-level data can rapidly identify areas most in need of increased access to primary care services. We have termed this a Multiple Attribute Primary Care Targeting Strategy. This model can be used to plan health services delivery as well as to target and evaluate interventions designed to improve health care access.

  2. Meaningful use care coordination criteria: Perceived barriers and benefits among primary care providers.

    PubMed

    Cohen, Genna R; Adler-Milstein, Julia

    2016-04-01

    Stage 2 and proposed Stage 3 meaningful use criteria ask providers to support patient care coordination by electronically generating, exchanging, and reconciling key information during patient care transitions. A stratified random sample of primary care practices in Michigan (n = 328) that had already met Stage 1 meaningful use criteria was surveyed, in order to identify the anticipated barriers to meeting these criteria as well as the expected impact on patient care coordination from doing so. The top three barriers, as identified by >65% of the primary care providers surveyed, were difficulty sending and receiving patient information electronically, a lack of provider and practice staff time, and the complex workflow changes required. Despite these barriers, primary care providers expressed strong agreement that meeting the proposed Stage 3 care coordination criteria would improve their patients' treatment and ensure they know about their patients' visits to other providers. The survey results suggest the need to enhance policy approaches and organizational strategies to address the key barriers identified by providers and practices in order to realize important care coordination benefits. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  3. Defining Team Effort Involved in Patient Care from the Primary Care Physician's Perspective.

    PubMed

    Hwang, Andrew S; Atlas, Steven J; Hong, Johan; Ashburner, Jeffrey M; Zai, Adrian H; Grant, Richard W; Hong, Clemens S

    2017-03-01

    A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches and lead to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians. To identify and characterize high-effort patients from the physician's perspective. Cohort study. Ninety-nine primary care physicians in an academic primary care network. From a list of 100 randomly selected patients in their panels, PCPs identified patients who required a high level of team-based effort and patients they considered complex. For high-effort patients, PCPs indicated which factors influenced their decision: medical/care coordination, behavioral health, and/or socioeconomic factors. We examined differences in patient characteristics based on PCP-defined effort and complexity. Among 9594 eligible patients, PCPs classified 2277 (23.7 %) as high-effort and 2676 (27.9 %) as complex. Behavioral health issues were the major driver of effort in younger patients, while medical/care coordination issues predominated in older patients. Compared to low-effort patients, high-effort patients were significantly (P < 0.01 for all) more likely to have higher rates of medical (e.g. 23.2 % vs. 6.3 % for diabetes) and behavioral health problems (e.g. 9.8 % vs. 2.9 % for substance use disorder), more frequent primary care visits (10.9 vs. 6.0 visits), and higher acute care utilization rates (25.8 % vs. 7.7 % for emergency department [ED] visits and 15.0 % vs. 3.9 % for hospitalization). Almost one in five (18 %) patients who were considered high-effort were not deemed complex by the same PCPs. Patients defined as high-effort by their primary care physicians, not all of whom were medically complex, appear to have a high burden of psychosocial issues that may not be accounted for in current chronic disease-focused risk adjustment approaches.

  4. Electronic health records and support for primary care teamwork.

    PubMed

    O'Malley, Ann S; Draper, Kevin; Gourevitch, Rebecca; Cross, Dori A; Scholle, Sarah Hudson

    2015-03-01

    Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges. Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size. EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time. Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges. EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association.

  5. The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care

    PubMed Central

    Reddy, Ashok; Pollack, Craig E.; Asch, David A.; Canamucio, Anne; Werner, Rachel M.

    2017-01-01

    IMPORTANCE Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. OBJECTIVE To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. DESIGN, SETTING, AND PARTICIPANTS Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326 374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184 501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. EXPOSURES Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). MAIN OUTCOMES AND MEASURES Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). RESULTS Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, −5.3; 95% CI, −6.0 to −4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, −1.1; 95% CI, −2.1 to −0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, −1.44; 95

  6. The Readiness for Integrated Care Questionnaire (RICQ): An instrument to assess readiness to integrate behavioral health and primary care.

    PubMed

    Scott, Victoria C; Kenworthy, Tara; Godly-Reynolds, Erin; Bastien, Gilberte; Scaccia, Jonathan; McMickens, Courtney; Rachel, Sharon; Cooper, Sayon; Wrenn, Glenda; Wandersman, Abraham

    2017-01-01

    Integration of behavioral health and primary care services is a promising approach for reducing health disparities. The growing national emphasis on care coordination has mobilized efforts to integrate behavioral health and primary care services across the United States. These efforts align with broader health care system goals of improving health care quality, health equity, utilization efficiency, and patient outcomes. Drawing from our work on a multiyear integrated care initiative (Integrated Care Leadership Program; ICLP) and an implementation science heuristic for organizational readiness (Readiness = Motivation x General Capacity and Innovation-Specific Capacity; R = MC2), this article describes the development and implementation of a tool to assess organizational readiness for integrated care, referred to as the Readiness for Integrated Care Questionnaire (RICQ). The tool was piloted with 11 health care practices that serve vulnerable, underprivileged populations. Initial results from the RICQ revealed that participating practices were generally high in motivation, innovation-specific capacities, and general capacities at the start of ICLP. Additionally, analyses indicated that practices particularly needed support with increasing staff capacities (general knowledge and skills), improving access to and use of resources, and simplifying the steps in integrating care so the effort appears less daunting and difficult to health care team members. We discuss insights from the initial use of RICQ and practical implications of the new tool for driving integrated care efforts that can contribute to health equity. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

  7. [Gender analysis of primary care professionals' perceptions and attitudes to informal care].

    PubMed

    del Mar García-Calvente, María; del Río Lozano, María; Castaño López, Esther; Mateo Rodríguez, Inmaculada; Maroto Navarro, Gracia; Hidalgo Ruzzante, Natalia

    2010-01-01

    To analyze primary care professionals' perceptions and attitudes to informal care from a gender perspective. We performed a qualitative study using interviews and a discussion group. Eighteen primary care professionals were selected in the Health District of Grenada (Spain) by means of intentional sampling. Content analysis was performed with the following categories: a) perceptions: concepts of dependency and informal care, gender differences and impact on health, b) attitudes: not in favor of change, in favor of change and the right not to provide informal care. The health professionals emphasized the non-professional, free and strong emotional component of informal care. These professionals assigned the family (especially women) the main responsibility for caregiving and used stereotypes to differentiate between care provided by men and by women. The professionals agreed that women had a greater psychological burden associated with care, mainly because they more frequently provide caregiving on their own than men. Three major attitudes emerged among health professionals about informal care: those who did not question the current situation and idealized the family as the most appropriate framework for caregiving; those who proposed changes toward a more universal dependency system that would relieve families; and those who adopted an intermediate position, favoring education to achieve wellbeing in caregivers and prevent them from ceasing to provide care. We identified perceptions and attitudes that showed little sensitivity to gender equality, such as a conservative attitude that assigned the family the primary responsibility for informal care and some sexist stereotypes that attributed a greater ability for caregiving to women. Specific training in gender equality is required among health professionals to reduce inequalities in informal care. Copyright © 2009 SESPAS. Published by Elsevier Espana. All rights reserved.

  8. Do primary care professionals agree about progress with implementation of primary care teams: results from a cross sectional study.

    PubMed

    Tierney, E; O'Sullivan, M; Hickey, L; Hannigan, A; May, C; Cullen, W; Kennedy, N; Kineen, L; MacFarlane, A

    2016-11-22

    Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals' views of this process. This study compares Primary Healthcare Professionals' perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland. Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests. There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by

  9. Adult obesity management in primary care, 2008-2013.

    PubMed

    Fitzpatrick, Stephanie L; Stevens, Victor J

    2017-06-01

    In the U.S., the occurrence of weight counseling in primary care for patients with obesity decreased by 10% between 1995-1996 and 2007-2008. There have been several national recommendations and policies to improve obesity management since 2008. The purpose of this study was to examine the rates of body mass index (BMI) screening, obesity diagnosis, and weight management counseling in the U.S. from 2008 to 2013. The National Ambulatory Medical Care Survey visit-level data for adults 18 and over with a primary care visit during survey years 2008-2009, 2010-2011, and 2012-2013 was included in the analyses using SAS v9.3. Study outcomes included percent of visits with: BMI screening; obesity diagnosis; and weight counseling. We compared survey years on these outcomes using 2008-2009 as the reference as well as examined patient and practice-level predictors. Analyses were conducted from 2015 to early 2017. Of the total 55,608 adult primary care visits sampled, 14,143 visits (25%) were with patients with obesity. BMI screening significantly increased between 2008-2009 and 2012-2013 from 54% to 73% (OR=1.75, 95% CI 1.28-2.41); however, percent of visits with an obesity diagnosis remained low at <30%. Weight management counseling during visits significantly declined from 33% to 21% between 2008-2009 and 2012-2013 (OR=0.62, 95% CI 0.41-0.92). Despite emerging recommendations and policies, from 2008 to 2013, obesity management in primary care remained suboptimal. Identifying practical strategies to enforce policies and implement evidence-based behavioral treatment in primary care should be a high priority in healthcare reform. Copyright © 2017 Elsevier Inc. All rights reserved.

  10. Identifying HIV/AIDS primary care development needs.

    PubMed

    Foong, Andrew L S; Ng, S F; Lee, Christopher K C

    2005-04-01

    This paper reports a study aimed at identifying the primary health care experiences of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in Malaysia. The rationale behind the study was to enable informed action for developing more responsive and effective primary care. Reports such as from the World Health Organisation forecast sharp escalations in the incidence of HIV/AIDS in Malaysia and the Asia-Pacific region within the next few years. With sparse information on the course of infection on the local population and an understanding of health care needs of those afflicted, health services would be ill-prepared for projected increases. Semi-structured interviews were conducted with a convenience sample of 99 patients attending two major HIV/AIDS clinics in Malaysia. Several gaps in care provision were highlighted, such as with treatment/consultation facilities and availability and accessibility of information. What is also evident is that there are a number of good support services available but not well publicized to those in need of them. That includes health professionals who could be making appropriate referrals. The lack of communications and inter-professional working appears to be part of the problem. The findings provide baseline data and preliminary insights to government and other service providers towards advancing, optimizing and refining existing policies and infrastructure. Although the availability of a number of primary care facilities have been identified, the study indicates the need for more effective co-ordinated efforts with clear leadership to pull together scarce resources towards the aim of some degree of seamless primary care provision. It is suggested that nurses would be well placed for such a role in view of the nature of their education and training that helps prepare them for the multi-faceted role.

  11. Delivery of primary health care to persons who are socio-economically disadvantaged: does the organizational delivery model matter?

    PubMed Central

    2013-01-01

    Background As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada. Methods Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity. Results Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only. Conclusions Primary care service measures did not differ significantly across socio-economic status or primary care delivery

  12. Delivery of primary health care to persons who are socio-economically disadvantaged: does the organizational delivery model matter?

    PubMed

    Dahrouge, Simone; Hogg, William; Ward, Natalie; Tuna, Meltem; Devlin, Rose Anne; Kristjansson, Elizabeth; Tugwell, Peter; Pottie, Kevin

    2013-12-17

    As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada. Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity. Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only. Primary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation

  13. Facilitators and barriers of implementing the chronic care model in primary care: a systematic review.

    PubMed

    Kadu, Mudathira K; Stolee, Paul

    2015-02-06

    The Chronic Care Model (CCM) is a framework developed to redesign care delivery for individuals living with chronic diseases in primary care. The CCM and its various components have been widely adopted and evaluated, however, little is known about different primary care experiences with its implementation, and the factors that influence its successful uptake. The purpose of this review is to synthesize findings of studies that implemented the CCM in primary care, in order to identify facilitators and barriers encountered during implementation. This study identified English-language, peer-reviewed research articles, describing the CCM in primary care settings. Searches were performed in three data bases: Web of Knowledge, Pubmed and Scopus. Article abstracts and titles were read based on whether they met the following inclusion criteria: 1) studies published after 2003 that described or evaluated the implementation of the CCM; 2) the care setting was primary care; 3) the target population of the study was adults over the age of 18 with chronic conditions. Studies were categorized by reference, study design and methods, participants and setting, study objective, CCM components used, and description of the intervention. The next stage of data abstraction involved qualitative analysis of cited barriers and facilitators using the Consolidating Framework for Research Implementation. This review identified barriers and facilitators of implementation across various primary care settings in 22 studies. The major emerging themes were those related to the inner setting of the organization, the process of implementation and characteristics of the individual healthcare providers. These included: organizational culture, its structural characteristics, networks and communication, implementation climate and readiness, presence of supportive leadership, and provider attitudes and beliefs. These findings highlight the importance of assessing organizational capacity and needs prior

  14. Health Care's Other "Big Deal": Direct Primary Care Regulation in Contemporary American Health Law.

    PubMed

    Chappell, Glenn E

    2017-03-01

    Direct primary care is a promising, market-based alternative to the fee-for-service payment structure that shapes doctor–patient relationships in America. Instead of billing patients and insurers service by service, direct primary care doctors charge their patients a periodic, prenegotiated fee in exchange for providing a wide range of healthcare services and increased availability compared to traditional practices. This “subscription” model is intended to eliminate the administrative burdens associated with insurer interaction, which, in theory, allows doctors to spend more time with their patients and less time doing paperwork. Direct practices have become increasingly popular since Congress passed the Affordable Care Act (ACA). This growth has been driven by legislation in several states that resolves a number of legal questions that slowed the model’s growth and by the ACA’s recognition of the model as a permissible way to cover primary care in "approved" health plans. Yet legal scholars have hardly focused on direct primary care. Given the model’s growth, however, the time is ripe for a more focused legal inquiry. This Note begins that inquiry. After tracing the model’s evolution and its core components, this Note substantively examines the laws in states that regulate direct practices and analyzes how those laws address a number of potential policy concerns. It then analyzes direct primary care’s broader role in the contemporary American healthcare marketplace. Based upon that analysis, this Note concludes that direct primary care is a beneficial innovation that harmonizes well with a cooperative-federalism-based healthcare policy model.

  15. The Complexity of Primary Care Psychology: Theoretical Foundations.

    PubMed

    Smit, E H; Derksen, J J L

    2015-07-01

    How does primary care psychology deal with organized complexity? Has it escaped Newtonian science? Has it, as Weaver (1991) suggests, found a way to 'manage problems with many interrelated factors that cannot be dealt by statistical techniques'? Computer simulations and mathematical models in psychology are ongoing positive developments in the study of complex systems. However, the theoretical development of complex systems in psychology lags behind these advances. In this article we use complexity science to develop a theory on experienced complexity in the daily practice of primary care psychologists. We briefly answer the ontological question of what we see (from the perspective of primary care psychology) as reality, the epistemological question of what we can know, the methodological question of how to act, and the ethical question of what is good care. Following our empirical study, we conclude that complexity science can describe the experienced complexity of the psychologist and offer room for personalized client-centered care. Complexity science is slowly filling the gap between the dominant reductionist theory and complex daily practice.

  16. Together Achieving More: Primary Care Team Communication and Alcohol-Related Healthcare Utilization and Costs.

    PubMed

    Mundt, Marlon P; Zakletskaia, Larissa I; Shoham, David A; Tuan, Wen-Jan; Carayon, Pascale

    2015-10-01

    Identifying and engaging excessive alcohol users in primary care may be an effective way to improve patient health outcomes, reduce alcohol-related acute care events, and lower costs. Little is known about what structures of primary care team communication are associated with alcohol-related patient outcomes. Using a sociometric survey of primary care clinic communication, this study evaluated the relation between team communication networks and alcohol-related utilization of care and costs. Between May 2013 and December 2013, a total of 155 healthcare employees at 6 primary care clinics participated in a survey on team communication. Three-level hierarchical modeling evaluated the link between connectedness within the care team and the number of alcohol-related emergency department visits, hospital days, and associated medical care costs in the past 12 months for each team's primary care patient panel. Teams (n = 31) whose registered nurses displayed more strong (at least daily) face-to-face ties and strong (at least daily) electronic communication ties had 10% fewer alcohol-related hospital days (rate ratio [RR] = 0.90; 95% confidence interval [CI]: 0.84, 0.97). Furthermore, in an average team size of 19, each additional team member with strong interaction ties across the whole team was associated with $1,030 (95% CI: -$1,819, -$241) lower alcohol-related patient healthcare costs per 1,000 team patients in the past 12 months. Conversely, teams whose primary care practitioner (PCP) had more strong face-to-face communication ties and more weak (weekly or several times a week) electronic communication ties had 12% more alcohol-related hospital days (RR = 1.12; 95% CI: 1.03, 1.23) and $1,428 (95% CI: $378, $2,478) higher alcohol-related healthcare costs per 1,000 patients in the past 12 months. The analyses controlled for patient age, gender, insurance, and comorbidity diagnoses. Excessive alcohol-using patients may fair better if cared for by teams whose

  17. Age-related variation in primary care-type presentations to emergency departments.

    PubMed

    Freed, Gary; Gafforini, Sarah; Carson, Norman

    2015-08-01

    A significant amount of attention has been paid to the increase in emergency department (ED) presentations in Australia. Questions have arisen regarding whether all of those presenting to the ED are actually in need of true emergency services. Under-standing the characteristics of those patients who may be cared for in non-emergency settings is important for future health system strategies. The aim of this study was to identify age-related variation in primary care type emergency department (ED) presentations over time. A secondary analysis of data from the Victorian emergency minimum dataset (VEMD) between 2002-13 was conducted. The main outcomes were patterns of primary care type ED presentations for different ages groups over time, age-specific patterns of specific primary care type exclusion criteria and primary care type ED presentations by residents from aged care facilities. The proportion of triage category 4 or 5 ED presentations that met the criteria for a primary care type visit was greatest in the 0-4-year age group and tended to decrease as the age of the patient increased. Triage category 4 or 5 presentation by ambulance was uncommon in the younger age groups, surpassed 10% in the 50-54-year age group, and was >70% for those aged >90 years. The greater proportion of residential aged care facility patients who arrived by ambulance resulted in a much smaller proportion of primary care type visits. There are marked differences by age in the proportion of triage category 4 or 5 ED presentations that met the criteria for primary care type visits. These results indicate it was primarily younger patients who presented to the ED with non-urgent conditions. Most might be able to safely receive care in a primary care setting.

  18. Care coordination and provider stress in primary care management of high-risk patients.

    PubMed

    Okunogbe, Adeyemi; Meredith, Lisa S; Chang, Evelyn T; Simon, Alissa; Stockdale, Susan E; Rubenstein, Lisa V

    2018-01-01

    Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members' stress. To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress. Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses. A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems. The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them. The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04-0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model. Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress.

  19. Effective recruitment strategies in primary care research: a systematic review.

    PubMed

    Ngune, Irene; Jiwa, Moyez; Dadich, Ann; Lotriet, Jaco; Sriram, Deepa

    2012-01-01

    Patient recruitment in primary care research is often a protracted and frustrating process, affecting project timeframes, budget and the dissemination of research findings. Yet, clear guidance on patient recruitment strategies in primary care research is limited. This paper addresses this issue through a systematic review. Articles were sourced from five academic databases - AustHealth, CINAHL, the Cochrane Methodology Group, EMBASE and PubMed/Medline; grey literature was also sourced from an academic library and the Primary Healthcare Research & Information Service (PHCRIS) website. Two reviewers independently screened the articles using the following criteria: (1) published in English, (2) reported empirical research, (3) focused on interventions designed to increase patient recruitment in primary care settings, and (4) reported patient recruitment in primary care settings. Sixty-six articles met the inclusion criteria. Of these, 23 specifically focused on recruitment strategies and included randomised trials (n = 7), systematic reviews (n = 8) and qualitative studies (n = 8). Of the remaining articles, 30 evaluated recruitment strategies, while 13 addressed the value of recruitment strategies using descriptive statistics and/or qualitative data. Among the 66 articles, primary care chiefly included general practice (n = 30); nursing and allied health services, multiple settings, as well as other community settings (n = 30); and pharmacy (n = 6). Effective recruitment strategies included the involvement of a discipline champion, simple patient eligibility criteria, patient incentives and organisational strategies that reduce practitioner workload. The most effective recruitment in primary care research requires practitioner involvement. The active participation of primary care practitioners in both the design and conduct of research helps to identify strategies that are congruent with the context in which patient care is delivered. This is reported to be the

  20. Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care-based model.

    PubMed

    Chi, Felicia W; Parthasarathy, Sujaya; Mertens, Jennifer R; Weisner, Constance M

    2011-10-01

    How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry. In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure. A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without. Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

  1. College Students' Reasons for Depression Nondisclosure in Primary Care

    ERIC Educational Resources Information Center

    Meyer, William J.; Morrison, Patrick; Lombardero, Anayansi; Swingle, Kelsey; Campbell, Duncan G.

    2016-01-01

    Unwillingness to share depression experiences with primary care physicians contributes to the undertreatment of depression. This project examined college students' reasons for depression nondisclosure to primary care providers (PCPs). Undergraduate participants read a vignette describing someone with depression and completed measures of disclosure…

  2. Willingness of Rhode Island Dentists to Provide Limited Preventive Primary Care.

    PubMed

    Dang, Catherine Tuyet Mai; Shield, Renee R; Giddon, Donald B

    2016-07-01

    In response to the shortage of primary care physicians and the need for greater intercollaboration among health professionals, dentists with sufficient medical and surgical training are an untapped resource to provide limited preventive primary care (LPPC), such as chairside screening for chronic diseases. The objective of this study was to determine attitudes of Rhode Island dentists toward becoming more involved in the overall health of their patients. Using a 5-point scale (1 being highest), a pretested survey was administered to 92 respondent RI dentists who were asked to indicate their willingness to become more involved in patients' overall health, and undergo additional training to provide LPPC. Their moderate level of willingness was offset by great concern for liability, with older dentists being significantly more willing to assume these additional responsibilities than younger dentists (p< .05). Rank order of designation of oral health providers among dentist, dental physician, oral physician, odontologist, stomatologist, and stomiatrist was still dentist first, but with no significant difference between the mean ranks of dentist and oral physician.[Full article available at http://rimed.org/rimedicaljournal-2016-07.asp, free with no login].

  3. Primary health care in the Czech Republic: brief history and current issues

    PubMed Central

    Holcik, Jan; Koupilova, Ilona

    2000-01-01

    Abstract The objective of this paper is to describe the recent history, current situation and perspectives for further development of the integrated system of primary care in the Czech Republic. The role of primary care in the whole health care system is discussed and new initiatives aimed at strengthening and integrating primary care are outlined. Changes brought about by the recent reform processes are generally seen as favourable, however, a lack of integration of health services under the current system is causing various kinds of problems. A new strategy for development of primary care in the Czech Republic encourages integration of care and defines primary care as co-ordinated and complex care provided at the level of the first contact of an individual with the health care system. PMID:16902697

  4. The Importance of Somatic Symptoms in Depression in Primary Care

    PubMed Central

    Tylee, André; Gandhi, Paul

    2005-01-01

    Objective: Patients with depression present with psychological and somatic symptoms, including general aches and pains. In primary care, somatic symptoms often dominate. A review of the literature was conducted to ascertain the importance of somatic symptoms in depression in primary care. Data sources and extraction: MEDLINE, EMBASE, and PsychLIT/PsychINFO databases (1985–January 2004) were searched for the terms depression, depressive, depressed AND physical, somatic, unexplained symptoms, complaints, problems; somatised, somatized symptoms; somatisation, somatization, somatoform, psychosomatic; pain; recognition, underrecognition; diagnosis, underdiagnosis; acknowledgment, underacknowledgment; treatment, undertreatment AND primary care, ambulatory care; primary physician; office; general practice; attribution, reattribution; and normalising, normalizing. Only English-language publications and abstracts were considered. Study selection: More than 80 papers related to somatic symptoms in depression were identified using the content of their titles and abstracts. Data synthesis: Approximately two thirds of patients with depression in primary care present with somatic symptoms. These patients are difficult to diagnose, feel an increased burden of disease, rely heavily on health care services, and are harder to treat. Patient and physician factors that prevent discussion of psychological symptoms during consultations must be overcome. Conclusions: Educational initiatives that raise awareness of somatic symptoms in depression and help patients to reattribute these symptoms should help to improve the recognition of depression in primary care. PMID:16163400

  5. Incentive-Based Primary Care: Cost and Utilization Analysis

    PubMed Central

    Hollander, Marcus J; Kadlec, Helena

    2015-01-01

    Context: In its fee-for-service funding model for primary care, British Columbia, Canada, introduced incentive payments to general practitioners as pay for performance for providing enhanced, guidelines-based care to patients with chronic conditions. Evaluation of the program was conducted at the health care system level. Objective: To examine the impact of the incentive payments on annual health care costs and hospital utilization patterns in British Columbia. Design: The study used Ministry of Health administrative data for Fiscal Year 2010–2011 for patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and/or hypertension. In each disease group, cost and utilization were compared across patients who did, and did not, receive incentive-based care. Main Outcome Measures: Health care costs (eg, primary care, hospital) and utilization measures (eg, hospital days, readmissions). Results: After controlling for patients’ age, sex, service needs level, and continuity of care (defined as attachment to a general practice), the incentives reduced the net annual health care costs, in Canadian dollars, for patients with hypertension (by approximately Can$308 per patient), chronic obstructive pulmonary disease (by Can$496), and congestive heart failure (by Can$96), but not diabetes (incentives cost about Can$148 more per patient). The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups. Conclusion: Although the available literature on pay for performance shows mixed results, we showed that the funding model used in British Columbia using incentive payments for primary care might reduce health care costs and hospital utilization. PMID:26263389

  6. Incentive-Based Primary Care: Cost and Utilization Analysis.

    PubMed

    Hollander, Marcus J; Kadlec, Helena

    2015-01-01

    In its fee-for-service funding model for primary care, British Columbia, Canada, introduced incentive payments to general practitioners as pay for performance for providing enhanced, guidelines-based care to patients with chronic conditions. Evaluation of the program was conducted at the health care system level. To examine the impact of the incentive payments on annual health care costs and hospital utilization patterns in British Columbia. The study used Ministry of Health administrative data for Fiscal Year 2010-2011 for patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and/or hypertension. In each disease group, cost and utilization were compared across patients who did, and did not, receive incentive-based care. Health care costs (eg, primary care, hospital) and utilization measures (eg, hospital days, readmissions). After controlling for patients' age, sex, service needs level, and continuity of care (defined as attachment to a general practice), the incentives reduced the net annual health care costs, in Canadian dollars, for patients with hypertension (by approximately Can$308 per patient), chronic obstructive pulmonary disease (by Can$496), and congestive heart failure (by Can$96), but not diabetes (incentives cost about Can$148 more per patient). The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups. Although the available literature on pay for performance shows mixed results, we showed that the funding model used in British Columbia using incentive payments for primary care might reduce health care costs and hospital utilization.

  7. Experiences of family physicians who practise primary care obstetrics in groups.

    PubMed

    Koppula, Sudha; Brown, Judith B; Jordan, John M

    2011-02-01

    The purpose of this study was to explore the experiences of family physicians in primary care obstetrical groups. Using a qualitative approach, in-depth interviews were conducted with 12 Edmonton family physicians who participated in primary care obstetrical groups. Experiences with respect to several aspects of group obstetrical practice were examined including advantages and challenges of primary care obstetrical groups, provision of patient care by a group, fit with other work commitments, and sustainability of the groups. Study data were audiotaped and transcribed verbatim. Independent and team analysis was iterative and interpretive. Primary care obstetrical groups were found to preserve a family physician's enjoyment of obstetrics and allowed for continuity of care. They afforded work-life balance, allowed for collaboration, and provided support and a social network for group members. Such groups were found to facilitate short-term family physician absences, although long-term absences (such as maternity leaves) were considered challenging. Participants described conflict within primary care obstetrical groups and considered sustainability to be a challenge. Family physicians' continued involvement in obstetrics could be facilitated by their participation in primary care obstetrical groups.

  8. [A historical and conceptual model for Primary Health Care: challenges for the organization of primary care and the Family Health Strategy in large Brazilian cities].

    PubMed

    Conill, Eleonor Minho

    2008-01-01

    This paper focuses on the experience with Primary Health Care as a strategy for reorganizing the health care model, based on reforms in this direction and their implementation in the Brazilian case. The article identifies a shift in the discourse concerning health sector reforms, with a return to emphasis on primary care and integration of services. The Brazilian context demands reflection on the possibilities for synergy between this strategy and other social policies and the factors needed to ensure adequate performance. Evaluation research has suggested that primary care activities are slightly superior as compared to traditional health care units, despite persistent difficulties in access, physical infrastructure, team formation, management, and organization of the network. These difficulties correlate with a low level of public financing, persistent segmentation of the system, and weak integration of primary care services with other levels of care. From the technical perspective, a reasonable target is to guarantee the strategy's continuity with the necessary adjustments, conditioned by the dynamics of the health care technical models involved in the dispute.

  9. Interprofessional education: preparing psychologists for success in integrated primary care.

    PubMed

    Cubic, Barbara; Mance, Janette; Turgesen, Jeri N; Lamanna, Jennifer D

    2012-03-01

    Rapidly occurring changes in the healthcare arena mean time is of the essence for psychology to formalize a strategic plan for training in primary care settings. The current article articulates factors affecting models of integrated care in Academic Health Centers (AHCs) and describes ways to identify and utilize resources at AHCs to develop interprofessional educational and clinical integrated care opportunities. The paper asserts that interprofessional educational experiences between psychology and other healthcare providers are vital to insure professionals value one another's disciplines in health care reform endeavors, most notably the patient-centered initiatives. The paper highlights ways to create shared values and common goals between primary care providers and psychologists, which are needed for trainee internalization of integrated care precepts. A developmental perspective to training from pre-doctoral, internship and postdoctoral levels for psychologists in integrated care is described. Lastly, a call to action is given for the field to develop more opportunities for psychology trainees to receive education and training within practica, internships and postdoctoral fellowships in primary care settings to address the reality that most patients seek their mental health treatment in primary care settings.

  10. Bridging the gap between primary care and the cancer system

    PubMed Central

    Sisler, Jeffrey; McCormack-Speak, Pat

    2009-01-01

    ABSTRACT PROBLEM BEING ADDRESSED Patient care is poorly coordinated between family physicians and the cancer system and the working relationships are not strong. OBJECTIVE OF PROGRAM To improve integration of patient care and communication between FPs and cancer specialists; enhance FPs’ knowledge of cancer and the cancer system; and promote the role of primary care within the cancer care system. PROGRAM DESCRIPTION The Uniting Primary Care and Oncology (UPCON) Network of CancerCare Manitoba has created partnerships with 12 primary care clinics in Winnipeg, Man, by providing the following: access to the provincial electronic medical record for cancer; small group continuing professional development for a “lead physician” from each clinic to make him or her the local cancer resource; educational outreach to all clinic staff; and changes within CancerCare Manitoba to highlight the role of FPs. CONCLUSION Lead physicians are appreciated by their clinic colleagues, and these FPs are the main users of the cancer electronic medical record. A strong cancer continuing professional development program has been implemented and a voice for primary care has been created within the agency. The UPCON Network is now expanding throughout Manitoba. PMID:19282538

  11. Standing on the Precipice: Evaluating Final-Year Physiotherapy Students' Perspectives of Their Curriculum as Preparation for Primary Health Care Practice

    PubMed Central

    O'Donoghue, Grainne; Doody, Catherine; O'Neill, Geraldine; Barrett, Terry; Cusack, Tara

    2016-01-01

    Purpose: To explore final-year physiotherapy students' perceptions of primary health care practice to determine (1) aspects of their curriculum that support their learning, (2) deficiencies in their curriculum, and (3) areas that they believe should be changed to adequately equip them to make the transition from student to primary health care professional. Methods: Framework analysis methodology was used to analyze group opinion obtained using structured group feedback sessions. Sixty-eight final-year physiotherapy students from the four higher education institutions in Ireland participated. Results: The students identified several key areas that (1) supported their learning (exposure to evidence-based practice, opportunities to practise with problem-based learning, and interdisciplinary learning experiences); (2) were deficient (primary health care placements, additional active learning sessions, and further education and practice opportunities for communication and health promotion), and (3) required change (practice placements in primary health care, better curriculum organization to accommodate primary health care throughout the programme with the suggestion of a specific primary health care module). Conclusion: This study provides important insights into physiotherapy students' perceptions of primary health care. It also provides important indicators of the curriculum changes needed to increase graduates' confidence in their ability to take up employment in primary health care. PMID:27909366

  12. Improving collaboration between primary care and mental health services.

    PubMed

    Kates, Nick; Arroll, Bruce; Currie, Elizabeth; Hanlon, Charlotte; Gask, Linda; Klasen, Henrikje; Meadows, Graham; Rukundo, Godfrey; Sunderji, Nadiya; Ruud, Torleif; Williams, Mark

    2018-06-20

    Previous guidelines and planning documents have identified the key role primary care providers play in delivering mental health care, including the recommendation from the WHO that meeting the mental health needs of the population in many low and middle income countries will only be achieved through greater integration of mental health services within general medical settings. This position paper aims to build upon this work and present a global framework for enhancing mental health care delivered within primary care. This paper synthesizes previous guidelines, empirical data from the literature and experiences of the authors in varied clinical settings to identify core principles and the key elements of successful collaboration, and organizes these into practical guidelines that can be adapted to any setting. The paper proposes a three-step approach. The first is mental health services that any primary care provider can deliver with or without the presence of a mental health professional. Second is practical ways that effective collaboration can enhance this care. The third looks at wider system changes required to support these new roles and how better collaboration can lead to new responses to respond to challenges facing all mental health systems. This simple framework can be applied in any jurisdiction or country to enhance the detection, treatment, and prevention of mental health problems, reinforcing the role of the primary care provider in delivering care and showing how collaborative care can lead to better outcomes for people with mental health and addiction problems.

  13. Shaping the future: a primary care research and development strategy for Scotland.

    PubMed

    Hannaford, P; Hunt, J; Sullivan, F; Wyke, S

    1999-09-01

    Primary care is at the centre of the National Health Service (NHS) in Scotland; however, its R & D capacity is insufficiently developed. R&D is a potentially powerful way of improving the health and well-being of the population, and of securing high quality care for those who need it. In order to achieve this, any Scottish strategy for primary care R&D should aim to develop both a knowledge-based service and a research culture in primary care. In this way, decisions will be made based upon best available evidence, whatever the context. Building on existing practice and resources within primary care research, this strategy for achieving a thriving research culture in Scottish primary care has three key components: A Scottish School of Primary Care which will stimulate and co-ordinate a cohesive programme of research and training. A comprehensive system of funding for training and career development which will ensure access to a range of research training which will ensure that Scotland secures effective leadership for its primary care R&D. Designated research and development practices (DRDPs) which will build on the work of existing research practices, in the context of Local Health Care Co-operatives (LHCCs) and Primary Care Trusts (PCTs), to create a co-operative environment in which a range of primary care professionals can work together to improve their personal and teams' research skills, and to support research development in their areas. A modest investment will create substantial increases in both the quality and quantity of research being undertaken in primary care. This investment should be targeted at both existing primary care professionals working in service settings in primary care, LHCCs and PCTs, and at centres of excellence (including University departments). A dual approach will foster collaboration and will allow existing centres of excellence both to undertake more primary care research and to support the development of service based primary care

  14. Factors associated with professional satisfaction in primary care: Results from EUprimecare project.

    PubMed

    Sanchez-Piedra, Carlos Alberto; Jaruseviciene, Lina; Prado-Galbarro, Francisco Javier; Liseckiene, Ida; Sánchez-Alonso, Fernando; García-Pérez, Sonia; Sarria Santamera, Antonio

    2017-12-01

    Given the importance of primary care to healthcare systems and population health, it seems crucial to identify factors that contribute to the quality of primary care. Professional satisfaction has been linked with quality of primary care. Physician dissatisfaction is considered a risk factor for burnout and leaving medicine. This study explored factors associated with professional satisfaction in seven European countries. A survey was conducted among primary care physicians. Estonia, Finland, Germany and Hungary used a web-based survey, Italy and Lithuania a telephone survey, and Spain face to face interviews. Sociodemographic information (age, sex), professional experience and qualifications (years since graduation, years of experience in general practice), organizational variables related to primary care systems and satisfaction were included in the final version of the questionnaire. A logistic regression analysis was performed to assess the factors associated with satisfaction among physicians. A total of 1331 primary care physicians working in primary care services responded to the survey. More than half of the participants were satisfied with their work in primary care services (68.6%). We found significant associations between satisfaction and years of experience (OR = 1.01), integrated network of primary care centres (OR = 2.8), patients having direct access to specialists (OR = 1.3) and professionals having access to data on patient satisfaction (OR = 1.3). Public practice, rather than private practice, was associated with lower primary care professional satisfaction (OR = 0.8). Elements related to the structure of primary care are associated with professional satisfaction. At the individual level, years of experience seems to be associated with higher professional satisfaction.

  15. Measurement tools and process indicators of patient safety culture in primary care. A mixed methods study by the LINNEAUS collaboration on patient safety in primary care

    PubMed Central

    Parker, Dianne; Wensing, Michel; Esmail, Aneez; Valderas, Jose M

    2015-01-01

    ABSTRACT Background: There is little guidance available to healthcare practitioners about what tools they might use to assess the patient safety culture. Objective: To identify useful tools for assessing patient safety culture in primary care organizations in Europe; to identify those aspects of performance that should be assessed when investigating the relationship between safety culture and performance in primary care. Methods: Two consensus-based studies were carried out, in which subject matter experts and primary healthcare professionals from several EU states rated (a) the applicability to their healthcare system of several existing safety culture assessment tools and (b) the appropriateness and usefulness of a range of potential indicators of a positive patient safety culture to primary care settings. The safety culture tools were field-tested in four countries to ascertain any challenges and issues arising when used in primary care. Results: The two existing tools that received the most favourable ratings were the Manchester patient safety framework (MaPsAF primary care version) and the Agency for healthcare research and quality survey (medical office version). Several potential safety culture process indicators were identified. The one that emerged as offering the best combination of appropriateness and usefulness related to the collection of data on adverse patient events. Conclusion: Two tools, one quantitative and one qualitative, were identified as applicable and useful in assessing patient safety culture in primary care settings in Europe. Safety culture indicators in primary care should focus on the processes rather than the outcomes of care. PMID:26339832

  16. Drivers of Continuing Education Learning Preferences for Veterans Affairs Women's Health Primary Care Providers.

    PubMed

    Zuchowski, Jessica L; Hamilton, Alison B; Washington, Donna L; Gomez, Arthur G; Veet, Laure; Cordasco, Kristina M

    2017-01-01

    Documented gaps in health professionals' training in women's health are a special concern for continuing education (CE). In the Veterans Affairs (VA) health care system, women veterans are a numerical minority, preferably assigned to designated women's health primary care providers (DWHPs). DWHPs need to maintain their knowledge and skills in women's health topics, in addition to general internal medicine topics. We explored drivers of VA DWHPs' learning preferences for women's health topics-ie, factors which influence greater and lesser learning interest. We conducted semistructured telephone interviews with DWHPs across six VA health care systems. Interviews were audio recorded, transcribed, and coded in ATLAS.ti. We synthesized results by grouping relevant coded sections of text to form emergent themes. Among the 31 DWHPs interviewed, reported drivers of learning interests among women's health topics were (1) high frequency of clinical incidence of particular issues; (2) perceived appropriateness of particular issues for management in primary care settings; and (3) perceived appropriateness of particular issues for partial management in primary care. Lower interest in particular women's health topics was associated with (1) perceived existing competency or recent training in an issue and (2) perceived need for specialty care management of an issue. Understanding drivers of DWHPs' CE learning priorities lays a foundation for developing CE programming that will be of interest to women's health primary care providers. Attention to drivers of learning interests may have applicability beyond women's health, suggesting a general approach for CE programming that prioritizes high-volume topics within the practice scope of target providers.

  17. Roles and Functions of Community Health Workers in Primary Care.

    PubMed

    Hartzler, Andrea L; Tuzzio, Leah; Hsu, Clarissa; Wagner, Edward H

    2018-05-01

    Community health workers have potential to enhance primary care access and quality, but remain underutilized. To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis. Analysis of 30 studies identified 12 functions (ie, care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, health education, and literacy support) and 3 prominent roles representing clusters of functions: clinical services, community resource connections, and health education and coaching. We discuss implications for community health worker training and clinical support in primary care. © 2018 Annals of Family Medicine, Inc.

  18. P-Care BPJS Acceptance Model in Primary Health Centers.

    PubMed

    Markam, Hosizah

    2017-01-01

    Electronic Medical Records (EMR) are increasingly adopted in healthcare facilities. Recently, implementation failure of electronic information systems is known to be caused by not only the quality of technical aspects, but also the user's behavior. It is known as applying the Technology Acceptance Model (TAM). This research aimed to analyze the acceptance model of p-care BPJS in the primary health centers. A total sample of 30 p-care BPJS users was drawn by multistage random sampling in which of these 30 primary health centers participated. Data analysis used both descriptive and inferential statistics. In the phase of structural model, it indicated that p-care BPJS acceptance model in the primary health centers was formed by Perceived Ease of Use (PEOU) and Perceived Usefulness (PU) through Attitude towards use of p-care BPJS and Behavioral Intention to use p-care BPJS.

  19. Health care policy and community pharmacy: implications for the New Zealand primary health care sector.

    PubMed

    Scahill, Shane; Harrison, Jeff; Carswell, Peter; Shaw, John

    2010-06-25

    The aim of our paper is to expose the challenges primary health care reform is exerting on community pharmacy and other groups. Our paper is underpinned by the notion that a broad understanding of the issues facing pharmacy will help facilitate engagement by pharmacy and stakeholders in primary care. New models of remuneration are required to deliver policy expectations. Equally important is redefining the place of community pharmacy, outlining the roles that are mooted and contributions that can be made by community pharmacy. Consistent with international policy shifts, New Zealand primary health care policy outlines broad directives which community pharmacy must respond to. Policymakers are calling for greater integration and collaboration, a shift from product to patient-centred care; a greater population health focus and the provision of enhanced cognitive services. To successfully implement policy, community pharmacists must change the way they think and act. Community pharmacy must improve relationships with other primary care providers, District Health Boards (DHBs) and Primary Health Organisations (PHOs). There is a requirement for DHBs to realign funding models which increase integration and remove the requirement to sell products in pharmacy in order to deliver services. There needs to be a willingness for pharmacy to adopt a user pays policy. General practitioners (GPs) and practice nurses (PNs) need to be aware of the training and skills that pharmacists have, and to understand what pharmacists can offer that benefits their patients and ultimately general practice. There is also a need for GPs and PNs to realise the fiscal and professional challenges community pharmacy is facing in its attempt to improve pharmacy services and in working more collaboratively within primary care. Meanwhile, community pharmacists need to embrace new approaches to practice and drive a clearly defined agenda of renewal in order to meet the needs of health funders, patients

  20. Impact of an Interprofessional Primary Care Training on Fear of Cancer Recurrence on Clinicians' Knowledge, Self-Efficacy, Anticipated Practice Behaviors, and Attitudes Toward Survivorship Care.

    PubMed

    Berrett-Abebe, Julie; Cadet, Tamara; Nekhlyudov, Larissa; Vitello, Joan; Maramaldi, Peter

    2018-02-10

    There are an estimated 15.5 million cancer survivors in the United States, with numbers projected to increase. Many cancer survivors are receiving survivorship care in primary care settings, yet primary care providers report a need for additional training on addressing medical and psychosocial concerns of cancer survivors. This paper presents findings from a pilot study on the effectiveness of a novel training for interprofessional primary care providers on the clinically significant issue of fear of cancer recurrence. The on-site training was provided to a total of 46 participants, including physicians (61%), physician assistants (11%), nurse practitioners (7%), nurses (17%), and social workers (4%) in six different primary care practices. The average number of years of professional experience was 18.8, with standard deviation of 10.9. Results of paired-sample t tests indicated that the training increased knowledge and self-efficacy of providers in identifying and addressing FCR. The training was well-received by participants, who had high confidence in implementing practice behavior changes, although they also identified barriers. Results suggest the feasibility of a brief training for continuing education and have implications for models of care delivery in cancer survivorship.

  1. Coordinating Mental Health Care across Primary Care and Schools: ADHD as a Case Example

    ERIC Educational Resources Information Center

    Power, Thomas J.; Blum, Nathan J.; Guevara, James P.; Jones, Heather A.; Leslie, Laurel K.

    2013-01-01

    Although primary care practices and schools are major venues for the delivery of mental health services to children, these systems are disconnected, contributing to fragmentation in service delivery. This paper describes barriers to collaboration across the primary care and school systems, including administrative and fiscal pressures, conceptual…

  2. Designing A Mixed Methods Study In Primary Care

    PubMed Central

    Creswell, John W.; Fetters, Michael D.; Ivankova, Nataliya V.

    2004-01-01

    BACKGROUND Mixed methods or multimethod research holds potential for rigorous, methodologically sound investigations in primary care. The objective of this study was to use criteria from the literature to evaluate 5 mixed methods studies in primary care and to advance 3 models useful for designing such investigations. METHODS We first identified criteria from the social and behavioral sciences to analyze mixed methods studies in primary care research. We then used the criteria to evaluate 5 mixed methods investigations published in primary care research journals. RESULTS Of the 5 studies analyzed, 3 included a rationale for mixing based on the need to develop a quantitative instrument from qualitative data or to converge information to best understand the research topic. Quantitative data collection involved structured interviews, observational checklists, and chart audits that were analyzed using descriptive and inferential statistical procedures. Qualitative data consisted of semistructured interviews and field observations that were analyzed using coding to develop themes and categories. The studies showed diverse forms of priority: equal priority, qualitative priority, and quantitative priority. Data collection involved quantitative and qualitative data gathered both concurrently and sequentially. The integration of the quantitative and qualitative data in these studies occurred between data analysis from one phase and data collection from a subsequent phase, while analyzing the data, and when reporting the results. DISCUSSION We recommend instrument-building, triangulation, and data transformation models for mixed methods designs as useful frameworks to add rigor to investigations in primary care. We also discuss the limitations of our study and the need for future research. PMID:15053277

  3. Diabetes management in an Australian primary care population.

    PubMed

    Krass, I; Hebing, R; Mitchell, B; Hughes, J; Peterson, G; Song, Y J C; Stewart, K; Armour, C L

    2011-12-01

    Worldwide studies have shown that significant proportions of patients with type 2 diabetes (T2DM) do not meet targets for glycaemic control, blood pressure (BP) and lipids, putting them at higher risk of developing complications. However, little is known about medicines management in Australian primary care populations with T2DM. The aim of this study was to (i) describe the management of a large group of patients in primary care, (ii) identify areas for improvement in management and (iii) determine any relationship between adherence and glycaemic, BP and lipid control. This was a retrospective, epidemiological study of primary care patients with T2DM diabetes, with HbA(1c) of >7%, recruited in 90 Australian community pharmacies. Data collected included demographic details, diabetes history, current medication regimen, height, weight, BP, physical activity and smoking status. Of the 430 patients, 98% used antidiabetics, 80% antihypertensives, 73% lipid lowering drugs and 38% aspirin. BP and all lipid targets were met by only 21% and 14% of the treated patients and 21% and 12% of the untreated patients respectively. Medication adherence was related to better glycaemic control (P = 0.04). An evidence-base prescribing practice gap was seen in this Australian primary care population of T2DM patients. Patients were undertreated with antihypertensive and lipid lowering medication, and several subgroups with co-morbidities were not receiving the recommended pharmacotherapy. Interventions are required to redress the current evidence-base prescribing practice gap in disease management in primary care. © 2011 Blackwell Publishing Ltd.

  4. Designing a mixed methods study in primary care.

    PubMed

    Creswell, John W; Fetters, Michael D; Ivankova, Nataliya V

    2004-01-01

    Mixed methods or multimethod research holds potential for rigorous, methodologically sound investigations in primary care. The objective of this study was to use criteria from the literature to evaluate 5 mixed methods studies in primary care and to advance 3 models useful for designing such investigations. We first identified criteria from the social and behavioral sciences to analyze mixed methods studies in primary care research. We then used the criteria to evaluate 5 mixed methods investigations published in primary care research journals. Of the 5 studies analyzed, 3 included a rationale for mixing based on the need to develop a quantitative instrument from qualitative data or to converge information to best understand the research topic. Quantitative data collection involved structured interviews, observational checklists, and chart audits that were analyzed using descriptive and inferential statistical procedures. Qualitative data consisted of semistructured interviews and field observations that were analyzed using coding to develop themes and categories. The studies showed diverse forms of priority: equal priority, qualitative priority, and quantitative priority. Data collection involved quantitative and qualitative data gathered both concurrently and sequentially. The integration of the quantitative and qualitative data in these studies occurred between data analysis from one phase and data collection from a subsequent phase, while analyzing the data, and when reporting the results. We recommend instrument-building, triangulation, and data transformation models for mixed methods designs as useful frameworks to add rigor to investigations in primary care. We also discuss the limitations of our study and the need for future research.

  5. Primary care and behavioral health practice size: the challenge for health care reform.

    PubMed

    Bauer, Mark S; Leader, Deane; Un, Hyong; Lai, Zongshan; Kilbourne, Amy M

    2012-10-01

    We investigated the size profile of US primary care and behavioral health physician practices since size may impact the ability to institute care management processes (CMPs) that can enhance care quality. We utilized 2009 claims data from a nationwide commercial insurer to estimate practice size by linking providers by tax identification number. We determined the proportion of primary care physicians, psychiatrists, and behavioral health providers practicing in venues of >20 providers per practice (the lower bound for current CMP practice surveys). Among primary care physicians (n=350,350), only 2.1% of practices consisted of >20 providers. Among behavioral health practitioners (n=146,992) and psychiatrists (n=44,449), 1.3% and 1.0% of practices, respectively, had >20 providers. Sensitivity analysis excluding single-physician practices as "secondary" confirmed findings, with primary care and psychiatrist practices of >20 providers comprising, respectively, only 19.4% and 8.8% of practices (difference: P<0.0001). In secondary analyses, bipolar disorder was used as a tracer condition to estimate practice census for a high-complexity, high-cost behavioral health condition; only 1.3-18 patients per practice had claims for this condition. The tax identification number method for estimating practice size has strengths and limitations that complement those of survey methods. The proportion of practices below the lower bound of prior CMP studies is substantial, and care models and policies will need to address the needs of such practices and their patients. Achieving a critical mass of patients for disorder-specific CMPs will require coordination across multiple small practices.

  6. Commentary: improving the supply and distribution of primary care physicians.

    PubMed

    Dorsey, E Ray; Nicholson, Sean; Frist, William H

    2011-05-01

    The current medical education system and reimbursement policies in the United States have contributed to a maldistribution of physicians by specialty and geography. The causes of this maldistribution include financial barriers that prevent the individuals who would be the most likely to serve in primary care and underserved areas from entering the profession, large taxpayer subsidies to teaching hospitals that provide incentives to act in ways that are not in the best interest of society, and reimbursement policies that discourage physicians from providing primary care. The authors propose that the maldistribution of physicians can be addressed successfully by reducing the financial barriers to becoming a primary care physician, aligning subsidies with societal interests, and providing financial incentives that target primary care. They suggest that the Patient Protection and Affordable Care Act of 2010 takes steps in the right direction but that more financially prudent measures should be taken as politicians revisit health care reform with heightened financial scrutiny. Copyright © by the Association of American medical Colleges.

  7. Naturopathy and the Primary Care Practice

    PubMed Central

    Fleming, Sara A.; Gutknecht, Nancy C.

    2010-01-01

    Synopsis Naturopathy is a distinct type of primary care medicine that blends age-old healing traditions with scientific advances and current research. It is guided by a unique set of principles that recognize the body's innate healing capacity, emphasize disease prevention, and encourage individual responsibility to obtain optimal health. Naturopathic treatment modalities include diet and clinical nutrition, behavioral change, hydrotherapy, homeopathy, botanical medicine, physical medicine, pharmaceuticals, and minor surgery. Naturopathic physicians (NDs) are trained as primary care physicians in four-year, accredited doctoral-level naturopathic medical schools. Currently, there are 15 U.S. states, 2 U.S. territories, and a number of provinces in Canada, Australia, and New Zealand that recognize licensure for NDs. PMID:20189002

  8. Are attributes of organizational performance in large health care organizations relevant in primary care practices?

    PubMed

    Orzano, A John; Tallia, Alfred F; Nutting, Paul A; Scott-Cawiezell, Jill; Crabtree, Benjamin F

    2006-01-01

    Are organizational attributes associated with better health outcomes in large health care organizations applicable to primary care practices? In comparative case studies of two community family practices, it was found that attributes of organizational performance identified in larger health care organizations must be tailored to their unique context of primary care. Further work is required to adapt or establish the significance of the attributes of management infrastructure and information mastery.

  9. Patient Perceptions of Telehealth Primary Care Video Visits.

    PubMed

    Powell, Rhea E; Henstenburg, Jeffrey M; Cooper, Grace; Hollander, Judd E; Rising, Kristin L

    2017-05-01

    Telehealth is a care delivery model that promises to increase the flexibility and reach of health services. Our objective is to describe patient experiences with video visits performed with their established primary care clinicians. We constructed semistructured, in-depth qualitative interviews with adult patients following video visits with their primary care clinicians at a single academic medical center. Data were analyzed with a content analysis approach. Of 32 eligible patients, 19 were successfully interviewed. All patients reported overall satisfaction with video visits, with the majority interested in continuing to use video visits as an alternative to in-person visits. The primary benefits cited were convenience and decreased costs. Some patients felt more comfortable with video visits than office visits and expressed a preference for receiving future serious news via video visit, because they could be in their own supportive environment. Primary concerns with video visits were privacy, including the potential for work colleagues to overhear conversations, and questions about the ability of the clinician to perform an adequate physical examination. Primary care video visits are acceptable in a variety of situations. Patients identified convenience, efficiency, communication, privacy, and comfort as domains that are potentially important to consider when assessing video visits vs in-person encounters. Future studies should explore which patients and conditions are best suited for video visits. © 2017 Annals of Family Medicine, Inc.

  10. Integrated primary health care: Finnish solutions and experiences

    PubMed Central

    Kokko, Simo

    2009-01-01

    Background Finland has since 1972 had a primary health care system based on health centres run and funded by the local public authorities called ‘municipalities’. On the world map of primary health care systems, the Finnish solution claims to be the most health centre oriented and also the widest, both in terms of the numbers of staff and also of different professions employed. Offering integrated care through multi-professional health centres has been overshadowed by exceptional difficulties in guaranteeing a reasonable access to the population at times when they need primary medical or dental services. Solutions to the problems of access have been found, but they do not seem durable. Description of policy practice During the past 10 years, the health centres have become a ground of active development structural change, for which no end is in sight. Broader issues of municipal and public administration structures are being solved through rearranging primary health services. In these rearrangements, integration with specialist services and with social services together with mergers of health centres and municipalities are occurring at an accelerated pace. This leads into fundamental questions of the benefits of integration, especially if extensive integration leads into the threat of the loss of identity for primary health care. Discussion This article ends with some lessons to be learned from the situation in Finland for other countries. PMID:19590612

  11. Top studies relevant to primary care practice.

    PubMed

    Perry, Danielle; Kolber, Michael R; Korownyk, Christina; Lindblad, Adrienne J; Ramji, Jamil; Ton, Joey; Allan, G Michael

    2018-04-01

    To summarize 10 high-quality studies from 2017 that have strong relevance to primary care practice. Study selection involved routine literature surveillance by a group of primary care health professionals. This included screening abstracts of important journals and Evidence Alerts, as well as searching the American College of Physicians Journal Club. Topics of the 2017 articles include whether treating subclinical hypothyroidism improves outcomes or symptoms; whether evolocumab reduces cardiovascular disease as well as low-density lipoprotein levels; whether lifestyle interventions reduce medication use in patients with diabetes; whether vitamin D prevents cardiovascular disease, cancer, or upper respiratory tract infections; whether canagliflozin reduces clinical events in patients with diabetes; how corticosteroid injections affect knee osteoarthritis; whether drained abscesses benefit from antibiotic treatment; whether patients with diabetes benefit from bariatric surgery; whether exenatide reduces clinical events in patients with diabetes; and whether tympanostomy tubes affect outcomes in recurrent acute otitis media or chronic otitis media. We provide brief summaries, context where needed, and final recommendations for 10 studies with potential effects on primary care. We also briefly review 5 "runner-up" studies. Research from 2017 produced several high-quality studies in diabetes management. These have demonstrated benefit for alternative therapies and offered evidence not previously available. This year's selection of studies also provided information on a variety of conditions and therapies that are, or might become, more common in primary care settings. Copyright© the College of Family Physicians of Canada.

  12. Factors that influence career choice in primary care among medical students starting social service in Honduras.

    PubMed

    Puertas, E Benjamín; Rivera, Tamara Y

    2016-11-01

    To 1) describe patterns of specialty choice; 2) investigate relationships between career selection and selected demographic indicators; and 3) identify salary perception, factors that influence career choice in primary care, and factors that influence desired location of future medical practice. The study used a mixed-methods approach that included a cross-sectional questionnaire survey applied to 234 last-year medical students in Honduras (September 2014), and semi-structured interviews with eight key informants (October 2014). Statistical analysis included chi-square and factor analysis. An alpha level of 0.05 was used to determine significance. In the qualitative analysis, several codes were associated with each other, and five major themes emerged. Primary care careers were the preferred choice for 8.1% of students, who preferred urban settings for future practice location. The perceived salary of specialties other than primary care was significantly higher than those of general practitioners, family practitioners, and pediatricians (P < 0.001). Participants considered "making a difference," income, teaching, prestige, and challenging work the most important factors influencing career choice. Practice in ambulatory settings was significantly associated with a preference for primary care specialties (P = < 0.05). Logistic regression analysis found that factors related to patient-based care were statistically significant for selecting primary care (P = 0.006). The qualitative analysis further endorsed the survey findings, identifying additional factors that influence career choice (future work option; availability of residency positions; and social factors, including violence). Rationales behind preference of a specialty appeared to be based on a combination of ambition and prestige, and on personal and altruistic considerations. Most factors that influence primary care career choice are similar to those found in the literature. There are several factors

  13. Computer use in primary care practices in Canada.

    PubMed

    Anisimowicz, Yvonne; Bowes, Andrea E; Thompson, Ashley E; Miedema, Baukje; Hogg, William E; Wong, Sabrina T; Katz, Alan; Burge, Fred; Aubrey-Bassler, Kris; Yelland, Gregory S; Wodchis, Walter P

    2017-05-01

    To examine the use of computers in primary care practices. The international Quality and Cost of Primary Care study was conducted in Canada in 2013 and 2014 using a descriptive cross-sectional survey method to collect data from practices across Canada. Participating practices filled out several surveys, one of them being the Family Physician Survey, from which this study collected its data. All 10 Canadian provinces. A total of 788 family physicians. A computer use scale measured the extent to which family physicians integrated computers into their practices, with higher scores indicating a greater integration of computer use in practice. Analyses included t tests and 2 tests comparing new and traditional models of primary care on measures of computer use and electronic health record (EHR) use, as well as descriptive statistics. Nearly all (97.5%) physicians reported using a computer in their practices, with moderately high computer use scale scores (mean [SD] score of 5.97 [2.96] out of 9), and many (65.7%) reported using EHRs. Physicians with practices operating under new models of primary care reported incorporating computers into their practices to a greater extent (mean [SD] score of 6.55 [2.64]) than physicians operating under traditional models did (mean [SD] score of 5.33 [3.15]; t 726.60 = 5.84; P < .001; Cohen d = 0.42, 95% CI 0.808 to 1.627) and were more likely to report using EHRs (73.8% vs 56.7%; [Formula: see text]; P < .001; odds ratio = 2.15). Overall, there was a statistically significant variability in computer use across provinces. Most family physicians in Canada have incorporated computers into their practices for administrative and scholarly activities; however, EHRs have not been adopted consistently across the country. Physicians with practices operating under the new, more collaborative models of primary care use computers more comprehensively and are more likely to use EHRs than those in practices operating under traditional models of

  14. Computer use in primary care practices in Canada

    PubMed Central

    Anisimowicz, Yvonne; Bowes, Andrea E.; Thompson, Ashley E.; Miedema, Baukje; Hogg, William E.; Wong, Sabrina T.; Katz, Alan; Burge, Fred; Aubrey-Bassler, Kris; Yelland, Gregory S.; Wodchis, Walter P.

    2017-01-01

    Abstract Objective To examine the use of computers in primary care practices. Design The international Quality and Cost of Primary Care study was conducted in Canada in 2013 and 2014 using a descriptive cross-sectional survey method to collect data from practices across Canada. Participating practices filled out several surveys, one of them being the Family Physician Survey, from which this study collected its data. Setting All 10 Canadian provinces. Participants A total of 788 family physicians. Main outcome measures A computer use scale measured the extent to which family physicians integrated computers into their practices, with higher scores indicating a greater integration of computer use in practice. Analyses included t tests and 2 tests comparing new and traditional models of primary care on measures of computer use and electronic health record (EHR) use, as well as descriptive statistics. Results Nearly all (97.5%) physicians reported using a computer in their practices, with moderately high computer use scale scores (mean [SD] score of 5.97 [2.96] out of 9), and many (65.7%) reported using EHRs. Physicians with practices operating under new models of primary care reported incorporating computers into their practices to a greater extent (mean [SD] score of 6.55 [2.64]) than physicians operating under traditional models did (mean [SD] score of 5.33 [3.15]; t726.60 = 5.84; P < .001; Cohen d = 0.42, 95% CI 0.808 to 1.627) and were more likely to report using EHRs (73.8% vs 56.7%; χ12=25.43; P < .001; odds ratio = 2.15). Overall, there was a statistically significant variability in computer use across provinces. Conclusion Most family physicians in Canada have incorporated computers into their practices for administrative and scholarly activities; however, EHRs have not been adopted consistently across the country. Physicians with practices operating under the new, more collaborative models of primary care use computers more comprehensively and are more likely

  15. Costing interventions in primary care.

    PubMed

    Kernick, D

    2000-02-01

    Against a background of increasing demands on limited resources, studies that relate benefits of health interventions to the resources they consume will be an important part of any decision-making process in primary care, and an accurate assessment of costs will be an important part of any economic evaluation. Although there is no such thing as a gold standard cost estimate, there are a number of basic costing concepts that underlie any costing study. How costs are derived and combined will depend on the assumptions that have been made in their derivation. It is important to be clear what assumptions have been made and why in order to maintain consistency across comparative studies and prevent inappropriate conclusions being drawn. This paper outlines some costing concepts and principles to enable primary care practitioners and researchers to have a basic understanding of costing exercises and their pitfalls.

  16. Access to primary care for socio-economically disadvantaged older people in rural areas: A qualitative study.

    PubMed

    Ford, John A; Turley, Rachel; Porter, Tom; Shakespeare, Tom; Wong, Geoff; Jones, Andy P; Steel, Nick

    2018-01-01

    We aim to explore the barriers to accessing primary care for socio-economically disadvantaged older people in rural areas. Using a community recruitment strategy, fifteen people over 65 years, living in a rural area, and receiving financial support were recruited for semi-structured interviews. Four focus groups were held with rural health professionals. Interviews and focus groups were audio-recorded and transcribed. Thematic analysis was used to identify barriers to primary care access. Older people's experience can be understood within the context of a patient perceived set of unwritten rules or social contract-an individual is careful not to bother the doctor in return for additional goodwill when they become unwell. However, most found it difficult to access primary care due to engaged telephone lines, availability of appointments, interactions with receptionists; breaching their perceived social contract. This left some feeling unwelcome, worthless or marginalised, especially those with high expectations of the social contract or limited resources, skills and/or desire to adapt to service changes. Health professionals' described how rising demands and expectations coupled with service constraints had necessitated service development, such as fewer home visits, more telephone consultations, triaging calls and modifying the appointment system. Multiple barriers to accessing primary care exist for this group. As primary care is re-organised to reduce costs, commissioners and practitioners must not lose sight of the perceived social contract and models of care that form the basis of how many older people interact with the service.

  17. Utilization of Routine Primary Care Services Among Dancers.

    PubMed

    Alimena, Stephanie; Air, Mary E; Gribbin, Caitlin; Manejias, Elizabeth

    2016-01-01

    This study examines the current utilization of primary and preventive health care services among dancers in order to assess their self-reported primary care needs. Participants were 37 dancers from a variety of dance backgrounds who presented for a free dancer health screening in a large US metropolitan area (30 females, 7 males; mean age: 27.5 ± 7.4 years; age range: 19 to 49 years; mean years of professional dancing: 6.4 ± 5.4 years). Dancers were screened for use of primary care, mental health, and women's health resources using the Health Screen for Professional Dancers developed by the Task Force on Dancer Health. Most dancers had health insurance (62.2%), but within the last 2 years, only approximately half of them (54.1%) reported having a physical examination by a physician. Within the last year, 54.1% of dancers had had a dental check-up, and 56.7% of female dancers received gynecologic care. Thirty percent of female participants indicated irregular menstrual cycles, 16.7% had never been to a gynecologist, and 16.7% were taking birth control. Utilization of calcium and vitamin D supplementation was 27.0% and 29.7%, respectively, and 73.0% were interested in nutritional counseling. A high rate of psychological fatigue and sleep deprivation was found (35.1%), along with a concomitant high rate of self-reported need for mental health counseling (29.7%). Cigarette and recreational drug use was low (5.4% and 5.4%); however, 32.4% engaged in binge drinking within the last year (based on the CDC definition). These findings indicate that dancers infrequently access primary care services, despite high self-reported need for nutritional, mental, and menstrual health counseling and treatment. More studies are warranted to understand dancers' primary health care seeking behavior.

  18. Primary and community care workforce planning and development.

    PubMed

    Hurst, Keith

    2006-09-01

    This article reports a study that provided primary and community care managers with information, allowing them to: (a) evaluate the size and mix of their workforce; and (b) develop knowledgeable and skilled teams to meet the demands of growing and changing services. Primary and community care services are growing in the United Kingdom, but workforce planning and development, despite their wide-ranging cost and quality implications, have not received the same attention. Indeed, most primary and community care workforce planning and development issues are universal. Demand 1-1 side workforce planning is concerned not only with the number, but also with staff mix; but how these autonomous and isolated practitioners spend their time is unique. The other side of the equation, workforce supply, raises many recruitment and retention challenges for managers in many countries. Any country's main workforce planning methods apply equally well to primary care, but each is flawed. A second, main problem is that the methods lead to fragmented services, whereas modern workforce planning methods should be multidisciplinary. Consequently, it has never been more important for managers to have data and algorithms to develop appropriate care teams. A large and versatile workforce database, profiling 304 English primary care trusts using demographic, socio-economic, mortality, morbidity, staffing and performance workforce-related variables, compiled in 2002 and updated yearly, is described. Data were supplemented with a systematic literature review leading to a 340-item annotated bibliography; and qualitative interviews with managers. Workforce size and mix are historical and irrational at best. Moreover, the number of variables that influence staffing is growing, thereby complicating workforce planning. Evaluating and adjusting the size and mix of teams using empirically determined community demand and performance variables based on the area's socio-economic characteristics is

  19. 45 CFR 156.245 - Treatment of direct primary care medical homes.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 45 Public Welfare 1 2013-10-01 2013-10-01 false Treatment of direct primary care medical homes... direct primary care medical homes. A QHP issuer may provide coverage through a direct primary care medical home that meets criteria established by HHS, so long as the QHP meets all requirements that are...

  20. 45 CFR 156.245 - Treatment of direct primary care medical homes.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 45 Public Welfare 1 2014-10-01 2014-10-01 false Treatment of direct primary care medical homes... direct primary care medical homes. A QHP issuer may provide coverage through a direct primary care medical home that meets criteria established by HHS, so long as the QHP meets all requirements that are...