A Model for Catalyzing Educational and Clinical Transformation in Primary Care: Outcomes From a Partnership Among Family Medicine, Internal Medicine, and Pediatrics.

PubMed

Eiff, M Patrice; Green, Larry A; Holmboe, Eric; McDonald, Furman S; Klink, Kathleen; Smith, David Gary; Carraccio, Carol; Harding, Rose; Dexter, Eve; Marino, Miguel; Jones, Sam; Caverzagie, Kelly; Mustapha, Mumtaz; Carney, Patricia A

2016-09-01

To report findings from a national effort initiated by three primary care certifying boards to catalyze change in primary care training. In this mixed-method pilot study (2012-2014), 36 faculty in 12 primary care residencies (family medicine, internal medicine, pediatrics) from four institutions participated in a professional development program designed to prepare faculty to accelerate change in primary care residency training by uniting them in a common mission to create effective ambulatory clinical learning environments. Surveys administered at baseline and 12 months after initial training measured changes in faculty members' confidence and skills, continuity clinics, and residency training programs. Feasibility evaluation involved assessing participation. The authors compared quantitative data using Wilcoxon signed-rank and Bhapkar tests. Observational field notes underwent narrative analysis. Most participants attended two in-person training sessions (92% and 72%, respectively). Between baseline and 12 months, faculty members' confidence in leadership improved significantly for 15/19 (79%) variables assessed; their self-assessed skills improved significantly for 21/22 (95%) competencies. Two medical home domains ("Continuity of Care," "Support/Care Coordination") improved significantly (P < .05) between the two time periods. Analyses of qualitative data revealed that interdisciplinary learning communities formed during the program and served to catalyze transformational change. Results suggest that improvements in faculty perceptions of confidence and skills occurred and that the creation of interdisciplinary learning communities catalyzed transformation. Lengthening the intervention period, engaging other professions involved in training the primary care workforce, and a more discriminating evaluation design are needed to scale this model nationally.

Clinical data integration model. Core interoperability ontology for research using primary care data.

PubMed

Ethier, J-F; Curcin, V; Barton, A; McGilchrist, M M; Bastiaens, H; Andreasson, A; Rossiter, J; Zhao, L; Arvanitis, T N; Taweel, A; Delaney, B C; Burgun, A

2015-01-01

This article is part of the Focus Theme of METHODS of Information in Medicine on "Managing Interoperability and Complexity in Health Systems". Primary care data is the single richest source of routine health care data. However its use, both in research and clinical work, often requires data from multiple clinical sites, clinical trials databases and registries. Data integration and interoperability are therefore of utmost importance. TRANSFoRm's general approach relies on a unified interoperability framework, described in a previous paper. We developed a core ontology for an interoperability framework based on data mediation. This article presents how such an ontology, the Clinical Data Integration Model (CDIM), can be designed to support, in conjunction with appropriate terminologies, biomedical data federation within TRANSFoRm, an EU FP7 project that aims to develop the digital infrastructure for a learning healthcare system in European Primary Care. TRANSFoRm utilizes a unified structural / terminological interoperability framework, based on the local-as-view mediation paradigm. Such an approach mandates the global information model to describe the domain of interest independently of the data sources to be explored. Following a requirement analysis process, no ontology focusing on primary care research was identified and, thus we designed a realist ontology based on Basic Formal Ontology to support our framework in collaboration with various terminologies used in primary care. The resulting ontology has 549 classes and 82 object properties and is used to support data integration for TRANSFoRm's use cases. Concepts identified by researchers were successfully expressed in queries using CDIM and pertinent terminologies. As an example, we illustrate how, in TRANSFoRm, the Query Formulation Workbench can capture eligibility criteria in a computable representation, which is based on CDIM. A unified mediation approach to semantic interoperability provides a flexible and extensible framework for all types of interaction between health record systems and research systems. CDIM, as core ontology of such an approach, enables simplicity and consistency of design across the heterogeneous software landscape and can support the specific needs of EHR-driven phenotyping research using primary care data.

Using Quality Experts from Manufacturing to Transform Primary Care

ERIC Educational Resources Information Center

Steiner, Rose M.; Walsworth, David T.

2010-01-01

Introduction: 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…

Transformational leadership in primary care: Clinicians' patterned approaches to care predict patient satisfaction and health expectations.

PubMed

Huynh, Ho Phi; Sweeny, Kate; Miller, Tricia

2018-04-01

Clinicians face the complex challenge of motivating their patients to achieve optimal health while also ensuring their satisfaction. Inspired by transformational leadership theory, we proposed that clinicians' motivational behaviors can be organized into three patient care styles (transformational, transactional, and passive-avoidant) and that these styles differentially predict patient health outcomes. In two studies using patient-reported data and observer ratings, we found that transformational patient care style positively predicted patients' satisfaction and health expectations above and beyond transactional and passive-avoidant patient care style. These findings provide initial support for the patient care style approach and suggest novel directions for the study of clinicians' motivational behaviors.

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.

Interprofessional transformation of clinical education: The first six years of the Veterans Affairs Centers of Excellence in Primary Care Education.

PubMed

Harada, Nancy D; Traylor, Laural; Rugen, Kathryn Wirtz; Bowen, Judith L; Smith, C Scott; Felker, Bradford; Ludke, Deborah; Tonnu-Mihara, Ivy; Ruberg, Joshua L; Adler, Jayson; Uhl, Kimberly; Gardner, Annette L; Gilman, Stuart C

2018-02-20

This paper describes the Centers of Excellence in Primary Care Education (CoEPCE), a seven-site collaborative project funded by the Office of Academic Affiliations (OAA) within the Veterans Health Administration of the United States Department of Veterans Affairs (VA). The CoEPCE was established to fulfill OAA's vision of large-scale transformation of the clinical learning environment within VA primary care settings. This was accomplished by funding new Centers within VA facilities to develop models of interprofessional education (IPE) to teach health professions trainees to deliver high quality interprofessional team-based primary care to Veterans. Using reports and data collected and maintained by the National Coordinating Center over the first six years of the project, we describe program inputs, the multicomponent intervention, activities undertaken to develop the intervention, and short-term outcomes. The findings have implications for lessons learned that can be considered by others seeking large-scale transformation of education within the clinical workplace and the development of interprofessional clinical learning environments. Within the VA, the CoEPCE has laid the foundation for IPE and collaborative practice, but much work remains to disseminate this work throughout the national VA system.

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

A cluster randomised controlled trial evaluating the effectiveness of eHealth-supported patient recruitment in primary care research: the TRANSFoRm study protocol.

PubMed

Mastellos, Nikolaos; Andreasson, Anna; Huckvale, Kit; Larsen, Mark; Curcin, Vasa; Car, Josip; Agreus, Lars; Delaney, Brendan

2015-02-03

Opportunistic recruitment is a highly laborious and time-consuming process that is currently performed manually, increasing the workload of already busy practitioners and resulting in many studies failing to achieve their recruitment targets. The Translational Medicine and Patient Safety in Europe (TRANSFoRm) platform enables automated recruitment, data collection and follow-up of patients, potentially improving the efficiency, time and costs of clinical research. This study aims to assess the effectiveness of TRANSFoRm in improving patient recruitment and follow-up in primary care trials. This multi-centre, parallel-arm cluster randomised controlled trial will compare TRANSFoRm-supported with standard opportunistic recruitment. Participants will be general practitioners and patients with gastro-oesophageal reflux disease from 40 primary care centres in five European countries. Randomisation will take place at the care centre level. The intervention arm will use the TRANSFoRm tools for recruitment, baseline data collection and follow-up. The control arm will use web-based case report forms and paper self-completed questionnaires. The primary outcome will be the proportion of eligible patients successfully recruited at the end of the 16-week recruitment period. Secondary outcomes will include the proportion of recruited patients with complete baseline and follow-up data and the proportion of participants withdrawn or lost to follow-up. The study will also include an economic evaluation and measures of technology acceptance and user experience. The study should shed light on the use of eHealth to improve the effectiveness of recruitment and follow-up in primary care research and provide an evidence base for future eHealth-supported recruitment initiatives. Reporting of results is expected in October 2015. EudraCT: 2014-001314-25.

Primary Care Reform: Can Quebec's Family Medicine Group Model Benefit from the Experience of Ontario's Family Health Teams?

PubMed Central

Breton, Mylaine; Lévesque, Jean-Frédéric; Pineault, Raynald; Hogg, William

2011-01-01

Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care. PMID:23115575

Impact of health literacy, accessibility and coordination of care on patient's satisfaction with primary care in Germany.

PubMed

Altin, Sibel Vildan; Stock, Stephanie

2015-10-22

Although health policy makers call for the transformation of health care organizations to health literacy responsive ones, there is limited evidence on the care experiences of patients with limited health literacy skills (HL) in respect to health care quality. We explored if HL and patient-reported experiences regarding access to care and support in care-coordination in primary care organizations (PCO) have an impact on patients satisfaction with the care received by their personal general practitioner (GP). A nationwide representative survey was administered in a random sample of 1125 German adults. Binary logistic regression analyses were performed to determine whether HL and perceived access to and coordination of care were associated with satisfaction with care received in primary care adjusting for demographics and health status. In the unadjusted as well as adjusted model, better accessibility of the primary care practice (β= 1.858; 2.032 p < 0.001) frequent support in care coordination by the general practitioner (β = 2.680; 2.820 p < 0.001) as well as sufficient HL (β = 0.888; 1.228 p < 0.05) were independent predictors of a higher satisfaction with care received in the general practice. German adults with sufficient HL and positive experiences regarding care coordination and access to care are more satisfied with care received by their personal general practitioner. This result is from major importance for primary care organizations intending to transform their processes and structures to respond to the health literacy needs of their patients more effectively.

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

Should Dental Schools Train Dentists to Routinely Provide Limited Preventive Primary Medical Care? Two Viewpoints: Viewpoint 1: Dentists Should Be Trained to Routinely Provide Limited Preventive Primary Care and Viewpoint 2: Dentists Should Be Trained in Primary Care Medicine to Enable Comprehensive Patient Management Within Their Scope of Practice.

PubMed

Giddon, Donald B; Donoff, R Bruce; Edwards, Paul C; Goldblatt, Lawrence I

2017-05-01

This Point/Counterpoint acknowledges the transformation of dental practice from a predominantly technically based profession with primary emphasis on restoration of the tooth and its supporting structures to that of a more medically based specialty focusing on the oral and maxillofacial complex. While both viewpoints accept the importance of this transformation, they differ on the ultimate desired outcome and how changes should be implemented during training of dentists as oral health professionals. Viewpoint 1 argues that, in response to a shortage of both primary care providers and access to affordable oral health care, dentists need to be able and willing to provide limited preventive primary care (LPPC), and dental educators should develop and implement training models to prepare them. Among changes proposed are consideration of three types of practitioners: oral physicians with sufficient training to provide LPPC; dentists with excellent technical proficiency but minimal medical and surgical training; and mid-level providers to provide simple restorative and uncomplicated surgical care. Viewpoint 2 argues that the objective of dentists' education in primary care medicine is to help them safely and effectively provide all aspects of oral health care, including appropriate preventive medical care, that already fall within their scope of knowledge and practice. Dental educators should encourage students to use this knowledge to take full ownership of non-tooth-related pathologic conditions of the oral and maxillofacial complex not currently managed in the dental setting, but encouraging graduates to expand into non-dental LPPC outside the recognized scope of practice will only further exacerbate fragmentation of care.

Implementing Quality Improvement in Small, Autonomous Primary Care Practices: Implications for the Patient Centered Medical Home

PubMed Central

Arar, Nedal H.; Noel, Polly H.; Leykum, Luci; Zeber, John E.; Romero, Raquel; Parchman, Michael L.

2012-01-01

Background Implementing improvement programs to enhance quality of care within primary care clinics is complex, with limited practical guidance available to help practices during the process. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient-centered medical homes (PCMH). This study examined practice members’ perceptions of the opportunities and challenges associated with implementing changes in their practice. Methods Semi-structured interviews were conducted with a purposive sample of 56 individuals working in 16 small, community-based primary care practices. The interview consisted of open-ended questions focused on participants’ perceptions of: (1) practice vision, (2) perceived need for practice improvement, and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analyzed. Results Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients’ involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking/follow-up system, standardization of processes of care, and overall clinic documentations. Changes related to the patients’ involvement in their care included improving (a) health education, and (b) self care management. Among the internal barriers were: staff readiness for change, poor communication, and relationship difficulties among team members. External barriers were: insurance regulations, finances and patient health literacy. Practice Implications Transforming their practices to more patient-centered models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programs. Successful strategy for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members’ perceived needs and planned improvement efforts. PMID:22186171

Transforming primary care in the New Orleans safety-net: the patient experience.

PubMed

Schmidt, Laura A; Rittenhouse, Diane R; Wu, Kevin J; Wiley, James A

2013-02-01

The patient-centered medical home (PCMH) is a key service delivery innovation in health reform. However, there are growing questions about whether the changes in clinics promoted by the PCMH model lead to improvements in the patient experience. To test the hypothesis that PCMH improvements in safety-net primary care clinics are associated with a more positive patient experience. Multilevel cross-sectional analysis of patients nested within the primary care clinics that serve them. Primary care clinic leaders and patients throughout the City of New Orleans health care safety-net. Dependent variables included patient ratings of accessibility, coordination, and confidence in the quality/safety of care. The key independent variable was a score measuring PCMH structural and process improvements at the clinic level. Approximately two thirds of patients in New Orleans gave positive ratings to their clinics on access and quality/safety, but only one third did for care coordination. In all but the largest clinics, patient experiences of care coordination were positively associated with the clinic's use of PCMH structural and process changes. Results for patient ratings of access and quality/safety were mixed. Among primary care clinics in the New Orleans safety-net, use of more PCMH improvements at the clinic level led to more positive patient rating of care coordination, but not of accessibility or confidence in quality/safety. Ongoing efforts to pilot, demonstrate, implement, and evaluate the PCMH should consider how the impact of medical practice transformation could vary across different aspects of the patient experience.

Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients.

PubMed

Quigley, Denise D; Predmore, Zachary S; Chen, Alex Y; Hays, Ron D

Patient-centered medical home (PCMH) has gained momentum as a model for primary-care health services reform. We conducted interviews at 14 primary care practices undergoing PCMH transformation in a large urban federally qualified health center in California and used grounded theory to identify common themes and patterns. We found clinics pursued a common sequence of changes in PCMH transformation: Clinics began with National Committee for Quality Assurance (NCQA) level 3 recognition, adding care coordination staff, reorganizing data flow among teams, and integrating with a centralized quality improvement and accountability infrastructure. Next, they realigned to support continuity of care. Then, clinics improved access by adding urgent care, patient portals, or extending hours. Most then improved planning and management of patient visits. Only a handful worked explicitly on improving access with same day slots, scheduling processes, and test result communication. The clinics' changes align with specific NCQA PCMH standards but also include adding physicians and services, culture changes, and improved communication with patients. NCQA PCMH level 3 recognition is only the beginning of a continuous improvement process to become patient centered. Full PCMH transformation took time and effort and relied on a sequential approach, with an early focus on foundational changes that included use of a robust quality improvement strategy before changes to delivery of and access to care.

Tilling the Soil while Sowing the Seeds: Combining Resident Education with Medical Home Transformation

ERIC Educational Resources Information Center

Muench, John; Jarvis, Kelly; Boverman, Josh; Hardman, Joseph; Hayes, Meg; Winkle, Jim

2012-01-01

In order to successfully integrate screening, brief intervention, and referral to treatment (SBIRT) into primary care, education of clinicians must be paired with sustainable transformation of the clinical settings in which they practice. The SBIRT Oregon project adopted this strategy in an effort to fully integrate SBIRT into 7 primary care…

Correlation of the Care by Design primary care practice redesign model and the principles of the patient-centered medical home.

PubMed

Egger, Marlene J; Day, Julie; Scammon, Debra L; Li, Yao; Wilson, Andrew; Magill, Michael K

2012-01-01

Health care reform requires major changes in the organization and delivery of primary care. In 2003, the University of Utah Community Clinics began developing Care by Design (CBD), a primary care model emphasizing access, care teams, and planned care. In 2007, leading primary care organizations published joint principles of the patient-centered medical home (PCMH), the basis for recognition of practices as PCMHs by the National Committee for Quality Assurance (NCQA). The objective of this study was to compare CBD and PCMH metrics conceptually and statistically. This was an observational study in 10 urban and rural primary care clinics including 56 providers. A self-evaluation included the CBD Extent of Use survey and self-estimated PCMH values. The main and secondary outcome measures were CBD scores and PCMH values, respectively. CBD and PCMH principles share common themes such as appropriate access, team-based care, the use of an augmented electronic medical record, planned care, and self-management support. CBD focuses more on the process of practice transformation. The NCQA PCMH standards focus more on structure, including policy, capacity, and populated electronic medical record fields. The Community Clinics' clinic-level PCMH/CBD correlations were low (P > .05.) Practice redesign requires an ability to assess uptake of the redesign as a transformation progresses. The correlation of CBD and PCMH is substantial conceptually but low statistically. PCMH and CBD focus on complementary aspects of redesign: PCMH on structure and CBD on process. Both domains should be addressed in practice reform. Both metrics are works in progress.

The patient centered medical home: mental models and practice culture driving the transformation process.

PubMed

Cronholm, Peter F; Shea, Judy A; Werner, Rachel M; Miller-Day, Michelle; Tufano, Jim; Crabtree, Benjamin F; Gabbay, Robert

2013-09-01

The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. The PCMH model is a departure from more traditional models of healthcare delivery and requires significant transformation to be realized. To describe factors shaping mental models and practice culture driving the PCMH transformation process in a large multi-payer PCMH demonstration project. Individual interviews were conducted at 17 primary care practices in South Eastern Pennsylvania. A total of 118 individual interviews were conducted with clinicians (N = 47), patient educators (N = 4), office administrators (N = 12), medical assistants (N = 26), front office staff (N = 7), nurses (N = 4), care managers (N = 11), social workers (N = 4), and other stakeholders (N = 3). A multi-disciplinary research team used a grounded theory approach to develop the key constructs describing factors shaping successful practice transformation. Three central themes emerged from the data related to changes in practice culture and mental models necessary for PCMH practice transformation: 1) shifting practice perspectives towards proactive, population-oriented care based in practice-patient partnerships; 2) creating a culture of self-examination; and 3) challenges to developing new roles within the practice through distribution of responsibilities and team-based care. The most tension in shifting the required mental models was displayed between clinician and medical assistant participants, revealing significant barriers towards moving away from clinician-centric care. Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, self-assessment, and the development of shared decision-making. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of team-based care.

Sustainability and transformation plans: translating the perspectives.

PubMed

Thakrar, Sonali V; Bell, Diane

2017-10-02

Each local health economy has been tasked with producing a sustainability and transformation plan. A health economy is a system that controls and contributes to health-care resource and the effects of health services on its population. This includes commissioners, acute providers, primary care providers, community services, public health and the voluntary sector. Sustainability and transformation plans represent a shift in the way health care is planned for in England. The aim of each sustainability and transformation plan is to deliver care within existing resource limits by improving quality of care, developing new models of care and improving efficiency of care provision. The tight timescales for production of sustainability and transformation plans mean that in most cases there has been limited clinical engagement; as a result many clinicians have limited sight, understanding or ownership of the proposals within sustainability and transformation plans. As sustainability and transformation plans move into the implementation phase, this article explores the role of the clinician in the ongoing design and delivery of the local sustainability and transformation plans. By finding the common ground between the perspectives of the clinician, the commissioner and system leaders, the motivation of clinicians can be aligned with the ambitions of the sustainability and transformation plan. The common goal of a sustainability and transformation plan and the necessary collaboration required to make it successful is discussed. Ultimately, such translation is essential: clinicians are intelligent, adaptive and motivated individuals who must have a lead role in constructing and implementing plans that transform health and social care.

SO MUCH TO DO, SO LITTLE TIME: CARE FOR THE SOCIALLY DISADVANTAGED AND THE 15-MINUTE VISIT

PubMed Central

Fiscella, Kevin; Epstein, Ronald M

2008-01-01

There is much to do in primary care and little time to do it. Currently, primary care delivery is organized around visits, often 15 minutes or less, during which much is expected of clinicians. This includes establishing partnerships with patient and families; addressing acute and chronic biomedical and psychosocial problems; prevention, care coordination; and ensuring informed decision-making that respects patients’ needs and preferences. Visit-based care discriminates against socially disadvantaged patients, who often require more time due to complex health care needs and the challenge of establishing partnerships and communicating across chasms of race, ethnicity, education, language, and culture. Rushed visits exacerbate disparities in health car due to competing demands, miscommunications and activation of unconscious physician stereotypes. Addressing health care disparities requires radical transformation in the structure and financing of primary care and the roles of the health care team members and patients. One such innovation, the patient-centered medical home, organizes care around patients’ needs, not visits. Thus, face-to-face visits and physician-centered care are supplanted by team-based care that relies on multiple communication modalities, expanded health information technology, population management, culturally-sensitive outreach and follow-up, and coaching patients to assume more active roles in care. Implementation requires payment reform that allocates resources based on the true costs of providing high quality care to socially disadvantaged patients. Ensuring success will require physician leadership and training in new care models, transformation in primary care culture, and redesign of care around the needs of patients, particularly those needing care the most. PMID:18809810

Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents.

PubMed

Chang, Anna; Bowen, Judith L; Buranosky, Raquel A; Frankel, Richard M; Ghosh, Nivedita; Rosenblum, Michael J; Thompson, Sara; Green, Michael L

2013-06-01

The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs? The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs). The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs. The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Effective Strategic Planning for Community Colleges Founded upon Transformational Management Theory

ERIC Educational Resources Information Center

Joseph, Oscar, III

2013-01-01

The transformational management philosophy creates a culture that has purpose, moral standards, and high achievement outcomes (Yukl, 2006). The primary focus of transformational management theory is to be humane, while exhibiting behavioral characteristics of kindness, care, compassion, and principled centeredness (ethical disposition) designed to…

Tilling the soil while sowing the seeds: combining resident education with medical home transformation.

PubMed

Muench, John; Jarvis, Kelly; Boverman, Josh; Hardman, Joseph; Hayes, Meg; Winkle, Jim

2012-01-01

In order to successfully integrate screening, brief intervention, and referral to treatment (SBIRT) into primary care, education of clinicians must be paired with sustainable transformation of the clinical settings in which they practice. The SBIRT Oregon project adopted this strategy in an effort to fully integrate SBIRT into 7 primary care residency clinics. Residents were trained to assess and intervene in their patients' unhealthy substance use, whereas clinic staff personnel were trained to carry out a multistep screening process. Electronic medical record tools were created to further integrate and track SBIRT processes. This article describes how a resident training curriculum complemented and was informed by the transformation of workflow processes within the residents' home clinics.

Recommendations for a mixed methods approach to evaluating the patient-centered medical home.

PubMed

Goldman, Roberta E; Parker, Donna R; Brown, Joanna; Walker, Judith; Eaton, Charles B; Borkan, Jeffrey M

2015-03-01

There is a strong push in the United States to evaluate whether the patient-centered medical home (PCMH) model produces desired results. The explanatory and contextually based questions of how and why PCMH succeeds in different practice settings are often neglected. We report the development of a comprehensive, mixed qualitative-quantitative evaluation set for researchers, policy makers, and clinician groups. To develop an evaluation set, the Brown Primary Care Transformation Initiative convened a multidisciplinary group of PCMH experts, reviewed the PCMH literature and evaluation strategies, developed key domains for evaluation, and selected or created methods and measures for inclusion. The measures and methods in the evaluation set (survey instruments, PCMH meta-measures, patient outcomes, quality measures, qualitative interviews, participant observation, and process evaluation) are meant to be used together. PCMH evaluation must be sufficiently comprehensive to assess and explain both the context of transformation in different primary care practices and the experiences of diverse stakeholders. In addition to commonly assessed patient outcomes, quality, and cost, it is critical to include PCMH components integral to practice culture transformation: patient and family centeredness, authentic patient activation, mutual trust among practice employees and patients, and transparency, joy, and collaboration in delivering and receiving care in a changing environment. This evaluation set offers a comprehensive methodology to enable understanding of how PCMH transformation occurs in different practice settings. This approach can foster insights about how transformation affects critical outcomes to achieve meaningful, patient-centered, high-quality, and cost-effective sustainable change among diverse primary care practices. © 2015 Annals of Family Medicine, Inc.

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

PubMed

Keith, Rosalind E; Crosson, Jesse C; O'Malley, Ann S; Cromp, DeAnn; Taylor, Erin Fries

2017-02-10

Much research does not address the practical needs of stakeholders responsible for introducing health care delivery interventions into organizations working to achieve better outcomes. In this article, we present an approach to using the Consolidated Framework for Implementation Research (CFIR) to guide systematic research that supports rapid-cycle evaluation of the implementation of health care delivery interventions and produces actionable evaluation findings intended to improve implementation in a timely manner. To present our approach, we describe a formative cross-case qualitative investigation of 21 primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a multi-payer supported primary care practice transformation intervention led by the Centers for Medicare and Medicaid Services. Qualitative data include observational field notes and semi-structured interviews with primary care practice leadership, clinicians, and administrative and medical support staff. We use intervention-specific codes, and CFIR constructs to reduce and organize the data to support cross-case analysis of patterns of barriers and facilitators relating to different CPC components. Using the CFIR to guide data collection, coding, analysis, and reporting of findings supported a systematic, comprehensive, and timely understanding of barriers and facilitators to practice transformation. Our approach to using the CFIR produced actionable findings for improving implementation effectiveness during this initiative and for identifying improvements to implementation strategies for future practice transformation efforts. The CFIR is a useful tool for guiding rapid-cycle evaluation of the implementation of practice transformation initiatives. Using the approach described here, we systematically identified where adjustments and refinements to the intervention could be made in the second year of the 4-year intervention. We think the approach we describe has broad application and encourage others to use the CFIR, along with intervention-specific codes, to guide the efficient and rigorous analysis of rich qualitative data. NCT02318108.

Part 1--unravelling primary health care conceptual predicaments through the lenses of complexity and political economy: a position paper for progressive transformation.

PubMed

Félix-Bortolotti, Margot

2009-10-01

To disentangle the concepts of primary health care and primary care as well as their conceptual and empirical ramifications for progressive transformation. over 400 international and interdisciplinary abstracts and papers with 96 annotated bibliography abstracts of literature across multiple dimensions relating to the knowledge base around mechanisms in PHC development were reviewed. The text is confronted with the reality, as it exists in the field and makes the case for complexity perspectives to assess this phenomenon in its context. PHC complexity is an important analytical tool to interrogate the ways in which this phenomenon is socially constructed as well as in the matrices in which it is embedded. It is also a potent analytical tool to assist in the deconstruction of prevalent linear thinking built around PHC as a whole.

Cultivating engaged leadership through a learning collaborative: lessons from primary care renewal in Oregon safety net clinics.

PubMed

McMullen, Carmit K; Schneider, Jennifer; Firemark, Alison; Davis, James; Spofford, Mark

2013-01-01

The aim of this study was to explore how learning collaboratives cultivate leadership skills that are essential for implementing patient-centered medical homes (PCMHs). We conducted an ethnographic evaluation of a payor-incentivized PCMH implementation in Oregon safety net clinics, known as Primary Care Renewal. Analyses primarily drew on in-depth interviews with organizational leaders who were involved in the initiative. We solicited perspectives on the history, barriers, facilitators, and other noteworthy factors related to the implementation of PCMH. We reviewed and summarized transcripts and created and applied a coding dictionary to identify emergent leadership themes. We reviewed field notes from clinic site visits and observations of learning collaborative activities for additional information on the role of engaged leadership. Interview data suggested that organizations followed a similar, sequential process of Primary Care Renewal implementation having 2 phases-inspiration and implementation-and that leaders needed and learned different leadership skills in each phase. Leaders reported that collaborative learning opportunities were critical for developing engaged leadership skills during the inspiration phase of transformation. Facilitative and modeling aspects of engaged leadership were most important for codesigning a vision and plan for change. Adaptive leadership skills became more important during the implementation phase, when specific operational and management skills were needed to foster standardization and spread of the Primary Care Renewal initiative throughout participating clinics. The PCMH has received much attention as a way to reorganize and potentially improve primary care. Documenting steps and stages for cultivating leaders with the vision and skills to transform their organizations into PCMHs may offer a useful roadmap to other organizations considering a similar transformation.

Behavior medicine specialist.

PubMed

Tuso, Phillip

2014-01-01

Total Health is a vision for the future and a strategy to prevent preventable disease, save lives, and make health care more affordable. Total Health means health of mind (behavior health) and health of body (physical health). To achieve Total Health we need healthy people in healthy communities. A behavior medicine specialist is a psychologist who works in the medical home with the primary care physician instead of in the Mental Health Department with a psychiatrist. The key to achieving Total Health will be to transform our current health care system from a focus on treating disease to a focus on preventing disease. This transformation will require complex behavior change interventions and services not usually provided in the medical home. The behavior medicine specialist will bring the knowledge and experience used to treat mental illness into the medical home to help the primary care physician improve the care of all patients in the medical home. The behavior medicine specialist will help improve outcomes in synergy with the primary care physician by universal screening of high-risk diseases, stepped care protocols, and efficient use of all resources available to care for patients in the medical home (health education classes, wellness coaches, and online social networking lifestyle management programs). These interventions should increase patient satisfaction, increase access to specialty care (psychiatry), and help us achieve Total Health.

Prospects for rebuilding primary care using the patient-centered medical home.

PubMed

Landon, Bruce E; Gill, James M; Antonelli, Richard C; Rich, Eugene C

2010-05-01

Existing research suggests that models of enhanced primary care lead to health care systems with better performance. What the research does not show is whether such an approach is feasible or likely to be effective within the U.S. health care system. Many commentators have adopted the model of the patient-centered medical home as policy shorthand to address the reinvention of primary care in the United States. We analyze potential barriers to implementing the medical home model for policy makers and practitioners. Among others, these include developing new payment models, as well as the need for up-front funding to assemble the personnel and infrastructure required by an enhanced non-visit-based primary care practice and methods to facilitate transformation of existing practices to functioning medical homes.

The Patient-Centered Medical Home (PCMH) Framing Typology for Understanding the Structure, Function, and Outcomes of PCMHs.

PubMed

Kieber-Emmons, Autumn M; Miller, William L

2017-01-01

Patient-centered medical homes (PCHMs) aspire to transform today's challenged primary care services. However, it is unclear which PCMH characteristics produce specific outcomes of interest for care delivery. This study tested a novel typology of PCMH practice transformation, the PCMH framing typology, and evaluated measurable outcomes by each type. Using the Patient-Centered Primary Care Collaborative 2012 to 2013 Annual Review, this secondary analysis of the published PCMH literature extracted data from publications of 59 PCMHs. Each of the 59 sites was categorized as 1 of 4 PCMH types: add-on, renovated, hybrid, or integrated. Six outcome measures (cost reductions, decreased emergency department/hospital utilization, improved quality, improved access, increased preventive services, and improved patient satisfaction) were independently coded for each site. Practices were combined based on type, and mean outcomes scores for each measure were displayed on radar graphs for comparison. While each type showed a characteristic pattern of success, only the integrated type improved in all 6 outcomes. No type achieved high success in all measures. There seem to be 4 types of PCMH, each of which shows a distinctive outcomes profile. Within the PCMH framing typology, direction is emerging for how best to transform primary care to achieve the greatest success. © Copyright 2017 by the American Board of Family Medicine.

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.

Strategies to Support the Integration of Behavioral Health and Primary Care: What Have We Learned Thus Far?

PubMed

Dickinson, W Perry

2015-01-01

The articles in this supplement contain a wealth of practical information regarding the integration of behavioral health and primary care. This type of integration effort is complex and greatly benefits from support from outside organizations, as well as collaboration with other practices attempting similar work. This editorial extracts from these articles some of the key lessons learned regarding the integration of behavioral health and primary care for practices and for organizations that support practice transformation. © Copyright 2015 by the American Board of Family Medicine.

Training doctors for primary care in China: Transformation of general practice education.

PubMed

Li, Donald

2016-01-01

China is known for developing a cadre of "Barefoot Doctors" to address her rural healthcare needs in past. The tradition of barefoot doctors has inspired similar developments in several other countries across world. Recently China has embarked upon an ambitious new mission to create a primary care workforce consisting of trained general practitioners having international standard skillsets. This editorial provides an insight into the current status of policy deliberations with regards to training of primary care doctors and a new surge in general practice education in China.

Health information technology: transforming chronic disease management and care transitions.

PubMed

Rao, Shaline; Brammer, Craig; McKethan, Aaron; Buntin, Melinda B

2012-06-01

Adoption of health information technology (HIT) is a key effort in improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety. Copyright © 2012 Elsevier Inc. All rights reserved.

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

PubMed

Scammon, Debra L; Tomoaia-Cotisel, Andrada; Day, Rachel L; Day, Julie; Kim, Jaewhan; Waitzman, Norman J; Farrell, Timothy W; Magill, Michael K

2013-12-01

To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. Convergent case study mixed methods design. Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence. © Health Research and Educational Trust.

Connecting the Dots and Merging Meaning: Using Mixed Methods to Study Primary Care Delivery Transformation

PubMed Central

Scammon, Debra L; Tomoaia-Cotisel, Andrada; Day, Rachel L; Day, Julie; Kim, Jaewhan; Waitzman, Norman J; Farrell, Timothy W; Magill, Michael K

2013-01-01

Objective. To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. Data Source/Study Setting. An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. Study Design. Convergent case study mixed methods design. Data Collection/Extraction Methods. Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. Principal Findings. Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. Conclusions. Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence. PMID:24279836

[Rethinking the place of primary healthcare in France--role of general practice].

PubMed

Gay, B

2013-06-01

Primary healthcare is poorly structured in France while it is well defined at the international level: it is the point of first medical contact of the population with the healthcare system. General practice is the clinical specialty oriented to primary healthcare. Data in the scientific literature highlight the need of refocusing the health system on primary care known to improve both morbi-mortality and care efficiency. In France, health authorities acknowledge general practitioners as playing a key role in the health care system: its time to move from intention to action. Structural changes are needed to achieve this reinforcement of primary healthcare: to re-orientate medical studies towards primary care; to develop research in primary care; to promote cooperation between care providers; to ease the daily workload of practitioners; to diversify methods of payment; to propose a guide for patient's use of primary care. The transformation of the healthcare system in France requires a real strategy of primary healthcare implementation. Regardless of financial constraints, it is possible to redistribute the resources towards ambulatory care. Strengthening the role of general practice and favoring its societal recognition will be the major stages of this change. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

The Comprehensive Primary Care Initiative: Effects On Spending, Quality, Patients, And Physicians.

PubMed

Peikes, Deborah; Dale, Stacy; Ghosh, Arkadipta; Taylor, Erin Fries; Swankoski, Kaylyn; O'Malley, Ann S; Day, Timothy J; Duda, Nancy; Singh, Pragya; Anglin, Grace; Sessums, Laura L; Brown, Randall S

2018-06-01

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.

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

Is Team-Based Primary Care Associated with Less Access Problems and Self-Reported Unmet Need in Canada?

PubMed

Zygmunt, Austin; Asada, Yukiko; Burge, Frederick

2017-10-01

As in many jurisdictions, the delivery of primary care in Canada is being transformed from solo practice to team-based care. In Canada, team-based primary care involves general practitioners working with nurses or other health care providers, and it is expected to improve equity in access to care. This study examined whether team-based care is associated with fewer access problems and less unmet need and whether socioeconomic gradients in access problems and unmet need are smaller in team-based care than in non-team-based care. Data came from the 2008 Canadian Survey of Experiences with Primary Health Care (sample size: 10,858). We measured primary care type as team-based or non-team-based and socioeconomic status by income and education. We created four access problem variables and four unmet need variables (overall and three specific components). For each, we ran separate logistic regression models to examine their associations with primary care type. We examined socioeconomic gradients in access problems and unmet need stratified by primary care type. Primary care type had no statistically significant, independent associations with access problems or unmet need. Among those with non-team-based care, a statistically significant education gradient for overall access problems existed, whereas among those with team-based care, no statistically significant socioeconomic gradients existed.

National Institutes of Health eliminates funding for national architecture linking primary care research.

PubMed

Peterson, Kevin A

2007-01-01

With the ending of the National Electronic Clinical Trial and Research Network (NECTAR) pilot programs and the abridgement of Clinical Research Associate initiative, the National Institutes of Health Roadmap presents a strategic shift for practice-based research networks from direct funding of a harmonized national infrastructure of cooperating research networks to a model of local engagement of primary care clinics performing practice-based research under the aegis of regional academic health centers through Clinical and Translational Science Awards. Although this may present important opportunities for partnering between community practices and large health centers, for primary care researchers, the promise of a transformational change that brings a unified national primary care community into the clinical research enterprise seems likely to remain unfulfilled.

Analysis of the performance of contractualization primary health care indicators in the period 2009-2015 in Lisbon and Tagus Valley.

PubMed

Monteiro, Baltazar Ricardo; Candoso, Fátima; Reis, Magda; Bastos, Sónia

2017-03-01

Reforms started in 1996 intended that Regional Health Administrations (ARS) should play a relevant role in the process of transforming an integrated model towards a contractual health care model. The essential tool of this transformation would be the Contractualization Agency, established in each ARS. Its role in the new contractualization culture was to negotiate prospective budgets with health care institutions, which included Primary Health Care (PHC). This paper is a longitudinal analysis of the development of a set of nine PHC contractualization indicators in three Health Center Clusters (ACeS) of the Regional Health Administration of Lisbon and Tagus Valley (ARSLVT). We have noticed that the setting of goals, in terms of external contractualization and its monitoring and follow-up are decisive and help health professionals to define trajectories and performance goals. We also recognize the need to revise baseline indicators by developing them into outcome indicators.

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.

Transforming Medical Education is the Key to Meeting North Carolina's Physician Workforce Needs.

PubMed

Cunningham, Paul R G; Baxley, Elizabeth G; Garrison, Herbert G

2016-01-01

To meet the needs of the population of North Carolina, an epic transformation is under way in health care. This transformation requires that we find new ways to educate and train physicians and other health care professionals. In this commentary, we propose that the success of the Brody School of Medicine in preparing a primary care physician workforce can serve as a model for meeting the state's future physician workforce needs. Other considerations include increasing graduate medical education positions through state funding and providing incentives for medical students who stay in North Carolina. ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

Transforming family practice in British Columbia: the General Practice Services Committee.

PubMed

Cavers, William J R; Tregillus, Valerie H F; Micco, Angela; Hollander, Marcus J

2010-12-01

To describe a new approach to primary care reform developed in British Columbia (BC) under the leadership of the General Practice Services Committee (GPSC). COMPOSITION OF THE COMMITTEE: The GPSC is a joint committee of the BC Ministry of Health Services, the BC Medical Association, and the Society of General Practitioners of BC. Representatives of BC's health authorities also attend as guests. This paper is based on the 2008-2009 annual report of the GPSC. It summarizes the history and main activities of the GPSC. The GPSC is currently supporting a number of key activities to transform primary care in BC. These activities include the Full Service Family Practice Incentive Program, which provides incentive payments to promote enhanced primary care; the Practice Support Program, which provides family physicians and their medical office assistants with various practical evidence-based strategies and tools for managing practice enhancement; the Family Physicians for BC Program to develop family practices in areas of identified need; the Shared Care Committee, which supports and enables the determination of appropriate scopes of practice among GPs, specialists, and other health care professionals; the Divisions of Family Practice, which are designed to facilitate interactions among family doctors and between doctors and their respective health authorities; and the Community Healthcare and Resource Directory, a Web-based resource to help health care providers find appropriate mental health resources. Early results indicate that the GPSC's initiatives are enhancing the delivery of primary care services in BC.

Transforming family practice in British Columbia

PubMed Central

Cavers, William J.R.; Tregillus, Valerie H.F.; Micco, Angela; Hollander, Marcus J.

2010-01-01

ABSTRACT OBJECTIVE To describe a new approach to primary care reform developed in British Columbia (BC) under the leadership of the General Practice Services Committee (GPSC). COMPOSITION OF THE COMMITTEE The GPSC is a joint committee of the BC Ministry of Health Services, the BC Medical Association, and the Society of General Practitioners of BC. Representatives of BC’s health authorities also attend as guests. METHOD This paper is based on the 2008–2009 annual report of the GPSC. It summarizes the history and main activities of the GPSC. REPORT The GPSC is currently supporting a number of key activities to transform primary care in BC. These activities include the Full Service Family Practice Incentive Program, which provides incentive payments to promote enhanced primary care; the Practice Support Program, which provides family physicians and their medical office assistants with various practical evidence-based strategies and tools for managing practice enhancement; the Family Physicians for BC Program to develop family practices in areas of identified need; the Shared Care Committee, which supports and enables the determination of appropriate scopes of practice among GPs, specialists, and other health care professionals; the Divisions of Family Practice, which are designed to facilitate interactions among family doctors and between doctors and their respective health authorities; and the Community Healthcare and Resource Directory, a Web-based resource to help health care providers find appropriate mental health resources. CONCLUSION Early results indicate that the GPSC’s initiatives are enhancing the delivery of primary care services in BC. PMID:21156899

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.

A Requirements Analysis for Primary Care at Womack Army Medical Center

DTIC Science & Technology

2006-06-16

posed by threats such as weapons of mass destruction and terrorism (Army Transformation Plan, 2001). The Army Transformation Plan revising European...Health Systems Specialist for Clark Health Clinic, Expansion Plan 14 personal comunication , May 2006) . Robinson Health Clinic supports the 8 2 nd

From cottage industry to a dominant mode of primary care: stages in the diffusion of a health care innovation (retail clinics).

PubMed

McKinlay, John B; Marceau, Lisa D

2012-09-01

Primary health care is essential to population health and there is increasing need for it, especially with an aging population with multiple comorbidities. Primary health care in the U.S. is widely considered in an ever-deepening crisis. This paper presents a detailed case study of the recent rise of a "disruptive innovation" - retail clinics - which have the potential to transform the face of primary health care in the US. We describe six stages in the diffusion of retail clinics, from cottage industry to a dominant mode for the delivery of primary health care, and consider sociopolitical influences that facilitate and impede their emerging potential. Retail clinics may provide a strategic opportunity to re-engineer the primary health care system, although they may also produce worrisome unanticipated consequences. Discussion concerning the potential threats and opportunities posed by retail clinics occurs in the absence of sound evidence concerning their comparative effectiveness and quality-of-care. This case study identifies the sociopolitical influences and processes that determine whether health care innovations rise or fall, and highlights critically important points along the pathway to health system change. Copyright © 2012 Elsevier Ltd. All rights reserved.

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.

A tale of four practices.

PubMed

Miller-Day, Michelle; Applequist, Janelle; Zabokrtsky, Keri; Dalton, Alexandra; Kellom, Katherine; Gabbay, Robert; Cronholm, Peter F

2017-09-18

Purpose The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. This transformation presents a challenge to many care delivery organizations. The purpose of this paper is to describe attributes shaping successful and unsuccessful practice transformation within four medical practice groups. Design/methodology/approach As part of a larger study of 25 practices transitioning into a PCMH, the current study focused on diabetes care and identified high- and low-improvement medical practices in terms of quantitative patient measures of glycosylated hemoglobin and qualitative assessments of practice performance. A subset of the top two high-improvement and bottom two low-improvement practices were identified as comparison groups. Semi-structured interviews were conducted with diverse personnel at these practices to investigate their experiences with practice transformation and data were analyzed using analytic induction. Findings Results show a variety of key attributes facilitating more successful PCMH transformation, such as empanelment, shared goals and regular meetings, and a clear understanding of PCMH transformation purposes, goals, and benefits, providing care/case management services, and facilitating patient reminders. Several barriers also exist to successful transformation, such as low levels of resources to handle financial expense, lack of understanding PCMH transformation purposes, goals, and benefits, inadequate training and management of technology, and low team cohesion. Originality/value Few studies qualitatively compare and contrast high and low performing practices to illuminate the experience of practice transformation. These findings highlight the experience of organizational members and their challenges in practice transformation while providing quality diabetes care.

Clinical coordination in accountable care organizations: A qualitative study.

PubMed

Lewis, Valerie A; Schoenherr, Karen; Fraze, Taressa; Cunningham, Aleen

2016-12-06

Accountable care organizations (ACOs) are becoming a common payment and delivery model. Despite widespread interest, little empirical research has examined what efforts or strategies ACOs are using to change care and reduce costs. Knowledge of ACOs' clinical efforts can provide important context for understanding ACO performance, particularly to distinguish arenas where ACOs have and have not attempted care transformation. The aim of the study was to understand ACOs' efforts to change clinical care during the first 18 months of ACO contracts. We conducted semistructured interviews between July and December 2013. Our sample includes ACOs that began performance contracts in 2012, including Medicare Shared Savings Program and Pioneer participants, stratified across key factors. In total, we conducted interviews with executives from 30 ACOs. Iterative qualitative analysis identified common patterns and themes. ACOs in the first year of performance contracts are commonly focusing on four areas: first, transforming primary care through increased access and team-based care; second, reducing avoidable emergency department use; third, strengthening practice-based care management; and fourth, developing new boundary spanner roles and activities. ACOs were doing little around transforming specialty care, acute and postacute care, or standardizing care across practices during the first 18 months of ACO performance contracts. Results suggest that cost reductions associated with ACOs in the first years of contracts may be related to primary care. Although in the long term many hope ACOs will achieve coordination across a wide array of care settings and providers, in the short term providers under ACO contracts are focused largely on primary care-related strategies. Our work provides a template of the common areas of clinical activity in the first years of ACO contracts, which may be informative to providers considering becoming an ACO. Further research will be needed to understand how these strategies are associated with performance.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Transforming primary healthcare by including the stakeholders involved in delivering care to people living in poverty: EQUIhealThY study protocol.

PubMed

Loignon, Christine; Hudon, Catherine; Boudreault-Fournier, Alexandrine; Dupéré, Sophie; Macaulay, Ann C; Pluye, Pierre; Gaboury, Isabelle; Haggerty, Jeannie L; Fortin, Martin; Goulet, Émilie; Lambert, Mireille; Pelissier-Simard, Luce; Boyer, Sophie; de Laat, Marianne; Lemire, Francine; Champagne, Louise; Lemieux, Martin

2013-03-11

Ensuring access to timely and appropriate primary healthcare for people living in poverty is an issue facing all countries, even those with universal healthcare systems. The transformation of healthcare practices and organization could be improved by involving key stakeholders from the community and the healthcare system in the development of research interventions. The aim of this project is to stimulate changes in healthcare organizations and practices by encouraging collaboration between care teams and people living in poverty. Our objectives are twofold: 1) to identify actions required to promote the adoption of professional practices oriented toward social competence in primary care teams; and 2) to examine factors that would encourage the inclusion of people living in poverty in the process of developing social competence in healthcare organizations. This study will use a participatory action research design applied in healthcare organizations. Participatory research is an increasingly recognized approach that is helpful for involving the people for whom the research results are intended. Our research team consists of 19 non-academic researchers, 11 academic researchers and six partners. A steering committee composed of academic researchers and stakeholders will have a decision-making role at each step, including knowledge dissemination and recommendations for new interventions. In this project we will adopt a multiphase approach and will use a variety of methods, including photovoice, group discussions and interviews. The proposed study will be one of only a few using participatory research in primary care to foster changes aimed at enhancing quality and access to care for people living in poverty. To our knowledge this will be the first study to use photovoice in healthcare organizations to promote new interventions. Our project includes partners who are targeted for practice changes and improvements in delivering primary care to persons living in poverty. By involving knowledge users, including service recipients, our study is more likely to produce a transformation of professional practices and encourage healthcare organizations to take into account the needs of persons living in poverty.

Transforming primary healthcare by including the stakeholders involved in delivering care to people living in poverty: EQUIhealThY study protocol

PubMed Central

2013-01-01

Background Ensuring access to timely and appropriate primary healthcare for people living in poverty is an issue facing all countries, even those with universal healthcare systems. The transformation of healthcare practices and organization could be improved by involving key stakeholders from the community and the healthcare system in the development of research interventions. The aim of this project is to stimulate changes in healthcare organizations and practices by encouraging collaboration between care teams and people living in poverty. Our objectives are twofold: 1) to identify actions required to promote the adoption of professional practices oriented toward social competence in primary care teams; and 2) to examine factors that would encourage the inclusion of people living in poverty in the process of developing social competence in healthcare organizations. Methods/design This study will use a participatory action research design applied in healthcare organizations. Participatory research is an increasingly recognized approach that is helpful for involving the people for whom the research results are intended. Our research team consists of 19 non-academic researchers, 11 academic researchers and six partners. A steering committee composed of academic researchers and stakeholders will have a decision-making role at each step, including knowledge dissemination and recommendations for new interventions. In this project we will adopt a multiphase approach and will use a variety of methods, including photovoice, group discussions and interviews. Discussion The proposed study will be one of only a few using participatory research in primary care to foster changes aimed at enhancing quality and access to care for people living in poverty. To our knowledge this will be the first study to use photovoice in healthcare organizations to promote new interventions. Our project includes partners who are targeted for practice changes and improvements in delivering primary care to persons living in poverty. By involving knowledge users, including service recipients, our study is more likely to produce a transformation of professional practices and encourage healthcare organizations to take into account the needs of persons living in poverty. PMID:23497400

Secure e-mailing between physicians and patients: transformational change in ambulatory care.

PubMed

Garrido, Terhilda; Meng, Di; Wang, Jian J; Palen, Ted E; Kanter, Michael H

2014-01-01

Secure e-mailing between Kaiser Permanente physicians and patients is widespread; primary care providers receive an average of 5 e-mails from patients each workday. However, on average, secure e-mailing with patients has not substantially impacted primary care provider workloads. Secure e-mail has been associated with increased member retention and improved quality of care. Separate studies associated patient portal and secure e-mail use with both decreased and increased use of other health care services, such as office visits, telephone encounters, emergency department visits, and hospitalizations. Directions for future research include more granular analysis of associations between patient-physician secure e-mail and health care utilization.

Family practice in Turkey.

PubMed

Ozsahin, Akatli Kursad

2014-03-01

The national project 'Transformation in Health' was started in 2005 to provide expert primary care by family physicians, and decrease expenses in Turkey. The number of family physicians was far below the need, so public physicians were promoted to family physician status after a 10-day intensive course. The government declared some satisfactory results, but privately paid family physicians were not accepted into the system. Furthermore, the government stopped paying for their services from private settings. Some family physicians became unemployed as the major payer for all forms of medical care in Turkey denied their services. The process showed it's value in time. Nevertheless, family physicians should be the core of this transformation as family medicine is an academic and a scientific discipline and a primary care-oriented specialty with its own specific educational content, research and base of evidence, which cannot be achieved through standard medical education.

Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees.

PubMed

Helfrich, Christian D; Dolan, Emily D; Simonetti, Joseph; Reid, Robert J; Joos, Sandra; Wakefield, Bonnie J; Schectman, Gordon; Stark, Richard; Fihn, Stephan D; Harvey, Henry B; Nelson, Karin

2014-07-01

A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed. To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT). Web-based, cross-sectional survey and administrative data from May 2012. A total of 4,539 VA primary care personnel from 588 VA primary care clinics. The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity. Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout. Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.

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.

From Our Practices to Yours: Key Messages for the Journey to Integrated Behavioral Health.

PubMed

Gold, Stephanie B; Green, Larry A; Peek, C J

The historic, cultural separation of primary care and behavioral health has caused the spread of integrated care to lag behind other practice transformation efforts. The Advancing Care Together study was a 3-year evaluation of how practices implemented integrated care in their local contexts; at its culmination, practice leaders ("innovators") identified lessons learned to pass on to others. Individual feedback from innovators, key messages created by workgroups of innovators and the study team, and a synthesis of key messages from a facilitated discussion were analyzed for themes via immersion/crystallization. Five key themes were captured: (1) frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care; (2) initialize: define relationships and protocols up-front, understanding they will evolve; (3) build inclusive, empowered teams to provide the foundation for integration; (4) develop a change management strategy of continuous evaluation and course-correction; and (5) use targeted data collection pertinent to integrated care to drive improvement and impart accountability. Innovators integrating primary care and behavioral health discerned key messages from their practical experience that they felt were worth sharing with others. Their messages present insight into the challenges unique to integrating care beyond other practice transformation efforts. © Copyright 2017 by the American Board of Family Medicine.

78 FR 29753 - Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-21

...) meeting on ``Estimating the Costs of Supporting Primary Care Practice Transformation (R03)''. DATES: July... Extramural Research, Education and Priority Populations, AHRQ, 540 Gaither Road, Room 2038, Rockville...

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.

Facilitating pediatric patient-provider communications using wireless technology in children and adolescents with sickle cell disease.

PubMed

Jacob, Eufemia; Pavlish, Carol; Duran, Joana; Stinson, Jennifer; Lewis, Mary Ann; Zeltzer, Lonnie

2013-01-01

Use of wireless devices has the potential to transform delivery of primary care services for persons with sickle cell disease (SCD). The study examined text message communications between patients and an advanced practice registered nurse (APRN) and the different primary care activities that emerged with use of wireless technology. Patients (N = 37; mean age 13.9 ± 1.8 years; 45.9% male and 54.1% female) engaged in intermittent text conversations with the APRN as part of the Wireless Pain Intervention Program. Content analyses were used to analyze the content of text message exchanges between patients and the APRN. The primary care needs that emerged were related to pain and symptom management and sickle cell crisis prevention. Two primary care categories (collaborating and coaching), four primary care subcategories (screening, referring, informing, and supporting), and 16 primary care activities were evident in text conversations. The use of wireless technology may facilitate screening, prompt management of pain and symptoms, prevention or reduction of SCD-related complications, more efficient referral for treatments, timely patient education, and psychosocial support in children and adolescents with SCD. Copyright © 2013 National Association of Pediatric Nurse Practitioners. Published by Mosby, Inc. All rights reserved.

Payment Reform to Enhance Collaboration of Primary Care and Cardiology: A Review.

PubMed

Farmer, Steven A; Casale, Paul N; Gillam, Linda D; Rumsfeld, John S; Erickson, Shari; Kirschner, Neil M; de Regnier, Kevin; Williams, Bruce R; Martin, R Shawn; McClellan, Mark B

2018-01-01

The US health care system faces an unsustainable trajectory of high costs and inconsistent outcomes. The fee-for-service payment model has contributed to inefficiency, and new payment methods are a promising approach to improving value. Health reforms are needed to increase patient access, reduce costs, and improve health care quality, and the landmark Medicare Access and CHIP Reauthorization Act presents a roadmap for reform. The product of a collaboration between primary care and cardiology clinicians, this review describes a conceptual approach to delivery and payment reforms that aim to better support primary care-cardiology comanagement of chronic cardiovascular disease (CVD). Few existing alternative payment models specifically address long-term management of CVD. Primary care medical homes and accountable care organizations come closest, but both emphasize primary care, and cardiologists have often not been well engaged. A collaborative care framework should articulate distinct roles and responsibilities for primary care and cardiology in CVD comanagement. Finally, a series of payment models aim to better support clinicians in providing accountable, seamless, and patient-centered cardiac care. Clinical leadership is essential during this time of change in the health care system. Patients often struggle to navigate a fragmented and expensive system, whereas clinicians often practice with incomplete information about tests, treatments, and recommendations by their colleagues. The payment models described in this review offer an opportunity to create more satisfying approaches to patient care while improving value. These models have potential to support more effective coordination and to facilitate broader health care system transformation.

The Scholarisation of the French "Ecole Maternelle": Institutional Transformations since the 1970s

ERIC Educational Resources Information Center

Garnier, Pascale

2011-01-01

The transformations that have taken place in the French "ecole maternelle" (nursery school) over the last 30 years may be characterised by a dual dynamic, internal and external, of scholarisation. Firstly, the analysis of its changing position with regard to primary school and within early childhood education and care shows a relative…

Arts and health as a practice of liminality: Managing the spaces of transformation for social and emotional wellbeing with primary school children

PubMed Central

Atkinson, Sarah; Robson, Mary

2012-01-01

Intervention to enhance wellbeing through participation in the creative arts has a transformative potential, but the spatialities to this are poorly theorised. The paper examines arts-based interventions in two primary schools in which small groups of children are taken out of their everyday classrooms to participate in weekly sessions. The paper argues that such intervention is usefully seen as a practice of liminality, a distinct time and space that needs careful management to realise a transformative potential. Such management involves negotiating multiple sources of tension to balance different modes of power, forms of art practices and permeability of the liminal time-space. PMID:22840601

A Positive Deviance Approach to Understanding Key Features to Improving Diabetes Care in the Medical Home

PubMed Central

Gabbay, Robert A.; Friedberg, Mark W.; Miller-Day, Michelle; Cronholm, Peter F.; Adelman, Alan; Schneider, Eric C.

2013-01-01

PURPOSE The medical home has gained national attention as a model to reorganize primary care to improve health outcomes. Pennsylvania has undertaken one of the largest state-based, multipayer medical home pilot projects. We used a positive deviance approach to identify and compare factors driving the care models of practices showing the greatest and least improvement in diabetes care in a sample of 25 primary care practices in southeast Pennsylvania. METHODS We ranked practices into improvement quintiles on the basis of the average absolute percentage point improvement from baseline to 18 months in 3 registry-based measures of performance related to diabetes care: glycated hemoglobin concentration, blood pressure, and low-density lipoprotein cholesterol level. We then conducted surveys and key informant interviews with leaders and staff in the 5 most and least improved practices, and compared their responses. RESULTS The most improved/higher-performing practices tended to have greater structural capabilities (eg, electronic health records) than the least improved/lower-performing practices at baseline. Interviews revealed striking differences between the groups in terms of leadership styles and shared vision; sense, use, and development of teams; processes for monitoring progress and obtaining feedback; and presence of technologic and financial distractions. CONCLUSIONS Positive deviance analysis suggests that primary care practices’ baseline structural capabilities and abilities to buffer the stresses of change may be key facilitators of performance improvement in medical home transformations. Attention to the practices’ structural capabilities and factors shaping successful change, especially early in the process, will be necessary to improve the likelihood of successful medical home transformation and better care. PMID:23690393

[The need of transforming the health system in Mexico].

PubMed

López-Cervantes, Malaquías; Durán Arenas, Juan Luis; Villanueva Lozano, Marcia

2011-01-01

In this article we review the need for the transformation of the Mexican health care system given the deformities that the system developed in the last 60 years. We start by the discussion of two main deformities: the segmented answer to the health right, and the development of a segmented health care system based on the method of payment (formal workers contributions); and the development of a health care model based on specialties and hospital care. These deformities have resulted in a health care system characterized by high costs and low effectiveness. Even though the correction of the deformities imply complex modifications that involve political economic and legal aspects, in the short term we have the conditions in Mexico for the creation of a universal primary health care system, given the human and financial resources available in the country.

Research and evaluation in the transformation of primary care.

PubMed

Peek, C J; Cohen, Deborah J; deGruy, Frank V

2014-01-01

Across the United States, primary care practices are engaged in demonstration projects and quality improvement efforts aimed at integrating behavioral health and primary care. Efforts to make sustainable changes at the frontline of care have identified new research and evaluation needs. These efforts enable clinics and larger health care communities to learn from demonstration projects regarding what works and what does not when integrating mental health, substance use, and primary care under realistic circumstances. To do this, implementers need to measure their successes and failures to inform local improvement processes, including the efforts of those working on integration in separate but similar settings. We review how new research approaches, beyond the contributions of traditional controlled trials, are needed to inform integrated behavioral health. Illustrating with research examples from the field, we describe how research traditions can be extended to meet these new research and learning needs of frontline implementers. We further suggest that a shared language and set of definitions for the field (not just for a particular study) are critical for the aggregation of knowledge and learning across practices and for policymaking and business modeling.

Arts and health as a practice of liminality: managing the spaces of transformation for social and emotional wellbeing with primary school children.

PubMed

Atkinson, Sarah; Robson, Mary

2012-11-01

Intervention to enhance wellbeing through participation in the creative arts has a transformative potential, but the spatialities to this are poorly theorised. The paper examines arts-based interventions in two primary schools in which small groups of children are taken out of their everyday classrooms to participate in weekly sessions. The paper argues that such intervention is usefully seen as a practice of liminality, a distinct time and space that needs careful management to realise a transformative potential. Such management involves negotiating multiple sources of tension to balance different modes of power, forms of art practices and permeability of the liminal time-space. Copyright © 2012 Elsevier Ltd. All rights reserved.

The Impact of New Payment Models on Quality of Diabetes Care and Outcomes.

PubMed

McGinley, Erin L; Gabbay, Robert A

2016-06-01

Historic changes in healthcare reimbursement and payment models due to the Affordable Care Act in the United States have the potential to transform how providers care for chronic diseases such as diabetes. Payment experimentation has provided insights into how changing incentives for primary care providers can yield improvements in the triple aim: improving patient experience, improving the health of populations, and reducing costs of healthcare. Much of this has involved leveraging widespread adoption of the patient-centered medical home (PCMH) with diabetes often the focus. While evidence is mounting that the PCMH can improve diabetes outcomes, some PCMH demonstrations have displayed mixed results. One of the first large-scale PCMH demonstrations developed around diabetes was conducted by the Commonwealth of Pennsylvania. Different payment models were employed across a series of staggered regional rollouts that provided a case study for the influence of innovative payment models. These learning laboratories provide insights into the role of reimbursement models and changes in how practice transformation is implemented. Ultimately, evolving payment systems focused on the total cost of care, such as Accountable Care Organizations, hold promise to transform diabetes care and produce significant cost savings through the prevention of complications.

Effect of health system reforms in Turkey on user satisfaction

PubMed Central

Stokes, Jonathan; Gurol–Urganci, Ipek; Hone, Thomas; Atun, Rifat

2015-01-01

In 2003, the Turkish government introduced major health system changes, the Health Transformation Programme (HTP), to achieve universal health coverage (UHC). The HTP leveraged changes in all parts of the health system, organization, financing, resource management and service delivery, with a new family medicine model introducing primary care at the heart of the system. This article examines the effect of these health system changes on user satisfaction, a key goal of a responsive health system. Utilizing the results of a nationally representative yearly survey introduced at the baseline of the health system transformation, multivariate logistic regression analysis is used to examine the yearly effect on satisfaction with health services. During the 9–year period analyzed (2004–2012), there was a nearly 20% rise in reported health service use, coinciding with increased access, measured by insurance coverage. Controlling for factors known to contribute to user satisfaction in the literature, there is a significant (P < 0.001) increase in user satisfaction with health services in almost every year (bar 2006) from the baseline measure, with the odds of being satisfied with health services in 2012, 2.56 (95% confidence interval (CI) of 2.01–3.24) times that in 2004, having peaked at 3.58 (95% CI 2.82–4.55) times the baseline odds in 2011. Additionally, those who used public primary care services were slightly, but significantly (P < 0.05) more satisfied than those who used any other services, and increasingly patients are choosing primary care services rather than secondary care services as the provider of first contact. A number of quality indicators can probably help account for the increased satisfaction with public primary care services, and the increase in seeking first–contact with these providers. The implementation of primary care focused UHC as part of the HTP has improved user satisfaction in Turkey. PMID:26528391

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 workforce connections, and role change.

Effect of health system reforms in Turkey on user satisfaction.

PubMed

Stokes, Jonathan; Gurol-Urganci, Ipek; Hone, Thomas; Atun, Rifat

2015-12-01

In 2003, the Turkish government introduced major health system changes, the Health Transformation Programme (HTP), to achieve universal health coverage (UHC). The HTP leveraged changes in all parts of the health system, organization, financing, resource management and service delivery, with a new family medicine model introducing primary care at the heart of the system. This article examines the effect of these health system changes on user satisfaction, a key goal of a responsive health system. Utilizing the results of a nationally representative yearly survey introduced at the baseline of the health system transformation, multivariate logistic regression analysis is used to examine the yearly effect on satisfaction with health services. During the 9-year period analyzed (2004-2012), there was a nearly 20% rise in reported health service use, coinciding with increased access, measured by insurance coverage. Controlling for factors known to contribute to user satisfaction in the literature, there is a significant (P < 0.001) increase in user satisfaction with health services in almost every year (bar 2006) from the baseline measure, with the odds of being satisfied with health services in 2012, 2.56 (95% confidence interval (CI) of 2.01-3.24) times that in 2004, having peaked at 3.58 (95% CI 2.82-4.55) times the baseline odds in 2011. Additionally, those who used public primary care services were slightly, but significantly (P < 0.05) more satisfied than those who used any other services, and increasingly patients are choosing primary care services rather than secondary care services as the provider of first contact. A number of quality indicators can probably help account for the increased satisfaction with public primary care services, and the increase in seeking first-contact with these providers. The implementation of primary care focused UHC as part of the HTP has improved user satisfaction in Turkey.

Behavioral Health and the Comprehensive Primary Care (CPC) Initiative: findings from the 2014 CPC behavioral health survey.

PubMed

Zivin, Kara; Miller, Benjamin F; Finke, Bruce; Bitton, Asaf; Payne, Perry; Stowe, Edith C; Reddy, Ashok; Day, Timothy J; Lapin, Pauline; Jin, Janel L; Sessums, Laura L

2017-08-29

Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation. We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores. One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers. This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.

Engaging patients in primary care practice transformation: theory, evidence and practice.

PubMed

Sharma, Anjana E; Grumbach, Kevin

2017-06-01

Patient engagement is a fundamental strategy for achieving patient centred care and is receiving increasing attention in primary care reform efforts such as the patient-centred medical home and related care models. Much of the prior published theory and evidence supporting patient engagement has focused on improving engagement in individual care. Much less is understood about engaging patients as partners in practice improvement at the primary care clinic or practice level. We review the historical and policy context for the growing interest in the USA and UK in patient engagement at the primary care practice level, highlight findings from systematic reviews of the research evidence on practice-level patient engagement and discuss practical considerations for implementing patient engagement. We conclude that while there are persuasive ethical and social justice reasons for empowering patient involvement in practice improvement at the clinic level, research conducted to date in primary care provides suggestive but not yet resounding evidence in support of the instrumental triple aim benefit of practice-level patient engagement. We propose a research agenda to better understand the process and outcomes of practice-level patient engagement and its potential advantages to both the practice and the patients and communities served. Better evidence as well as resources to support and incentivize effective and feasible engagement methods are needed to catalyse greater diffusion of practice-level patient engagement in primary care practices. © The Author 2016. Published by Oxford University Press.

RISQy business (Relationships, Incentives, Supports, and Quality): evolution of the British Columbia Model of Primary Care (patient-centered medical home).

PubMed

MacCarthy, Dan; Hollander, Marcus J

2014-01-01

In 2002, the British Columbia Ministry of Health and the British Columbia Medical Association (now Doctors of BC) came together to form the British Columbia General Practice Services Committee to bring about transformative change in primary care in British Columbia, Canada. This committee's approach to primary care was to respond to an operational problem--the decline of family practice in British Columbia--with an operational solution--assist general practitioners to provide better care by introducing new incentive fees into the fee-for-service payment schedule, and by providing additional training to general practitioners. This may be referred to as a "soft power" approach, which can be summarized in the abbreviation RISQ: focus on Relationships; provide Incentives for general practitioners to spend more time with their patients and provide guidelines-based care; Support general practitioners by developing learning modules to improve their practices; and, through the incentive payments and learning modules, provide better Quality care to patients and improved satisfaction to physicians. There are many similarities between the British Columbian approach to primary care and the US patient-centered medical home.

High Levels Of Capitation Payments Needed To Shift Primary Care Toward Proactive Team And Nonvisit Care.

PubMed

Basu, Sanjay; Phillips, Russell S; Song, Zirui; Bitton, Asaf; Landon, Bruce E

2017-09-01

Capitated payments in the form of fixed monthly payments to cover all of the costs associated with delivering primary care could encourage primary care practices to transform the way they deliver care. Using a microsimulation model incorporating data from 969 US practices, we sought to understand whether shifting to team- and non-visit-based care is financially sustainable for practices under traditional fee-for-service, capitated payment, or a mix of the two. Practice revenues and costs were computed for fee-for-service payments and a range of capitated payments, before and after the substitution of team- and non-visit-based services for low-complexity in-person physician visits. The substitution produced financial losses for simulated practices under fee-for-service payment of $42,398 per full-time-equivalent physician per year; however, substitution produced financial gains under capitated payment in 95 percent of cases, if more than 63 percent of annual payments were capitated. Shifting to capitated payment might create an incentive for practices to increase their delivery of team- and non-visit-based primary care, if capitated payment levels were sufficiently high. Project HOPE—The People-to-People Health Foundation, Inc.

Adaptation of neurological practice and policy to a changing US health-care landscape.

PubMed

Gorelick, Philip B

2016-04-01

Health care in the USA is undergoing a drastic transformation under the Patient Protection and Affordable Care Act. The Patient Protection and Affordable Care Act is driving major health-care policy changes by connecting payment for traditional health-care services to value-based care initiatives and emphasising population health and innovative mechanisms to deliver care. Under the Patient Protection and Affordable Care Act, neurological practice will need to adapt and transform. Therefore, neurological policy should consider employing a new framework for neurological residency training, developing interdisciplinary team approaches to neurological subspecialty care, and strengthening the primary care-neurological specialty care interface to avoid redundancies and other medical waste. Additionally, neurological policy will need to support a more robust review of diagnostic and care pathway use to reduce avoidable expenditures, and test and implement bundled payments for key neurological diagnoses. In view of an anticipated 19% shortage of US neurologists in the next 10 years, development of new neurological policy under the Patient Protection and Affordable Care Act is paramount. Copyright © 2016 Elsevier Ltd. All rights reserved.

Creating collaborative learning environments for transforming primary care practices now.

PubMed

Miller, William L; Cohen-Katz, Joanne

2010-12-01

The renewal of primary care waits just ahead. The patient-centered medical home (PCMH) movement and a refreshing breeze of collaboration signal its arrival with demonstration projects and pilots appearing across the country. An early message from this work suggests that the development of collaborative, cross-disciplinary teams may be essential for the success of the PCMH. Our focus in this article is on training existing health care professionals toward being thriving members of this transformed clinical care team in a relationship-centered PCMH. Our description of the optimal conditions for collaborative training begins with delineating three types of teams and how they relate to levels of collaboration. We then describe how to create a supportive, safe learning environment for this type of training, using a different model of professional socialization, and tools for building culture. Critical skills related to practice development and the cross-disciplinary collaborative processes are also included. Despite significant obstacles in readying current clinicians to be members of thriving collaborative teams, a few next steps toward implementing collaborative training programs for existing professionals are possible using competency-based and adult learning approaches. Grasping the long awaited arrival of collaborative primary health care will also require delivery system and payment reform. Until that happens, there is an abundance of work to be done envisioning new collaborative training programs and initiating a nation-wide effort to motivate and reeducate our colleagues. PsycINFO Database Record (c) 2010 APA, all rights reserved.

Practice Environments and Job Satisfaction in Patient-Centered Medical Homes

PubMed Central

Alidina, Shehnaz; Rosenthal, Meredith B.; Schneider, Eric C.; Singer, Sara J.; Friedberg, Mark W.

2014-01-01

PURPOSE We undertook a study to evaluate the effects of medical home transformation on job satisfaction in the primary care setting. METHODS We collected primary data from 20 primary care practices participating in medical home pilot projects in Rhode Island and Colorado from 2009 to 2011. We surveyed clinicians and staff about the quality of their practice environments (eg, office chaos, communication, difficulties in providing safe, high-quality care) and job satisfaction at baseline and 30 months, and about stress, burnout, and intention to leave at 30 months. We interviewed practice leaders about the impact of pilot project participation. We assessed longitudinal changes in the practice environment and job satisfaction and, in the final pilot year, examined cross-sectional associations between the practice environment and job satisfaction, stress, burnout, and intention to leave. RESULTS Between baseline and 30 months, job satisfaction improved in Rhode Island (P =.03) but not in Colorado. For both pilot projects, reported difficulties in providing safe, high-quality care decreased (P <.001), but emphasis on quality and the level of office chaos did not change significantly. In cross-sectional analyses, fewer difficulties in providing safe, high-quality care and more open communication were associated with greater job satisfaction. Greater office chaos and an emphasis on electronic information were associated with greater stress and burnout. CONCLUSIONS Medical home transformations that emphasize quality and open communication while minimizing office chaos may offer the best chances of improving job satisfaction. PMID:25024241

An evaluation of experiences and views of Scottish leadership training opportunities amongst primary care professionals.

PubMed

Power, Ailsa; Allbutt, Helen; Munro, Lucy; MacLeod, Marion; Kennedy, Susan; Cameron, Donald; Scoular, Ken; Orr, Graham; Gillies, John

2017-05-01

To determine experiences of leadership training of six primary care professions in Scotland and consider future development. A questionnaire on previous leadership course attendance and future intentions was distributed to community pharmacists, general dental practitioners, general practitioners, practice nurses, practice managers and optometrists. Analysis comprised descriptive statistics for closed questions and management of textual data. Formal leadership training participation was fairly low except for practice managers. Leadership was perceived to facilitate development of staff, problem-solving and team working. Preference for future delivery was similar across the six professions with e-modules and small group learning being preferred. Time and financial pressures to undertake courses were common barriers for professionals. Leadership is key to improve quality, safety and efficiency of care and help deliver innovative services and transformative change. To date, leadership provision for primary care professionals has typically been patchy, uni-disciplinary in focus and undertaken outwith work environments. Future development must reflect needs of busy primary care professionals and the reality of team working to deliver integrated services at local level.

The Patient-Centered Medical Home: Preparation of the Workforce, More Questions than Answers.

PubMed

Reynolds, P Preston; Klink, Kathleen; Gilman, Stuart; Green, Larry A; Phillips, Russell S; Shipman, Scott; Keahey, David; Rugen, Kathryn; Davis, Molly

2015-07-01

As American medicine continues to undergo significant transformation, the patient-centered medical home (PCMH) is emerging as an interprofessional primary care model designed to deliver the right care for patients, by the right professional, at the right time, in the right setting, for the right cost. A review of local, state, regional and national initiatives to train professionals in delivering care within the PCMH model reveals some successes, but substantial challenges. Workforce policy recommendations designed to improve PCMH effectiveness and efficiency include 1) adoption of an expanded definition of primary care, 2) fundamental redesign of health professions education, 3) payment reform, 4) responsiveness to local needs assessments, and 5) systems improvement to emphasize quality, population health, and health disparities.

Transitioning From Volume to Value: One Academic Medical Center's Approach to Improving Population Health.

PubMed

Halvorson, Stephanie A C; Tanski, Mary E; Yackel, Thomas R

2017-05-01

The U.S. health care system is undergoing a major transformation. Clinical delivery systems are now being paid according to the value of the care they provide, in accordance with the Triple Aim, which incorporates improving the quality and cost of care and the patient experience. Increasingly, financial risk is being transferred from insurers to clinical delivery systems that become responsible for both episode-based clinical care and the longitudinal care of patients. Thus, these delivery systems need to develop strategies to manage the health of populations. Academic medical centers (AMCs) serve a unique role in many markets yet may be ill prepared for this transformation. In 2013, Oregon Health & Science University (OHSU) partnered with a large health insurer and six other hospitals across the state to form Propel Health, a collaborative partnership designed to deliver the tools, methods, and support necessary for population health management. OHSU also developed new internal structures and transformed its business model to embrace this value-based care model. Each Propel Health partner included the employees and dependents enrolled in its employee medical plan, for approximately 55,000 covered individuals initially. By 2017, Propel Health is expected to cover 110,000 individuals. Other outcomes to measure in the future include the quality and cost of care provided under this partnership. Anticipated challenges to overcome include insufficient primary care networks, conflicting incentives, local competition, and the magnitude of the transformation. Still, the time is right for AMCs to commit to improving the health of populations.

Results of the 2017 National Resident Matching Program® and the American Osteopathic Association Intern/Resident Registration Program.

PubMed

Kozakowski, Stanley M; Travis, Alexandra; Marcinek, Julie P; Bentley, Ashley; Fetter, Gerald T

2017-10-01

The purpose of medicine as a profession is to meet the health needs of people and communities. Despite empirical evidence worldwide that an appropriate foundation of primary care in a health care system leads to improved health outcomes, improved experience of health care, a reduction in health disparities, and lower overall cost of care, publicly available data from National Resident Matching Program® (NRMP) and the American Osteopathic Association (AOA) Intern/Resident Registration Program show that PGY-1 family medicine and primary care positions offered in the NRMP Match continue to grow, but are losing ground in comparison to the growth of non-primary care specialties. In ACGME-accredited family medicine programs, DO students have been displacing non-US citizen IMGs while the proportion of US seniors has remained stable over the past decade. The impact of the displacement of non-US citizen IMGs by DO students in ACGME programs is unknown and deserves future research. Continuing trends in the growth of non-primary care specialties should raise great concern that the current primary shortage will be exacerbated, not serving the needs of the population. A major overhaul of the graduate medical education (GME) system is required to align the medical education system with the transformation of the health care system needed to improve quality, population health, and cost control.

[Technical efficiency assessment of public primary care providers in the Basque Country (Spain), 2010-2013].

PubMed

Cordero, José Manuel; Nuño-Solinís, Roberto; Orueta, Juan F; Polo, Cristina; Del Río-Cámara, Mario; Alonso-Morán, Edurne

2016-01-01

To evaluate the technical efficiency of primary care units operating in the Basque Health Service during the period 2010-2013, corresponding to the implementation of a care integration strategy by health authorities. This study included 11 of the 12 primary care units in the Basque Health Service during the period 2010-2013. Data envelopment analysis (DEA) was used to assess the technical efficiency of the units. In particular, we applied the extension DEA windows to analyse all units as if they were in a single period (33 observations) as well as a conditional model, which allowed incorporation of the effect of the characteristics of the population covered. The outputs considered were a quality index based on fulfilment of different requirements related to primary care delivery and the rate of avoidable hospitalizations (treated as an undesirable output). The inputs used were the number of physicians, the number of nurses and the costs of prescriptions. The morbidity index was included as an exogenous variable. The results showed that the efficiency of all the units improved during the study period. However, this improvement was not greater in the units incorporated in the integrated healthcare organisation. In a context of global transformation of care delivery in the Basque country in the study period, primary care units increased their efficiency. However, this effect was not larger in vertically integrated primary care providers. Copyright © 2015 SESPAS. Published by Elsevier Espana. All rights reserved.

A national evaluation of a dissemination and implementation initiative to enhance primary care practice capacity and improve cardiovascular disease care: the ESCALATES study protocol.

PubMed

Cohen, Deborah J; Balasubramanian, Bijal A; Gordon, Leah; Marino, Miguel; Ono, Sarah; Solberg, Leif I; Crabtree, Benjamin F; Stange, Kurt C; Davis, Melinda; Miller, William L; Damschroder, Laura J; McConnell, K John; Creswell, John

2016-06-29

The Agency for Healthcare Research and Quality (AHRQ) launched the EvidenceNOW Initiative to rapidly disseminate and implement evidence-based cardiovascular disease (CVD) preventive care in smaller primary care practices. AHRQ funded eight grantees (seven regional Cooperatives and one independent national evaluation) to participate in EvidenceNOW. The national evaluation examines quality improvement efforts and outcomes for more than 1500 small primary care practices (restricted to those with fewer than ten physicians per clinic). Examples of external support include practice facilitation, expert consultation, performance feedback, and educational materials and activities. This paper describes the study protocol for the EvidenceNOW national evaluation, which is called Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES). This prospective observational study will examine the portfolio of EvidenceNOW Cooperatives using both qualitative and quantitative data. Qualitative data include: online implementation diaries, observation and interviews at Cooperatives and practices, and systematic assessment of context from the perspective of Cooperative team members. Quantitative data include: practice-level performance on clinical quality measures (aspirin prescribing, blood pressure and cholesterol control, and smoking cessation; ABCS) collected by Cooperatives from electronic health records (EHRs); practice and practice member surveys to assess practice capacity and other organizational and structural characteristics; and systematic tracking of intervention delivery. Quantitative, qualitative, and mixed methods analyses will be conducted to examine how Cooperatives organize to provide external support to practices, to compare effectiveness of the dissemination and implementation approaches they implement, and to examine how regional variations and other organization and contextual factors influence implementation and effectiveness. ESCALATES is a national evaluation of an ambitious large-scale dissemination and implementation effort focused on transforming smaller primary care practices. Insights will help to inform the design of national health care practice extension systems aimed at supporting practice transformation efforts in the USA. NCT02560428 (09/21/15).

Stakeholders' Recommendations to Improve Patient-centered "LGBTQ" Primary Care in Rural and Multicultural Practices.

PubMed

Kano, Miria; Silva-Bañuelos, Alma Rosa; Sturm, Robert; Willging, Cathleen E

2016-01-01

Individuals among gender/sexual minorities share experiences of stigma and discrimination, yet have distinctive health care needs influenced by ethnic/racial minority and rural realities. We collected qualitative data from lesbian/gay/bisexual/transgender (LGBT) and queer persons across the largely rural, multicultural state of New Mexico, particularly those from understudied ethnic groups, regarding factors facilitating or impeding patient-centered primary care. The themes identified formed the basis for a statewide summit on LGBT health care guidelines and strategies for decreasing treatment gaps. Three to 15 individuals, ages 18 to 75 years, volunteered for 1 of 4 town hall dialogues (n = 32), and 175 people took part in the summit. Participants acknowledged health care gaps pertinent to LGBT youth, elders, American Indians, and Latinos/Latinas, expressing specific concern for rural residents. This preliminary research emphasizes the need to improve primary care practices that treat rural and ethnic-minority LGBT people and offers patient-driven recommendations to enhance care delivery while clinic-level transformations are implemented. © Copyright 2016 by the American Board of Family Medicine.

Patient-Centered Medical Home Exposure and Its Impact on PA Career Intentions.

PubMed

Kayingo, Gerald; Gilani, Owais; Kidd, Vasco Deon; Warner, Mary L

2016-10-01

The transformation of primary care (PC) training sites into patient-centered medical homes (PCMH) has implications for the education of health professionals. This study investigates the extent to which physician assistant (PA) students report learning about the PCMH model and how clinical exposure to PCMH might impact their interest in a primary care career. An electronic survey was distributed to second-year PA students who had recently completed their PC rotation from 12 PA programs. Descriptive statistics and ordered logistic regression analyses were used to characterize the results. A total of 202 second-year PA students completed the survey. When asked about their knowledge of the new health care delivery models, 30% of the students responded they had received instruction about the PCMH. Twenty- five percent of respondents stated they were oriented to new payment structures proposed in the Affordable Care Act and quality improvement principles. Based on their experiences in the primary care clerkship, 64% stated they were likely to pursue a career in primary care, 13% were not likely, and 23% were unsure. Predictors of interest in a primary care career included: (1) age greater than 35 years, (2) being a recipient of a NHSC scholarship, (3) clerkship site setting in an urban cluster of 2,500 to 50,000 people, (4) number of PCMH elements offered at site, and (4) positive impression of team-based care. PA students lack adequate instruction related to the new health care delivery models. Students whose clerkship sites offered greater number of PCMH elements were more interested in pursuing a career in primary care.

Informing mental health policies and services in the EMR: cost-effective deployment of human resources to deliver integrated community-based care.

PubMed

Ivbijaro, G; Patel, V; Chisholm, D; Goldberg, D; Khoja, T A M; Edwards, T M; Enum, Y; Kolkiewic, L A

2015-09-28

For EMR countries to deliver the expectations of the Global Mental Health Action Plan 2013-2020 & the ongoing move towards universal health coverage, all health & social care providers need to innovate and transform their services to provide evidence-based health care that is accessible, cost-effective & with the best patient outcomes. For the primary and community workforce, this includes general medical practitioners, practice & community nurses, community social workers, housing officers, lay health workers, nongovernmental organizations & civil society, including community spiritual leaders/healers. This paper brings together the current best evidence to support transformation & discusses key approaches to achieve this, including skill mix and/or task shifting and integrated care. The important factors that need to be in place to support skill mix/task shifting and good integrated care are outlined with reference to EMR countries.

Bench, Bedside, Curbside, and Home: Translational Research to Include Transformative Change Using Educational Research

ERIC Educational Resources Information Center

Felege, Christopher; Hahn, Emily; Hunter, Cheryl

2016-01-01

Translational research originated in the medical field during the 1990s to describe taking discovery based research through the steps of applying it to clinical research and patient-oriented care. This model is implicitly linear, depicting the flow of information from researchers' bench, to a clinical trial bedside, to a primary care physician's…

Patients' experiences of using a smartphone application to increase physical activity: the SMART MOVE qualitative study in primary care.

PubMed

Casey, Monica; Hayes, Patrick S; Glynn, Fergus; OLaighin, Gearóid; Heaney, David; Murphy, Andrew W; Glynn, Liam G

2014-08-01

Regular physical activity is known to help prevent and treat numerous non-communicable diseases. Smartphone applications (apps) have been shown to increase physical activity in primary care but little is known regarding the views of patients using such technology or how such technology may change behaviour. To explore patients' views and experiences of using smartphones to promote physical activity in primary care. This qualitative study was embedded within the SMART MOVE randomised controlled trial, which used an app (Accupedo-Pro Pedometer) to promote physical activity in three primary care centres in the west of Ireland. Taped and transcribed semi-structured interviews with a purposeful sample of 12 participants formed the basis of the investigation. Framework analysis was used to analyse the data. Four themes emerged from the analysis: transforming relationships with exercise; persuasive technology tools; usability; and the cascade effect. The app appeared to facilitate a sequential and synergistic process of positive change, which occurred in the relationship between the participants and their exercise behaviour; the study has termed this the 'Know-Check-Move' effect. Usability challenges included increased battery consumption and adjusting to carrying the smartphone on their person. There was also evidence of a cascade effect involving the families and communities of participants. Notwithstanding technological challenges, an app has the potential to positively transform, in a unique way, participants' relationships with exercise. Such interventions can also have an associated cascade effect within their wider families and communities. © British Journal of General Practice 2014.

Patients’ experiences of using a smartphone application to increase physical activity: the SMART MOVE qualitative study in primary care

PubMed Central

Casey, Monica; Hayes, Patrick S; Glynn, Fergus; ÓLaighin, Gearóid; Heaney, David; Murphy, Andrew W; Glynn, Liam G

2014-01-01

Background Regular physical activity is known to help prevent and treat numerous non-communicable diseases. Smartphone applications (apps) have been shown to increase physical activity in primary care but little is known regarding the views of patients using such technology or how such technology may change behaviour. Aim To explore patients’ views and experiences of using smartphones to promote physical activity in primary care. Design and setting This qualitative study was embedded within the SMART MOVE randomised controlled trial, which used an app (Accupedo-Pro Pedometer) to promote physical activity in three primary care centres in the west of Ireland. Method Taped and transcribed semi-structured interviews with a purposeful sample of 12 participants formed the basis of the investigation. Framework analysis was used to analyse the data. Results Four themes emerged from the analysis: transforming relationships with exercise; persuasive technology tools; usability; and the cascade effect. The app appeared to facilitate a sequential and synergistic process of positive change, which occurred in the relationship between the participants and their exercise behaviour; the study has termed this the ‘Know-Check-Move’ effect. Usability challenges included increased battery consumption and adjusting to carrying the smartphone on their person. There was also evidence of a cascade effect involving the families and communities of participants. Conclusion Notwithstanding technological challenges, an app has the potential to positively transform, in a unique way, participants’ relationships with exercise. Such interventions can also have an associated cascade effect within their wider families and communities. PMID:25071063

Stroke rehabilitation in ontario: an opportunity for health care transformation.

PubMed

Meyer, Matthew J; Meyer, John P; Foley, Norine; Salter, Katherine; McClure, J Andrew; Teasell, Robert

2011-11-01

In this article, Ontario's stroke rehabilitation system is used to exemplify the challenges faced by rehabilitation and healthcare systems across Canada who are attempting to provide quality care to patients in the face of increasing demands. Currently, Ontario's rehabilitation system struggles in its efforts to provide accessible and comprehensive care to patients recovering from stroke. We begin our exploration by identifying both the primary stakeholders and the underlying factors that have contributed to the current challenges. The framework put forward in the Canadian Medical Association's recommendations for transformation is then used to suggest a vision for a more patient-focused system incorporating three key principles: a broader perspective, a patient-first approach, and greater unity. The use of health information technology, proper incentives, and greater accountability are discussed as mechanisms to improve the quality and efficiency of care.

Going "all in" to transform the Tulsa community's health and health care workforce.

PubMed

Clancy, Gerard P; Duffy, F Daniel

2013-12-01

Oklahoma's health status ranks among the lowest of the states', yet many Oklahomans oppose the best-known aspects of federal health reform legislation. To address this situation, the University of Oklahoma College of Medicine's School of Community Medicine in Tulsa adopted an "all-in," fully committed approach to transform the Tulsa region's health care delivery system and health care workforce teaching environment by leading community-wide initiatives that took advantage of lesser-known health reform provisions. Medical school leaders shared a vision of improved health for the region with a focus on equity in care for underserved populations. They engaged Tulsa stakeholders to implement health system changes to improve care access, quality, and efficiency. A partnership between payers, providers, and health systems transformed primary care practices into patient-centered medical homes (PCMHs) and instituted both community-wide care coordination and a regional health information exchange. To emphasize the importance of these new approaches to improving the health of an entire community, the medical school began to transform the teaching environment by adding several interdependent experiences. These included an annual interdisciplinary summer institute in which students and faculty from across the university could explore firsthand the social determinants of health as well as student-run PCMH clinics for the uninsured to teach systems-based practice, team-based learning, and health system improvement. The authors share lessons learned from these collaborations. They conclude that working across competitive boundaries and going all in are necessary to improve the health of a community.

The Health IT Regional Extension Center Program: evolution and lessons for health care transformation.

PubMed

Lynch, Kimberly; Kendall, Mat; Shanks, Katherine; Haque, Ahmed; Jones, Emily; Wanis, Maggie G; Furukawa, Michael; Mostashari, Farzad

2014-02-01

Assess the Regional Extension Center (REC) program's progress toward its goal of supporting over 100,000 providers in small, rural, and underserved practices to achieve meaningful use (MU) of an electronic health record (EHR). Data collected January 2010 through June 2013 via monitoring and evaluation of the 4-year REC program. Descriptive study of 62 REC programs. Primary data collected from RECs were merged with nine other datasets, and descriptive statistics of progress by practice setting and penetration of targeted providers were calculated. RECs recruited almost 134,000 primary care providers (PCPs), or 44 percent of the nation's PCPs; 86 percent of these were using an EHR with advanced functionality and almost half (48 percent) have demonstrated MU. Eighty-three percent of Federally Qualified Health Centers and 78 percent of the nation's Critical Access Hospitals were participating with an REC. RECs have made substantial progress in assisting PCPs with adoption and MU of EHRs. This infrastructure supports small practices, community health centers, and rural and public hospitals to use technology for care delivery transformation and improvement. © Health Research and Educational Trust.

A Focused Ethnography of Baccalaureate Nursing Students Who Are Using Motivational Interviewing.

PubMed

Howard, Lisa M; Williams, Beverly A

2016-09-01

The purpose of this article is to describe how nursing students learned and used motivational interviewing (MI) in a community-based clinical context at a primary care vascular risk reduction clinic focused on health promotion. A focused ethnography was used to access a sample of 20 undergraduate nursing students, 16 patients, and 2 instructors. Data were generated from participant observations, field notes, student journals, and interviews (one-on-one and focus group). Central to the students' experience was their transformation because of learning and using MI. Three sub themes describe the social processes that shaped the student experience: learning a relational skill, engaging patients, and collaborating as partners. It is feasible for nursing students to learn MI and use this approach to enhance collaborative care in a primary care setting. The experience can be transformative for students. Supporting patients to adopt healthy lifestyles is a significant role for nurses in practice. The findings provide key insights and strategies for nurse educators teaching students a collaborative communication approach, such as MI, to engage patients in health behavior change. © 2016 Sigma Theta Tau International.

The Transformation Process in Nurses Caring for Dying Patients.

PubMed

Huang, Ching-Chi; Chen, Jih-Yuan; Chiang, Hsien-Hsien

2016-06-01

Despite the recent increase in attention to end-of-life hospice care, little empirical evidence regarding the process of emotional or mental transformation in caregivers is available. This study explores the transformative process that occurs in nurses because of the spiritual suffering and conflict associated with after caring for dying patients. A phenomenological approach was used to investigate eight nurses (27-40 years old) working in the hospice ward of a medical center in Taipei. Data were collected through open-ended questions using semistructured interviews and were analyzed reflectively. A three-stage transformation in the emotional processes of participants was observed. In the first stage, the participants experienced acute emotional suffering because of facing the death of their patients, potentially exacerbated by their own memories of losing family members. In the second stage, the participants adopted coping strategies to improve self-care. These strategies included attempting to soothe patients, helping patients face or deal with unfulfilled business, and participating in funeral or memorial services. In the third stage, the participants learned to provide better care through emancipatory reflection and a reassertion of responsibilities toward the self, patients, and patient families. After the third stage, the initial emotional impact morphed into a medium for self-strengthening, and participants became more adept at detecting patient needs and at providing care to complete the transformational process fully. Emotional suffering was the primary factor that induced participants to transform their personal and professional selves. Adequate emotional self-management, dialogue with other nurses, and personal reflection are crucial actions that nurses may use to cultivate personal growth, implement ethical practice, interact with other nurses, and engage in personal reflection. Strategies such as caring for patients, implementing reflective nursing practices, focusing on patient needs, and utilizing past experiences enable nurses to develop a heightened sense of responsibility and awareness, thus empowering them to take better care of themselves and their patients.

Principles of strengths-based nursing leadership for strengths-based nursing care: a new paradigm for nursing and healthcare for the 21st century.

PubMed

Gottlieb, Laurie N; Gottlieb, Bruce; Shamian, Judith

2012-06-01

The current healthcare system is slowly evolving into a new system built on a vision of health promotion, primary care and community-based home care, with hospitals still being a core pillar of the healthcare system but not its primary service. This transformation requires a new approach to practice, namely, Strengths-Based Nursing Care (SBC). SBC is about mobilizing, capitalizing and developing a person's strengths to promote health and facilitate healing. For nurses to practise SBNC requires strong nursing leadership that creates conditions to enable them to do so. Strengths-Based Nursing Leadership complements and acts in synergy with, SBNC. This paper describes eight principles of Strengths-Based Nursing Leadership to support SBNC.

The cost-effectiveness of screening for oral cancer in primary care.

PubMed

Speight, P M; Palmer, S; Moles, D R; Downer, M C; Smith, D H; Henriksson, M; Augustovski, F

2006-04-01

To use a decision-analytic model to determine the incremental costs and outcomes of alternative oral cancer screening programmes conducted in a primary care environment. The cost-effectiveness of oral cancer screening programmes in a number of primary care environments was simulated using a decision analysis model. Primary data on actual resource use and costs were collected by case note review in two hospitals. Additional data needed to inform the model were obtained from published costs, from systematic reviews and by expert opinion using the Trial Roulette approach. The value of future research was determined using expected value of perfect information (EVPI) for the decision to screen and for each of the model inputs. Hypothetical screening programmes conducted in a number of primary care settings. Eight strategies were compared: (A) no screen; (B) invitational screen--general medical practice; (C) invitational screen--general dental practice; (D) opportunistic screen--general medical practice; (E) opportunistic screen--general dental practice; (F) opportunistic high-risk screen--general medical practice; (G) opportunistic high-risk screen--general dental practice; and (H) invitational screen--specialist. A hypothetical population over the age of 40 years was studied. The main measures were mean lifetime costs and quality-adjusted life-years (QALYs) of each alternative screening scenario and incremental cost-effectiveness ratios (ICERs) to determine the additional costs and benefits of each strategy over another. No screening (strategy A) was always the cheapest option. Strategies B, C, E and H were never cost-effective and were ruled out by dominance or extended dominance. Of the remaining strategies, the ICER for the whole population (age 49-79 years) ranged from pound 15,790 to pound 25,961 per QALY. Modelling a 20% reduction in disease progression always gave the lowest ICERs. Cost-effectiveness acceptability curves showed that there is considerable uncertainty in the optimal decision identified by the ICER, depending on both the maximum amount that the NHS may be prepared to pay and the impact that treatment has on the annual malignancy transformation rate. Overall, however, high-risk opportunistic screening by a general dental or medical practitioner (strategies F and G) may be cost-effective. EVPIs were high for all parameters with population values ranging from pound 8 million to pound 462 million. However, the values were significantly higher in males than females but also varied depending on malignant transformation rate, effects of treatment and willingness to pay. Partial EVPIs showed the highest values for malignant transformation rate, disease progression, self-referral and costs of cancer treatment. Opportunistic high-risk screening, particularly in general dental practice, may be cost-effective. This screening may more effectively be targeted to younger age groups, particularly 40-60 year olds. However, there is considerable uncertainty in the parameters used in the model, particularly malignant transformation rate, disease progression, patterns of self-referral and costs. Further study is needed on malignant transformation rates of oral potentially malignant lesions and to determine the outcome of treatment of oral potentially malignant lesions. Evidence has been published to suggest that intervention has no greater benefit than 'watch and wait'. Hence a properly planned randomised controlled trial may be justified. Research is also needed into the rates of progression of oral cancer and on referral pathways from primary to secondary care and their effects on delay and stage of presentation.

Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home

PubMed Central

Bleser, William K.; Miller-Day, Michelle; Naughton, Dana; Bricker, Patricia L.; Cronholm, Peter F.; Gabbay, Robert A.

2014-01-01

PURPOSE The current model of primary care in the United States limits physicians’ ability to offer high-quality care. The patient-centered medical home (PCMH) shows promise in addressing provision of high-quality care, but achieving a PCMH practice model often requires comprehensive organizational change. Guided by Solberg’s conceptual framework for practice improvement, which argues for shared prioritization of improvement and change, we describe strategies for obtaining organizational buy-in to and whole-staff engagement of PCMH transformation and practice improvement. METHODS Semistructured interviews with 136 individuals and 7 focus groups involving 48 individuals were conducted in 20 small- to mid-sized medical practices in Pennsylvania during the first regional rollout of a statewide PCMH initiative. For this study, we analyzed interview transcripts, monthly narrative reports, and observer notes from site visits to identify discourse pertaining to organizational buy-in and strategies for securing buy-in from personnel. Using a consensual qualitative research approach, data were reduced, synthesized, and managed using qualitative data management and analysis software. RESULTS We identified 13 distinct strategies used to obtain practice buy-in, reflecting 3 overarching lessons that facilitate practice buy-in: (1) effective communication and internal PCMH campaigns, (2) effective resource utilization, and (3) creation of a team environment. CONCLUSION Our study provides a list of strategies useful for facilitating PCMH transformation in primary care. These strategies can be investigated empirically in future research, used to guide medical practices undergoing or considering PCMH transformation, and used to inform health care policy makers. Our study findings also extend Solberg’s conceptual framework for practice improvement to include buy-in as a necessary condition across all elements of the change process. PMID:24445102

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.

The strategic nature of individual change behavior: How physicians and their staff implement medical home care.

PubMed

Hoff, Timothy; Scott, Sarah

The patient-centered medical home (PCMH) model of care is central to primary care system success and transformation. Less is known about which PCMH activities primary care workers most frequently perform, if or why they might view that work more favorably, and how such work may function strategically to advance individual and organizational adaptation to new demands, as well as deliver good patient care. Understanding better how primary care physicians and staff perceive, experience, and use certain types of PCMH work for adapting to new demands looms a key imperative for gaining insights into PCMH implementation at the workplace level. Using a worker adaptation perspective that emphasizes the role of social learning and individual agency, this study explores the strategic nature of PCMH implementation through 51 in-depth interviews with physicians and staff in six accredited PCMHs. Select medical home activities were identified, in which primary care physicians and staff most engaged on a daily basis, and they fell into five distinct PCMH work domains labeled team care, medical home responsibilities, care management, access, and medication management. These activities had common features such as high levels of familiarity, simplicity, and camaraderie. In addition, through their experiences performing these activities, physicians and staff appeared to gain strategic benefits for themselves and the larger organization including enhanced self-efficacy and readiness for change. The findings show that particular forms of PCMH work not only advance patient care in favorable ways but also enhance individual and organizational capacity for adapting to this innovative model and its demands. This knowledge adds to our understanding of how to implement PCMH care in ways that are good for workers, primary care organizations, and patients and offers practical guidance as to which forms of PCMH work should be encouraged, incented, and rewarded.

Process and Outcomes of Patient-Centered Medical Care With Alaska Native People at Southcentral Foundation

PubMed Central

Driscoll, David L.; Hiratsuka, Vanessa; Johnston, Janet M.; Norman, Sara; Reilly, Katie M.; Shaw, Jennifer; Smith, Julia; Szafran, Quenna N.; Dillard, Denise

2013-01-01

PURPOSE This study describes key elements of the transition to a patient-centered medical home (PCMH) model at Southcentral Foundation (SCF), a tribally owned and managed primary care system, and evaluates changes in emergency care use for any reason, for asthma, and for unintentional injuries, during and after the transition. METHODS We conducted a time series analyses of emergency care use from medical record data. We also conducted 45 individual, in-depth interviews with PCMH patients (customer-owners), primary care clinicians, health system employees, and tribal leaders. RESULTS Emergency care use for all causes was increasing before the PCMH implementation, dropped during and immediately after the implementation, and subsequently leveled off. Emergency care use for adult asthma dropped before, during, and immediately after implementation, subsequently leveling off approximately 5 years after implementation. Emergency care use for unintentional injuries, a comparison variable, showed an increasing trend before and during implementation and decreasing trends after implementation. Interview participants observed improved access to primary care services after the transition to the PCMH tempered by increased staff fatigue. Additional themes of PCMH transformation included the building of relationships for coordinated, team-based care, and the important role of leadership in PCMH implementation. CONCLUSIONS All reported measures of emergency care use show a decreasing trend after the PCMH implementation. Before the implementation, overall use and use for unintentional injuries had been increasing. The combined quantitative and qualitative results are consistent with decreased emergency care use resulting from a decreased need for emergency care services due to increased availability of primary care services and same-day appointments. PMID:23690385

The patient-centered medical home neighbor: A primary care physician's view.

PubMed

Sinsky, Christine A

2011-01-04

The American College of Physicians' position paper on the patient-centered medical home neighbor (PCMH-N) extends the work of the patient-centered medical home (PCMH) as a means of improving the delivery of health care. Recognizing that the PCMH does not exist in isolation, the PCMH-N concept outlines expectations for comanagement, communication, and care coordination and broadens responsibility for safe, effective, and efficient care beyond primary care to include physicians of all specialties. As such, it is a fitting follow-up to the PCMH and moves further down the road toward improved care for complex patients. Yet, there is more work to be done. Truly transforming the U.S. health care system around personalized medical homes embedded in highly functional medical neighborhoods will require better staffing models; more robust electronic information tools; aligned incentives for quality and efficiency within payment and regulatory policies; and a culture of greater engagement of patients, their families, and communities.

Droplet-based biosensing for lab-on-a-chip, open microfluidics platforms

USDA-ARS?s Scientific Manuscript database

Low cost, portable sensors can transform health care by bringing easily available diagnostic devices to low and middle income population, particularly in developing countries. Sample preparation, analyte handling and labeling are primary cost concerns for traditional lab-based diagnostic systems. La...

A qualitative comparison of primary care clinicians’ and their patients’ perspectives on achieving depression care: implications for improving outcomes

PubMed Central

2014-01-01

Background Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into “Patient-centered Medical Homes” (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient’s perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians’ and their patients’ perceptions of the patients’ experiences, expectations and preferences as they try to achieve care for depression. Methods We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings. Results Three processes on the way to satisfactory depression care emerged: 1. a journey, often from fractured to connected care; 2. a search for a personal understanding of their depression; 3. creation of unique therapeutic spaces for treating current depression and preventing future episodes. Relative to patients’ observations regarding stigma’s effects on accepting a depression diagnosis and seeking treatment, clinicians tended to underestimate the presence and effects of stigma. Patients preferred clinicians who were empathetic listeners, while clinicians worried that discussing depression could open “Pandora’s box” of lengthy discussions and set them irrecoverably behind in their clinic schedules. Clinicians and patients agreed that somatic manifestations of mental distress impeded the patients’ ability to understand their suffering as depression. Clinicians reported supporting several treatment modalities beyond guideline-based approaches for depression, yet also displayed surface-level understanding of the often multifaceted support webs their patient described. Conclusions Improving processes and outcomes in primary care may demand heightened ability to understand and measure the patients’ experiences, expectations and preferences as they receive primary care. Future research would investigate a potential mismatch between clinicians’ and patients’ perceptions of the effects of stigma on achieving care for depression, and on whether time spent discussing depression during the clinical visit improves outcomes. Improving care and outcomes for chronic disorders such as depression may require primary care clinicians to understand and support their patients’ unique ‘therapeutic spaces.’ PMID:24428952

How nurse-led practices perceive implementation of the patient-centered medical home.

PubMed

Frasso, Rosemary; Golinkoff, A; Klusaritz, Heather; Kellom, Katherine; Kollar-McArthur, Helen; Miller-Day, Michelle; Gabbay, Robert; Cronholm, Peter F

2017-04-01

The Affordable Care Act (ACA) promotes the Patient-Centered Medical Home (PCMH) model as a way to improve healthcare quality, the patient experience, and has identified nurse-led primary care as a mechanism meeting the increasing demand for quality primary care. The purpose of this study was to investigate the implementation of a PCMH model in nurse-led primary care practices and to identify facilitators and barriers to the implementation of this model. Data were collected through in-depth interviews with providers and staff in nurse-led practices. These data suggest two categories of processes that facilitate the integration of PCMH in the nurse-led practice setting: patient-oriented facilitators and organizational facilitators. In addition, a number of barriers were identified to implementing the PCMH model. Overall, these practices creatively engaged in the transformation process by structuring themselves as a complex adaptive system and building upon the core principles of nurse-led care. Since the core principles of nurse-led care map onto many of the same principles of the PCMH model, this study discusses the possibility that nurse-led practices may experience fewer barriers when transitioning into PCMHs. Copyright © 2017 Elsevier Inc. All rights reserved.

Point-of-care and point-of-procedure optical imaging technologies for primary care and global health

PubMed Central

Boppart, Stephen A.; Richards-Kortum, Rebecca

2015-01-01

Leveraging advances in consumer electronics and wireless telecommunications, low-cost, portable optical imaging devices have the potential to improve screening and detection of disease at the point of care in primary health care settings in both low- and high-resource countries. Similarly, real-time optical imaging technologies can improve diagnosis and treatment at the point of procedure by circumventing the need for biopsy and analysis by expert pathologists, who are scarce in developing countries. Although many optical imaging technologies have been translated from bench to bedside, industry support is needed to commercialize and broadly disseminate these from the patient level to the population level to transform the standard of care. This review provides an overview of promising optical imaging technologies, the infrastructure needed to integrate them into widespread clinical use, and the challenges that must be addressed to harness the potential of these technologies to improve health care systems around the world. PMID:25210062

Point-of-care and point-of-procedure optical imaging technologies for primary care and global health.

PubMed

Boppart, Stephen A; Richards-Kortum, Rebecca

2014-09-10

Leveraging advances in consumer electronics and wireless telecommunications, low-cost, portable optical imaging devices have the potential to improve screening and detection of disease at the point of care in primary health care settings in both low- and high-resource countries. Similarly, real-time optical imaging technologies can improve diagnosis and treatment at the point of procedure by circumventing the need for biopsy and analysis by expert pathologists, who are scarce in developing countries. Although many optical imaging technologies have been translated from bench to bedside, industry support is needed to commercialize and broadly disseminate these from the patient level to the population level to transform the standard of care. This review provides an overview of promising optical imaging technologies, the infrastructure needed to integrate them into widespread clinical use, and the challenges that must be addressed to harness the potential of these technologies to improve health care systems around the world. Copyright © 2014, American Association for the Advancement of Science.

Spreading a medical home redesign: effects on emergency department use and hospital admissions.

PubMed

Reid, Robert J; Johnson, Eric A; Hsu, Clarissa; Ehrlich, Kelly; Coleman, Katie; Trescott, Claire; Erikson, Michael; Ross, Tyler R; Liss, David T; Cromp, DeAnn; Fishman, Paul A

2013-01-01

The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions. The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

Courses offered by the Minas Health Channel: perception of primary care workers.

PubMed

Pereira, Lizziane D' Ávila; Sena, Roseni Rosângela de

2016-06-01

To analyse how primary healthcare workers perceive the impact of the Health Channel Mines courses in their work process. This is a descriptive exploratory qualitative study conducted with 38 professionals working in primary health care units of three municipalities in the state of Minas Gerais, Brazil. Data were collected in 2014 by means of semi-structured interviews and subjected to thematic content analysis. Data analysis revealed the following three categories: interest in training and its contribution to professional practice; factors that alter professional practices; and proposals for improvement. The study data demonstrated that the Mines Health Channel courses cannot single-handedly change professional practices. Continued and refresher education resources that enable the exchange and articulation of knowledge between the various specialities are needed to transform professional practices.

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

Risk-adjusted payment and performance assessment for primary care.

PubMed

Ash, Arlene S; Ellis, Randall P

2012-08-01

Many wish to change incentives for primary care practices through bundled population-based payments and substantial performance feedback and bonus payments. Recognizing patient differences in costs and outcomes is crucial, but customized risk adjustment for such purposes is underdeveloped. Using MarketScan's claims-based data on 17.4 million commercially insured lives, we modeled bundled payment to support expected primary care activity levels (PCAL) and 9 patient outcomes for performance assessment. We evaluated models using 457,000 people assigned to 436 primary care physician panels, and among 13,000 people in a distinct multipayer medical home implementation with commercially insured, Medicare, and Medicaid patients. Each outcome is separately predicted from age, sex, and diagnoses. We define the PCAL outcome as a subset of all costs that proxies the bundled payment needed for comprehensive primary care. Other expected outcomes are used to establish targets against which actual performance can be fairly judged. We evaluate model performance using R(2)'s at patient and practice levels, and within policy-relevant subgroups. The PCAL model explains 67% of variation in its outcome, performing well across diverse patient ages, payers, plan types, and provider specialties; it explains 72% of practice-level variation. In 9 performance measures, the outcome-specific models explain 17%-86% of variation at the practice level, often substantially outperforming a generic score like the one used for full capitation payments in Medicare: for example, with grouped R(2)'s of 47% versus 5% for predicting "prescriptions for antibiotics of concern." Existing data can support the risk-adjusted bundled payment calculations and performance assessments needed to encourage desired transformations in primary care.

Could Values and Social Structures in Singapore Facilitate Attainment of Patient-Focused, Cultural, and Linguistic Competency Standards in a Patient-Centered Medical Home Pilot?

PubMed Central

Shih, Jenny A; Shiow, Sue-Anne Toh Ee; Wee, Hwee-Lin

2015-01-01

Primary care practices in the United States are transforming into patient-centered medical homes (PCMHs) at a rapid pace. Newer PCMH standards have emphasized culturally and linguistically appropriate services (CLAS), but at this time, only some states in the United States have proposed or passed cultural competency training for health care professionals. Other countries are moving to PCMH models. Singapore, a small, ethnically diverse island nation, has national values and social structures that emphasize cultural and linguistic cohesion. In this piece, we examine Singapore’s first PCMH pilot with a national academic center and primary care practice group. Features such as common shared values, self-reliance, racial and religious harmony, patient experience surveillance, and incorporation of CLAS standards in routine health care transactions may predict success for the PCMH in Singapore, with some implications for the United States. PMID:28725822

Planning for district mental health services in South Africa: a situational analysis of a rural district site.

PubMed

Petersen, Inge; Bhana, Arvin; Campbell-Hall, Victoria; Mjadu, Sithembile; Lund, Crick; Kleintjies, Sharon; Hosegood, Victoria; Flisher, Alan J

2009-03-01

The shift in emphasis to universal primary health care in post-apartheid South Africa has been accompanied by a process of decentralization of mental health services to district level, as set out in the new Mental Health Care Act, no. 17, of 2002 and the 1997 White Paper on the Transformation of the Health System. This study sought to assess progress in South Africa with respect to deinstitutionalization and the integration of mental health into primary health care, with a view to understanding the resource implications of these processes at district level. A situational analysis in one district site, typical of rural areas in South Africa, was conducted, based on qualitative interviews with key stakeholders and the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). The findings suggest that the decentralization process remains largely limited to emergency management of psychiatric patients and ongoing psychopharmacological care of patients with stabilized chronic conditions. We suggest that, in a similar vein to other low- to middle-income countries, deinstitutionalization and comprehensive integrated mental health care in South Africa is hampered by a lack of resources for mental health care within the primary health care resource package, as well as the inefficient use of existing mental health resources.

The provider perspective: investigating the effect of the Electronic Patient-Reported Outcome (ePRO) mobile application and portal on primary care provider workflow.

PubMed

Hans, Parminder K; Gray, Carolyn Steele; Gill, Ashlinder; Tiessen, James

2018-03-01

Aim This qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows. The Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows. Over a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015. Findings Key issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change.

[Multimorbidity and primary care: Emergence of new forms of network organization].

PubMed

Lamothe, Lise; Sylvain, Chantal; Sit, Vanessa

2015-01-01

This study was designed to analyse the adaptive strategies used by primary care professionals to provide more adapted and continuous services to patients with more than one chronic disease. A qualitative case study was conducted in a primary care structure (GMF in Québec). Data were derived from two sources: semi-structured interviews and documents. Based on our thematic analysis of data, we illustrate the adaptive processes at play. Our analysis identified the challenges raised by the increased prevalence of patients with more than one chronic disease and how they influence adaptive strategic initiatives from professionals at the following levels: (1) the patients themselves, (2) the professional-patient relationship, (3) the relationships between professionals of the GMF (4) the relationships between the GMF and other healthcare organizations. The description of these phenomena illustrates the dynamic emergence ofa network form of organization. This phenomenon leads to transformation of the core of the healthcare production system. A deeper understanding of its emergence, impacts and management is necessary.

Determining the impact of a new physiotherapist-led primary care model for back pain: protocol for a pilot cluster randomized controlled trial.

PubMed

Miller, Jordan; Barber, David; Donnelly, Catherine; French, Simon; Green, Michael; Hill, Jonathan; MacDermid, Joy; Marsh, Jacquelyn; Norman, Kathleen; Richardson, Julie; Taljaard, Monica; Wideman, Timothy; Cooper, Lynn; McPhee, Colleen

2017-11-09

Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to: 1) Determine feasibility of patient recruitment, assessment procedures, and retention. 2) Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP) 3) Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes. This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites. If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas. ClinicalTrials.gov, NCT03320148 . Submitted for registration on 17 September 2017.

Connecting the dots: interprofessional health education and delivery system redesign at the Veterans Health Administration.

PubMed

Gilman, Stuart C; Chokshi, Dave A; Bowen, Judith L; Rugen, Kathryn Wirtz; Cox, Malcolm

2014-08-01

Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.

[Community diagnosis using qualitative techniques of expectations and experiences in a health area in need of social transformation].

PubMed

Ramos Ruiz, Juan Andrés; Pérez Milena, Alejandro; Enguix Martínez, Natalia; Alvarez Nieto, Carmen; Martínez Fernández, M Luz

2013-01-01

To know the views, experiences and expectations of care provided by the Andalusian Public Health System (SSPA) of users of an urban area in need of social transformation (ZNTS). Qualitative methodology (exploratory study). Urban basic health zone (16,000 inhabitants, 40% ZNTS). Purposive sampling of users of SSPA and community leaders. Homogeneity criteria: age. Heterogeneity criteria: sex, frequency, active/pensioner, level cultural/economic. Conversational techniques recorded by videotape and moderated by a sociologist (user dicussion groups and in-depth interviews for community leaders). transcription of speeches, coding, categories triangulation and final outcome. Seven groups (43 participants, 58% ZNTS) and 6 leaders. They want continuity of care and choice of professionals, but not the medical change without information and attention's discontinuity primary care/hospital. There's bad physical accesibility by the urban environment in the ZNTS and is criticized admission services and paperwork; the programmed appointment and the electronic prescriptions are improvements but asking more hospital referrals and reviews. There's good appreciation of the professionals (primary care-closer, hospital-greater technical capacity). It needs to improve nursing education and speed of emergency assistance. There's a lack of leadership in the system organization, very fragmented. They know a range of services focusing on the demand for care; other health activities not spread to the users. The SSPA should incorporate the views and expectations of communities in social risk to a real improvement in the quality of care. Copyright © 2012 Elsevier España, S.L. All rights reserved.

Linking Primary Care Information Systems and Public Health Vertical Programs in the Philippines: An Open-source Experience

PubMed Central

Tolentino, Herman; Marcelo, Alvin; Marcelo, Portia; Maramba, Inocencio

2005-01-01

Community-based primary care information systems are one of the building blocks for national health information systems. In the Philippines, after the devolution of health care to local governments, we observed “health information system islands” connected to national vertical programs being implemented in devolved health units. These structures lead to a huge amount of “information work” in the transformation of health information at the community level. This paper describes work done to develop and implement the open-source Community Based Health Information Tracking System (CHITS) Project, which was implemented to address this information management problem and its outcomes. Several lessons learned from the field as well as software development strategies are highlighted in building community level information systems that link to national level health information systems. PMID:16779052

Strong Foundations: Early Childhood Care and Education. EFA Global Monitoring Report, 2007

ERIC Educational Resources Information Center

United Nations Educational, Scientific and Cultural Organization (UNESCO), 2006

2006-01-01

Early childhood is a time of remarkable transformation and extreme vulnerability. Programmes that support young children during the years before they go to primary school provide strong foundations for subsequent learning and development. Such programmes also compensate for disadvantage and exclusion, offering a way out of poverty. This Report…

Spreading a Medical Home Redesign: Effects on Emergency Department Use and Hospital Admissions

PubMed Central

Reid, Robert J.; Johnson, Eric A.; Hsu, Clarissa; Ehrlich, Kelly; Coleman, Katie; Trescott, Claire; Erikson, Michael; Ross, Tyler R.; Liss, David T.; Cromp, DeAnn; Fishman, Paul A.

2013-01-01

PURPOSE The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy. METHODS We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices. RESULTS After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions. CONCLUSIONS The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports. PMID:23690382

Enhancing the Evidence for Behavioral Counseling: A Perspective From the Society of Behavioral Medicine.

PubMed

Alcántara, Carmela; Klesges, Lisa M; Resnicow, Ken; Stone, Amy; Davidson, Karina W

2015-09-01

U.S. Preventive Services Task Force (USPSTF) clinical guidelines at present rarely assign the highest grade recommendation to behavioral counseling interventions for chronic disease prevention or risk reduction because of concerns about the certainty and quality of the evidence base. As a result, the broad integration of behavioral counseling interventions in primary care remains elusive. Thus, there is an urgent need for novel perspectives on how to generate the highest-quality and -certainty evidence for primary care-focused behavioral counseling interventions. As members of the Society of Behavioral Medicine (SBM)--a multidisciplinary scientific organization committed to improving population health through behavior change--we review the USPSTF mandate and current recommendations for behavioral counseling interventions and provide a perspective for the future that calls for concerted and coordinated efforts among SBM, USPSTF, and other organizations invested in the rapid and wider uptake of beneficial, feasible, and referable primary care-focused behavioral counseling interventions. This perspective highlights five areas for further development, including (1) behavioral counseling-focused practice-based research networks; (2) promotion of USPSTF evidence standards and the increased use of pragmatic RCT design; (3) quality control and improvement procedures for behavioral counseling training; (4) systematic research on effective primary care-based collaborative care models; and (5) methodologic innovations that capitalize on disruptive technologies and healthcare transformation. Collective efforts to improve the health of all Americans in the 21st century and beyond must ensure that effective, feasible, and referable behavioral counseling interventions are embedded in modern primary care practice. Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Context for Understanding the National Demonstration Project and the Patient-Centered Medical Home

PubMed Central

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

2010-01-01

This article introduces a journal supplement evaluating the country’s first national demonstration of the patient-centered medical home (PCMH) concept. The PCMH is touted by some as a linchpin for renewing the foundering US health care system and its primary care foundation. The National Demonstration Project (NDP) tested a new model of care and compared facilitated and self-directed implementation approaches in a group-randomized clinical trial. The NDP asked what a national sample of 36 highly motivated family practices could accomplish in moving toward the PCMH ideal during 2 years within the current US health care payment and organizational system. Our independent evaluation used a multimethod approach that integrated qualitative methods to tell the NDP story from multiple perspectives and quantitative methods to assess and compare aspects that could be measured. The 7 scientific reports presented in this supplement explain the process, outcomes, lessons, and implications of the NDP. This introductory article provides context for making sense of the NDP. Important context includes the evolution of the PCMH concept and movement, the roots of the NDP and how it developed, and both what is valuable and what is problematic about family medicine and primary care. Together, the articles in this supplement show how primary care practices and the concept of the PCMH can continue to evolve. The evaluation depicts some of the early effects of this evolution on patients and practices, and shows how the process of practice development can be understood and how lessons from the NDP can inform ongoing and future efforts to transform primary care and health care systems. PMID:20530391

Early Impact Of CareFirst's Patient-Centered Medical Home With Strong Financial Incentives.

PubMed

Afendulis, Christopher C; Hatfield, Laura A; Landon, Bruce E; Gruber, Jonathan; Landrum, Mary Beth; Mechanic, Robert E; Zinner, Darren E; Chernew, Michael E

2017-03-01

In 2011 CareFirst BlueCross BlueShield, a large mid-Atlantic health insurance plan, implemented a payment and delivery system reform program. The model, called the Total Care and Cost Improvement Program, includes enhanced payments for primary care, significant financial incentives for primary care physicians to control spending, and care coordination tools to support progress toward the goal of higher-quality and lower-cost patient care. We conducted a mixed-methods evaluation of the initiative's first three years. Our quantitative analyses used spending and utilization data for 2010-13 to compare enrollees who received care from participating physician groups to similar enrollees cared for by nonparticipating groups. Savings were small and fully shared with providers, which suggests no significant effect on total spending (including bonuses). Our qualitative analysis suggested that early in the program, many physicians were not fully engaged with the initiative and did not make full use of its tools. These findings imply that this and similar payment reforms may require greater time to realize significant savings than many stakeholders had expected. Patience may be necessary if payer-led reform is going to lead to system transformation. Project HOPE—The People-to-People Health Foundation, Inc.

Proposal of a New Public Health End of Life approach for Brazil: how the Project EstaraoSeuLado-Primary Palliative Care is working and how it can help.

PubMed

Corrêa, Santiago

2018-01-01

Brazil has 206 million people, and 1.2 million deaths and 600,000 new cases of cancer per year. Palliative Care services are patchily distributed. The Family Health Strategy, made up from 41,000 primary care teams across Brazil forms a comprehensive primary care network. The Project EstaraoSeuLado-Primary Palliative Care developed working from Community Centers. We created a model based on compassionate communities, with community carers working alongside primary care teams. We identified people who need palliative care, gave them specific care and enrolled their carers into a program of monthly meetings called "Comunidade Cuidador". We discussed caring at end of life and provided skills training. During 2015 we ran 8 training programmes with an average of 10 carers. The major themes of discussion were carer burnout, dealing with denial and skills needed daily. The effect of these meetings was better relations between carers and professionals with expansion of the naturally occurring supportive network. The results of this project have been remarkable. The joint working of professionals and supportive networks together is recognised as being transformational. Carers themselves spread this approach by recommending it to others they know with life limiting illness. We will discuss the model and how it can be replicated more broadly across Brazil. Family Health teams can use tools of identification, evaluation and assessment working with networks including the community as an important part. We will propose a new model of End-of-Life Care to be adopted as national policy. We have implemented a compassionate community programme in the area of Rio Grande in Brazil. This has been a combination of primary care working in harmony with communities, providing education, resources and training to enhance the skill of communities to care for their dying. This is a necessary solution for Brazil, where resources and access to healthcare is limited. Our model is successful and increasing. We propose wider adoption of this model across Brazil and will present figures on the size of the challenge we face.

The Impact of the Patient-Centered Medical Home on Health Care Disparities: Exploring Stakeholder Perspectives on Current Standards and Future Directions.

PubMed

De Marchis, Emilia H; Doekhie, Kirti; Willard-Grace, Rachel; Olayiwola, J Nwando

2018-06-19

Over the past decade, the Patient-Centered Medical Home (PCMH) has become a preeminent model for primary care delivery. Simultaneously, health care disparities have gained increasing attention. There has been limited research on whether and how the PCMH can or should affect health care disparities. The authors conducted qualitative interviews with key stakeholders and experts on the PCMH model and health care disparities, including grant and policy makers, accreditors, researchers, patient advocates, primary care practices, practice transformation organizations, and payers, to assess perspectives on the role of the PCMH in addressing health care disparities. The application of grounded theory and thematic analysis elucidated best practice recommendations for the PCMH model's role in addressing health care disparities. Although the majority of stakeholders support greater integration of efforts to reduce health care disparities into the PCMH model, most stakeholders view the current PCMH model as having minimal or indirect influence on health care disparities. The majority supported greater integration of efforts to reduce health care disparities into the PCMH model. As the PCMH model continues to be refined, and as the health care system strives toward improving population health, there must be reflection on the policies and delivery systems that impact health care disparities.

Reforming primary healthcare: from public policy to organizational change.

PubMed

Gilbert, Frédéric; Denis, Jean-Louis; Lamothe, Lise; Beaulieu, Marie-Dominique; D'amour, Danielle; Goudreau, Johanne

2015-01-01

Governments everywhere are implementing reform to improve primary care. However, the existence of a high degree of professional autonomy makes large-scale change difficult to achieve. The purpose of this paper is to elucidate the change dynamics and the involvement of professionals in a primary healthcare reform initiative carried out in the Canadian province of Quebec. An empirical approach was used to investigate change processes from the inception of a public policy to the execution of changes in professional practices. The data were analysed from a multi-level, combined contextualist-processual perspective. Results are based on a longitudinal multiple-case study of five family medicine groups, which was informed by over 100 interviews, questionnaires, and documentary analysis. The results illustrate the multiple processes observed with the introduction of planned large-scale change in primary care services. The analysis of change content revealed that similar post-change states concealed variations between groups in the scale of their respective changes. The analysis also demonstrated more precisely how change evolved through the introduction of "intermediate change" and how cycles of prescribed and emergent mechanisms distinctively drove change process and change content, from the emergence of the public policy to the change in primary care service delivery. This research was conducted among a limited number of early policy adopters. However, given the international interest in turning to the medical profession to improve primary care, the results offer avenues for both policy development and implementation. The findings offer practical insights for those studying and managing large-scale transformations. They provide a better understanding of how deliberate reforms coexist with professional autonomy through an intertwining of change content and processes. This research is one of few studies to examine a primary care reform from emergence to implementation using a longitudinal multi-level design.

What kind of leadership does integrated care need?

PubMed

Kelley-Patterson, Deirdre

2012-01-01

Primary care clinicians and clinical commissioners are the current focus for much leadership investment and development. In this article I propose that we need to look beyond traditional thinking about effective leader behaviour and conventional approaches to leader development based on this thinking. The paper identifies some of the lessons that can be learnt from both the current academic discussion of collaborative leadership, and from an analysis of successes and failures of leadership within the NHS. Two leadership strategies are considered: the development of communities of practice and the use of connected mini-transformations to generate wider system transformation. In a period of systems change, with potential for conflict between providers and commissioners, these strategies are helpful in encouraging the 'mindfulness' that is needed to ensure integration across the complex landscape of healthcare in London.

Transformative unlearning: safety, discernment and communities of learning.

PubMed

Macdonald, Geraldine

2002-09-01

This paper aims to stimulate awareness about the intellectual and emotional work of 'unlearning' in knowledge workers in the emerging learning age. The importance of providing a safe space for dialogue to promote transformative learning, through building 'communities of learning', is highlighted. Unlearning is conceptualized within a transformative education paradigm, one whose primary orientation is discernment, a personal growth process involving the activities of receptivity, recognition and grieving. The author utilizes the metaphor of an unfolding spiral path to explore her experience of needing to 'unlearn' a trusted nursing practice prior to 'learning' new best caring practices related to infant sleep positions. Macro and micro approaches to facilitating unlearning in organizations, in learners and in nurses are suggested.

Power sharing. A transformational strategy for nurse retention, effectiveness, and extra effort.

PubMed

Trofino, Joan

2003-01-01

Power sharing with staff nurses is an essential strategy for organizational transformation. The current competitive health care environment requires a powerful team of participants, including staff at all levels, to provide health care in mutual partnership. The challenges of today's competitive and global environment call for collegial relationships among nurse executive leadership, middle nurse managers, and staff nurses. Research has demonstrated that middle nurse managers maintain primary responsibility for staff nurse retention. A higher retention rate was reported among nurses who were very satisfied with their nurse managers. Nurses considered favorably nurse managers who value staff contributions, promote information sharing, and exert influence for a stable work environment. Furthermore, as staff nurse satisfaction increased, effectiveness and extra effort also increased when staff nurses perceived transformational leadership strategies. Strategies for power sharing include serving as role models and mentors, energizing staff, resisting attitudes of staff ownership, reducing staff nurse stress of leader presence, and information sharing and commendations at meetings.

Assessing the evolution of primary healthcare organizations and their performance (2005-2010) in two regions of Québec province: Montréal and Montérégie

PubMed Central

2010-01-01

Background The Canadian healthcare system is currently experiencing important organizational transformations through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of proposing the transformation of PHC organizations by implementing new models of PHC organization. These models vary in their performance with respect to client affiliation, utilization of services, experience of care and perceived outcomes of care. Objectives In early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and population-level experience of care. The goal of the present research project is to track the evolution of PHC organizational models and their relative performance through the reform process (from 2005 until 2010) and to assess factors at the organizational and contextual levels that are associated with the transformation of PHC organizations and their performance. Methods/Design This study will consist of three interrelated surveys, hierarchically nested. The first survey is a population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This survey will assess the current affiliation of people with PHC organizations, their level of utilization of healthcare services, attributes of their experience of care, reception of preventive and curative services and perception of unmet needs for care. The second survey is an organizational survey of PHC organizations assessing aspects related to their vision, organizational structure, level of resources, and clinical practice characteristics. This information will serve to develop a taxonomy of organizations using a mixed methods approach of factorial analysis and principal component analysis. The third survey is an assessment of the organizational context in which PHC organizations are evolving. The five year prospective period will serve as a natural experiment to assess contextual and organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models (in 2010) and assess the impact of this evolution on the performance of PHC. Discussion The results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes. PMID:21122145

Assessing the evolution of primary healthcare organizations and their performance (2005-2010) in two regions of Québec province: Montréal and Montérégie.

PubMed

Levesque, Jean-Frédéric; Pineault, Raynald; Provost, Sylvie; Tousignant, Pierre; Couture, Audrey; Da Silva, Roxane Borgès; Breton, Mylaine

2010-12-01

The Canadian healthcare system is currently experiencing important organizational transformations through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of proposing the transformation of PHC organizations by implementing new models of PHC organization. These models vary in their performance with respect to client affiliation, utilization of services, experience of care and perceived outcomes of care. In early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and population-level experience of care. The goal of the present research project is to track the evolution of PHC organizational models and their relative performance through the reform process (from 2005 until 2010) and to assess factors at the organizational and contextual levels that are associated with the transformation of PHC organizations and their performance. This study will consist of three interrelated surveys, hierarchically nested. The first survey is a population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This survey will assess the current affiliation of people with PHC organizations, their level of utilization of healthcare services, attributes of their experience of care, reception of preventive and curative services and perception of unmet needs for care. The second survey is an organizational survey of PHC organizations assessing aspects related to their vision, organizational structure, level of resources, and clinical practice characteristics. This information will serve to develop a taxonomy of organizations using a mixed methods approach of factorial analysis and principal component analysis. The third survey is an assessment of the organizational context in which PHC organizations are evolving. The five year prospective period will serve as a natural experiment to assess contextual and organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models (in 2010) and assess the impact of this evolution on the performance of PHC. The results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes.

Public trust in primary care doctors, the medical profession and the healthcare system among Redhill residents in Singapore.

PubMed

Lee, Yi Yong; Ng, Choon Ta; Siti Aishah, M Ghazalie; Ngiam, Ju Zheng; Tai, Bee Choo; Lim, Meng Kin; Hughes, Kenneth

2007-08-01

There have been few studies on public trust in doctors and healthcare systems and this is the first in Singapore. A cross-sectional survey was carried out in Redhill in January 2005. Citizens or Permanent Residents aged > or =18 years were randomly selected, one per household to avoid cluster bias, and 361 participated (response rate 68.7%). An interview administered questionnaire included 3 questionnaires measuring public trust: "Interpersonal Trust in Physicians Scale" for primary care doctors; "Trust in Physicians Generally Scale" for the medical profession; and "Trust in Healthcare System Scale" for the Healthcare System. Questions were answered on a Likert scale: 1. Strongly Disagree, 2. Disagree, 3. Neutral, 4. Agree, 5. Strongly Agree. Individual transformed scores of trust (range, 0 to 100) were equally divided into 5 categories with their average being the transformed mean. Trust in primary care doctors (mean 59.7) had proportions (prevalence rates) of: very low 0.3%, low 2.5%, neutral 40.4%, high 54.0%, and very high 2.8%. Trust in the medical profession (mean 61.8) had proportions of: very low 1.0%, low 7.7%, neutral 33.7%, high 47.0%, and very high 10.5%. Trust in the healthcare system (mean 61.5) had proportions of: very low 0.5%, low 4.1%, neutral 40.0%, high 48.7%, and very high 6.7%. For areas of the healthcare system, proportions of high/very high trust were: "Healthcare Providers' Expertise" (70.8%), "Quality of Care" (61.5%), "Patient Focus of Providers" (58.7%), "Information Supply and Communication by Care Providers" (52.3%), "Quality of Cooperation" (43.3%), and Policies of the Healthcare System" (24.6%). While low proportions had low/very low trust, the high proportions with neutral trust and the rather low level of trust in "Policies of the Healthcare System" are causes for concern.

Permanent education in primary health care: perception of local health managers.

PubMed

Silva, Luiz Anildo Anacleto da; Soder, Rafael Marcelo; Petry, Letícia; Oliveira, Isabel Cristine

2017-05-04

To know the health education strategies advocated and developed for workers of primary care, in the view of managers. The study is characterized as a qualitative, descriptive and exploratory research. A semistructured interview was used to collect data. The sample population was chosen intentionally, with an audience of 26 municipal health managers ascribed to a regional health coordination office, located in the north/northwest of the Rio Grande do Sul State. The thematic analysis allowed the construction of two empirical categories: educational strategies, compartmentalized, discontinuous and with technicist bases; and the insipience/absence of educational proposals. The results show a reality that needs to be transformed by all people involved in health work process: teachers and students, users, members of health councils, workers and managers. Realistically, there is a quest for change in services, to qualify the comprehensiveness of health care.

Proactive Strategies to Address Health Equity and Disparities: Recommendations from a Bi-National Symposium.

PubMed

Haggerty, Jeannie; Chin, Marshall H; Katz, Alan; Young, Kue; Foley, Jonathan; Groulx, Antoine; Pérez-Stable, Eliseo J; Turnbull, Jeff; DeVoe, Jennifer E; Uchendo, Uche

2018-01-01

Health inequities persist in Canada and the United States. Both countries show differential health status and health care quality by social characteristics, making zip or postal code a greater predictor of health than genetics. Many social determinants of health overlap in the same individuals or communities, exacerbating their vulnerability. Many of the contributing factors and problems are structural and evade simple solutions. In March 2017 a binational Canada-US symposium was held in Washington DC involving 150 primary care thought leaders, including clinicians, researchers, patients, and policy makers to address transformation in integrated primary care. This commentary summarizes the session's principal insights and solutions of the session tackling health inequities at policy and delivery levels. The solution lies in intervening proactively to reduce disparities-developing risk-adjustment measures that integrate social factors; increasing the socioeconomic, racial, and ethnic diversity of health providers; teaching cultural humility; supporting community-oriented primary care; and integrating equity considerations into health system funding. We propose moving from retrospective analysis to proactive measures; from equality to equity; from needs-based to strength-based approaches; and from an individual to a population focus. © Copyright 2018 by the American Board of Family Medicine.

Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care.

PubMed

Hamilton, Alison B; Brunner, Julian; Cain, Cindy; Chuang, Emmeline; Luger, Tana M; Canelo, Ismelda; Rubenstein, Lisa; Yano, Elizabeth M

2017-09-01

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

The cost of sustaining a patient-centered medical home: experience from 2 states.

PubMed

Magill, Michael K; Ehrenberger, David; Scammon, Debra L; Day, Julie; Allen, Tatiana; Reall, Andreu J; Sides, Rhonda W; Kim, Jaewhan

2015-09-01

As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these "advanced primary care" functions. A key required input is personnel effort. This study's objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards. We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions. Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado. Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions. © 2015 Annals of Family Medicine, Inc.

Results from a patient-centered medical home pilot at UPMC Health Plan hold lessons for broader adoption of the model.

PubMed

Rosenberg, Cynthia Napier; Peele, Pamela; Keyser, Donna; McAnallen, Sandra; Holder, Diane

2012-11-01

The patient-centered medical home is a promising model for improving access to high-quality care for more Americans at lower cost. However, feasible pathways for achieving a transformation from current primary care practices to this new model have yet to be fully identified. We report on the experience of UPMC Health Plan-part of a large, integrated delivery and financing system headquartered in Pittsburgh, Pennsylvania-in its efforts to support primary care practices as they converted to patient-centered medical homes. From 2008 through 2010, sites participating in the UPMC pilot achieved lower medical and pharmacy costs; more efficient service delivery, such as lower hospital admissions and readmissions and less use of hospital emergency departments; and a 160 percent return on the plan's investment when compared with nonparticipating sites. We suggest approaches that could spur the adoption and spread of the model, including that payers be offered incentives to enter into patient-centered medical home contracts with interested providers; that payers increase efforts to provide primary care practices with access to usable data on their patient populations; and that telehealth be instituted to connect care managers to patients and practices when in-person visits are not possible or necessary.

Patient contributions during primary care consultations for hypertension after self-reporting via a mobile phone self-management support system.

PubMed

Bengtsson, Ulrika; Kjellgren, Karin; Hallberg, Inger; Lundin, Mona; Mäkitalo, Åsa

2018-03-01

This paper reports on how the clinical consultation in primary care is performed under the new premises of patients' daily self-reporting and self-generation of data. The aim was to explore and describe the structure, topic initiation and patients' contributions in follow-up consultations after eight weeks of self-reporting through a mobile phone-based hypertension self-management support system. A qualitative, explorative study design was used, examining 20 audio- (n = 10) and video-recorded (n = 10) follow-up consultations in primary care hypertension management, through interaction analysis. Clinical trials registry: ClinicalTrials.gov NCT01510301. Four primary health care centers in Sweden. Patients with hypertension (n = 20) and their health care professional (n = 7). The consultations comprised three phases: opening, examination and closing. The most common topic was blood pressure (BP) put in relation to self-reported variables, for example, physical activity and stress. Topic initiation was distributed symmetrically between parties and BP talk was lifestyle-centered. The patients' contributed to the interpretation of BP values by connecting them to specific occasions, providing insights to the link between BP measurements and everyday life activities. Patients' contribution through interpretations of BP values to specific situations in their own lives brought on consultations where the patient as a person in context became salient. Further, the patients' and health care professionals' equal contribution during the consultations showed actively involved patients. The mobile phone-based self-management support system can thus be used to support patient involvement in consultations with a person-centered approach in primary care hypertension management Key points   The clinical consultation is important to provide opportunities for patients to gain understanding of factors affecting high blood pressure, and for health care professionals to motivate and promote changes in life-style. This study shows that self-reporting as base for follow-up consultations in primary care hypertension management can support patients and professionals to equal participation in clinical consultations. Self-reporting combined with increased patient-health care professional interaction during follow-up consultations can support patients in understanding the blood pressure value in relation to their daily life. These findings implicate that the interactive mobile phone self-management support system has potential to support current transformations of patients as recipients of primary care, to being actively involved in their own health.

String scattering amplitudes and deformed cubic string field theory

NASA Astrophysics Data System (ADS)

Lai, Sheng-Hong; Lee, Jen-Chi; Lee, Taejin; Yang, Yi

2018-01-01

We study string scattering amplitudes by using the deformed cubic string field theory which is equivalent to the string field theory in the proper-time gauge. The four-string scattering amplitudes with three tachyons and an arbitrary string state are calculated. The string field theory yields the string scattering amplitudes evaluated on the world sheet of string scattering whereas the conventional method, based on the first quantized theory brings us the string scattering amplitudes defined on the upper half plane. For the highest spin states, generated by the primary operators, both calculations are in perfect agreement. In this case, the string scattering amplitudes are invariant under the conformal transformation, which maps the string world sheet onto the upper half plane. If the external string states are general massive states, generated by non-primary field operators, we need to take into account carefully the conformal transformation between the world sheet and the upper half plane. We show by an explicit calculation that the string scattering amplitudes calculated by using the deformed cubic string field theory transform into those of the first quantized theory on the upper half plane by the conformal transformation, generated by the Schwarz-Christoffel mapping.

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.

What kind of leadership does integrated care need?

PubMed Central

2012-01-01

Primary care clinicians and clinical commissioners are the current focus for much leadership investment and development. In this article I propose that we need to look beyond traditional thinking about effective leader behaviour and conventional approaches to leader development based on this thinking. The paper identifies some of the lessons that can be learnt from both the current academic discussion of collaborative leadership, and from an analysis of successes and failures of leadership within the NHS. Two leadership strategies are considered: the development of communities of practice and the use of connected mini-transformations to generate wider system transformation. In a period of systems change, with potential for conflict between providers and commissioners, these strategies are helpful in encouraging the ‘mindfulness’ that is needed to ensure integration across the complex landscape of healthcare in London. PMID:25949659

An "All Teach, All Learn" Approach to Research Capacity Strengthening in Indigenous Primary Health Care Continuous Quality Improvement.

PubMed

McPhail-Bell, Karen; Matthews, Veronica; Bainbridge, Roxanne; Redman-MacLaren, Michelle Louise; Askew, Deborah; Ramanathan, Shanthi; Bailie, Jodie; Bailie, Ross

2018-01-01

In Australia, Indigenous people experience poor access to health care and the highest rates of morbidity and mortality of any population group. Despite modest improvements in recent years, concerns remains that Indigenous people have been over-researched without corresponding health improvements. Embedding Indigenous leadership, participation, and priorities in health research is an essential strategy for meaningful change for Indigenous people. To centralize Indigenous perspectives in research processes, a transformative shift away from traditional approaches that have benefited researchers and non-Indigenous agendas is required. This shift must involve concomitant strengthening of the research capacity of Indigenous and non-Indigenous researchers and research translators-all must teach and all must learn. However, there is limited evidence about how to strengthen systems and stakeholder capacity to participate in and lead continuous quality improvement (CQI) research in Indigenous primary health care, to the benefit of Indigenous people. This paper describes the collaborative development of, and principles underpinning, a research capacity strengthening (RCS) model in a national Indigenous primary health care CQI research network. The development process identified the need to address power imbalances, cultural contexts, relationships, systems requirements and existing knowledge, skills, and experience of all parties. Taking a strengths-based perspective, we harnessed existing knowledge, skills and experiences; hence our emphasis on capacity "strengthening". New insights are provided into the complex processes of RCS within the context of CQI in Indigenous primary health care.

An “All Teach, All Learn” Approach to Research Capacity Strengthening in Indigenous Primary Health Care Continuous Quality Improvement

PubMed Central

McPhail-Bell, Karen; Matthews, Veronica; Bainbridge, Roxanne; Redman-MacLaren, Michelle Louise; Askew, Deborah; Ramanathan, Shanthi; Bailie, Jodie; Bailie, Ross; Matthews, Veronica

2018-01-01

In Australia, Indigenous people experience poor access to health care and the highest rates of morbidity and mortality of any population group. Despite modest improvements in recent years, concerns remains that Indigenous people have been over-researched without corresponding health improvements. Embedding Indigenous leadership, participation, and priorities in health research is an essential strategy for meaningful change for Indigenous people. To centralize Indigenous perspectives in research processes, a transformative shift away from traditional approaches that have benefited researchers and non-Indigenous agendas is required. This shift must involve concomitant strengthening of the research capacity of Indigenous and non-Indigenous researchers and research translators—all must teach and all must learn. However, there is limited evidence about how to strengthen systems and stakeholder capacity to participate in and lead continuous quality improvement (CQI) research in Indigenous primary health care, to the benefit of Indigenous people. This paper describes the collaborative development of, and principles underpinning, a research capacity strengthening (RCS) model in a national Indigenous primary health care CQI research network. The development process identified the need to address power imbalances, cultural contexts, relationships, systems requirements and existing knowledge, skills, and experience of all parties. Taking a strengths-based perspective, we harnessed existing knowledge, skills and experiences; hence our emphasis on capacity “strengthening”. New insights are provided into the complex processes of RCS within the context of CQI in Indigenous primary health care. PMID:29761095

[A new attempt to promote home medical care in Kashiwa city-usefulness of information and communication technology with seamless multidisciplinary cooperation].

PubMed

Iijima, Katsuya; Yoshie, Satoru; Kimata, Mari; Ihori, Mikio; Yamamoto, Takuma; Goto, Jun; Fujita, Shinsuke; Takabayashi, Katsuhiko; Kamata, Minoru; Tsuji, Tetsuo

2012-12-01

Due to the rapidly increasing super-aging society, medical policy in Japan should be redefined. Therefore, the medical and nursing home care system should now be revised greatly. We need to change the current principle that is based on cure only. The patients should receive hospitable care closely connected with their life in their home-town(region)throughout their lifetime. This is termed as "home medical care system". Here, we promote patient-centered medical home care, which implements the chronic and/or End-Of-Life care models, in Kashiwa city, Chiba prefecture. This system is a promising framework for primary care transformation. There is a need for a multidisciplinary team-based care system using information and communication technology(ICT)with smooth and seamless cooperation. However, increased awareness among the workers engaged in home medical care is first required.

[The transformation of the healthcare model in Catalonia to improve the quality of care].

PubMed

Padrosa, Josep Maria; Guarga, Àlex; Brosa, Francesc; Jiménez, Josep; Robert, Roger

2015-11-01

The changes taking place in western countries require health systems to adapt to the public's evolving needs and expectations. The healthcare model in Catalonia is undergoing significant transformation in order to provide an adequate response to this new situation while ensuring the system's sustainability in the current climate of economic crisis. This transformation is based on converting the current disease-centred model which is fragmented into different levels, to a more patient-centred integrated and territorial care model that promotes the use of a shared network of the different specialities, the professionals, resources and levels of care, entering into territorial agreements and pacts which stipulate joint goals or objectives. The changes the Catalan Health Service (CatSalut) has undergone are principally focused on increasing resolution capacity of the primary level of care, eliminating differences in clinical practice, evolving towards more surgery-centred hospitals, promoting alternatives to conventional hospitalization, developing remote care models, concentrating and organizing highly complex care into different sectors at a territorial level and designing specific health codes in response to health emergencies. The purpose of these initiatives is to improve the effectiveness, quality, safety and efficiency of the system, ensuring equal access for the public to these services and ensuring a territorial balance. These changes should be facilitated and promoted using several different approaches, including implementing shared access to clinical history case files, the new model of results-based contracting and payment, territorial agreements, alliances between centres, harnessing the potential of information and communications technology and evaluation of results. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Two-Year Costs and Quality in the Comprehensive Primary Care Initiative.

PubMed

Dale, Stacy B; Ghosh, Arkadipta; Peikes, Deborah N; Day, Timothy J; Yoon, Frank B; Taylor, Erin Fries; Swankoski, Kaylyn; O'Malley, Ann S; Conway, Patrick H; Rajkumar, Rahul; Press, Matthew J; Sessums, Laura; Brown, Randall

2016-06-16

The 4-year, multipayer Comprehensive Primary Care Initiative was started in October 2012 to determine whether several forms of support would produce changes in care delivery that would improve the quality and reduce the costs of care at 497 primary care practices in seven regions across the United States. Support included the provision of care-management fees, the opportunity to earn shared savings, and the provision of data feedback and learning support. We tracked changes in the delivery of care by practices participating in the initiative and used difference-in-differences regressions to compare changes over the first 2 years of the initiative in Medicare expenditures, health care utilization, claims-based measures of quality, and patient experience for Medicare fee-for-service beneficiaries attributed to initiative practices and a group of matched comparison practices. During the first 2 years, initiative practices received a median of $115,000 per clinician in care-management fees. The practices reported improvements in approaches to the delivery of primary care in areas such as management of the care of high-risk patients and enhanced access to care. Changes in average monthly Medicare expenditures per beneficiary did not differ significantly between initiative and comparison practices when care-management fees were not taken into account (-$11; 95% confidence interval [CI], -$23 to $1; P=0.07; negative values indicate less growth in spending at initiative practices) or when these fees were taken into account ($7; 95% CI, -$5 to $19; P=0.27). The only significant differences in other measures were a 3% reduction in primary care visits for initiative practices relative to comparison practices (P<0.001) and changes in two of the six domains of patient experience--discussion of decisions regarding medication with patients and the provision of support for patients taking care of their own health--both of which showed a small improvement in initiative practices relative to comparison practices (P=0.006 and P<0.001, respectively). Midway through this 4-year intervention, practices participating in the initiative have reported progress in transforming the delivery of primary care. However, at this point these practices have not yet shown savings in expenditures for Medicare Parts A and B after accounting for care-management fees, nor have they shown an appreciable improvement in the quality of care or patient experience. (Funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services; ClinicalTrials.gov number, NCT02320591.).

Primary care nursing role and care coordination: an observational study of nursing work in a community health center.

PubMed

Anderson, Daren R; St Hilaire, Daniel; Flinter, Margaret

2012-05-31

Care coordination is a core element of the Patient-Centered Medical Home and requires an effective, well educated nursing staff. A greater understanding of roles and tasks currently being carried out by nurses in primary care is needed to help practices determine how best to implement care coordination and transform into PCMHs. We conducted an observational study of primary care nursing in a Community Health Center by creating a classification schema for nursing responsibilities, directly observing and tracking nurses' work, and categorizing their activities. Ten nurses in eight different practice sites were observed for a total of 61 hours. The vast majority of nursing time was spent in vaccine and medication administration; telephone work; and charting and paper work, while only 15% of their time was spent in activity that was classified broadly as care coordination. Care coordination work appeared to be subsumed by other daily tasks, many of which could have been accomplished by other, lesser trained members of the health care team. Practices looking to implement care coordination need a detailed look at work flow, task assignments, and a critical assessment of staffing, adhering to the principal of each team member working to the highest level of his or her education and license. Care coordination represents a distinct responsibility that requires dedicated nursing time, separate from the day to day tasks in a busy practice. To fully support these new functions, reimbursement models are needed that support such non visit-based work and provide incentives to coordinate and manage complex cases, achieve improved clinical outcomes and enhance efficiency of the health system. This article describes our study methods, data collection, and analysis, results, and discussion about reorganizing nursing roles to promote care coordination.

EHRs in primary care practices: benefits, challenges, and successful strategies.

PubMed

Goetz Goldberg, Debora; Kuzel, Anton J; Feng, Lisa Bo; DeShazo, Jonathan P; Love, Linda E

2012-02-01

To understand the current use of electronic health records (EHRs) in small primary care practices and to explore experiences and perceptions of physicians and staff toward the benefits, challenges, and successful strategies for implementation and meaningful use of advanced EHR functions. Qualitative case study of 6 primary care practices in Virginia. We performed surveys and in-depth interviews with clinicians and administrative staff (N = 38) and observed interpersonal relations and use of EHR functions over a 16-month period. Practices with an established EHR were selected based on a maximum variation of quality activities, location, and ownership. Physicians and staff report increased efficiency in retrieving medical records, storing patient information, coordination of care, and office operations. Costs, lack of knowledge of EHR functions, and problems transforming office operations were barriers reported for meaningful use of EHRs. Major disruption to patient care during upgrades and difficulty utilizing performance tracking and quality functions were also reported. Facilitators for adopting and using advanced EHR functions include team-based care, adequate technical support, communication and training for employees and physicians, alternative strategies for patient care during transition, and development of new processes and work flow procedures. Small practices experience difficulty with implementation and utilization of advanced EHR functions. Federal and state policies should continue to support practices by providing technical assistance and financial incentives, grants, and/or loans. Small practices should consider using regional extension center services and reaching out to colleagues and other healthcare organizations with similar EHR systems for advice and guidance.

Stakeholder Perspectives on Changes in Hypertension Care Under the Patient-Centered Medical Home.

PubMed

O'Donnell, Alison J; Bogner, Hillary R; Cronholm, Peter F; Kellom, Katherine; Miller-Day, Michelle; McClintock, Heather F de Vries; Kaye, Elise M; Gabbay, Robert

2016-02-25

Hypertension is a major modifiable risk factor for cardiovascular and kidney disease, yet the proportion of adults whose hypertension is controlled is low. The patient-centered medical home (PCMH) is a model for care delivery that emphasizes patient-centered and team-based care and focuses on quality and safety. Our goal was to investigate changes in hypertension care under PCMH implementation in a large multipayer PCMH demonstration project that may have led to improvements in hypertension control. The PCMH transformation initiative conducted 118 semistructured interviews at 17 primary care practices in southeastern Pennsylvania between January 2011 and January 2012. Clinicians (n = 47), medical assistants (n = 26), office administrators (n = 12), care managers (n = 11), front office staff (n = 7), patient educators (n = 4), nurses (n = 4), social workers (n = 4), and other administrators (n = 3) participated in interviews. Study personnel used thematic analysis to identify themes related to hypertension care. Clinicians described difficulties in expanding services under PCMH to meet the needs of the growing number of patients with hypertension as well as how perceptions of hypertension control differed from actual performance. Staff and office administrators discussed achieving patient-centered hypertension care through patient education and self-management support with personalized care plans. They indicated that patient report cards were helpful tools. Participants across all groups discussed a team- and systems-based approach to hypertension care. Practices undergoing PCMH transformation may consider stakeholder perspectives about patient-centered, team-based, and systems-based approaches as they work to optimize hypertension care.

Advancing education in dental hygiene.

PubMed

Battrell, Ann; Lynch, Ann; Steinbach, Pam; Bessner, Sue; Snyder, Josh; Majeski, Jean

2014-06-01

The changing health care environment and societal imperatives indicate the need for transformative change within the dental hygiene profession to serve the emerging needs of the public. The American Dental Hygienists' Association is leading the way toward meaningful change. The American Dental Hygienists' Association (ADHA) has as its vision the integration of dental hygienists into the health care delivery system as essential primary care providers to expand access to oral health care. This article provides data on current dental hygiene education programs and those in development. Also included is a discussion regarding how the dental hygiene profession can better serve the health and wellness needs of society by transforming the way graduates are prepared for the future. ADHA's dental hygiene survey center data, policies and a futuristic analysis plus a review of the professional literature describe the current state of dental hygiene education and the profession. A discussion of societal, health care and educational trends that creates the imperative for transformation of the dental hygiene profession is provided. Ultimately, the purpose of advancing education in dental hygiene is to achieve better oral and overall health for more people. The profession's responsibility to the public includes evaluating its own ability to provide care and taking the steps necessary to ensure its maximum effectiveness. ADHA is leading this process for dental hygienists in diverse ways. It is imperative that the dental hygiene profession understands and embraces the changing health care environment. Through open dialog and the sharing of evidence the professional path will be determined along with forward movement for the benefit of society and the dental hygiene profession. Copyright © 2014 Elsevier Inc. All rights reserved.

Integrated specialty service readiness in health reform: connections in haemophilia comprehensive care.

PubMed

Pritchard, A M; Page, D

2008-05-01

The World Health Organization (WHO) has identified primary healthcare reform as a global priority whereby innovative practice changes are directed at improving health. This transformation to health reform in haemophilia service requires clarification of comprehensive care to reflect the WHO definition of health and key elements of primary healthcare reform. While comprehensive care supports effective healthcare delivery, comprehensive care must also be regarded beyond immediate patient management to reflect the broader system purpose in the care continuum with institutions, community agencies and government. Furthermore, health reform may be facilitated through integrated service delivery (ISD). ISD in specialty haemophilia care has the potential to reduce repetition of assessments, enhance care plan communication between providers and families, provide 24-h access to care, improve information availability regarding care quality and outcomes, consolidate access for multiple healthcare encounters and facilitate family self-efficacy and autonomy [1]. Three core aspects of ISD have been distinguished: clinical integration, information management and technology and vertical integration in local communities [2]. Selected examples taken from Canadian haemophilia comprehensive care illustrate how practice innovations are bridged with a broader system level approach and may support initiatives in other contexts. These innovations are thought to indicate readiness regarding ISD. Reflecting on the existing capacity of haemophilia comprehensive care teams will assist providers to connect and direct their existing strengths towards ISD and health reform.

Pathways to Medical Home Recognition: A Qualitative Comparative Analysis of the PCMH Transformation Process.

PubMed

Mendel, Peter; Chen, Emily K; Green, Harold D; Armstrong, Courtney; Timbie, Justin W; Kress, Amii M; Friedberg, Mark W; Kahn, Katherine L

2017-12-15

To understand the process of practice transformation by identifying pathways for attaining patient-centered medical home (PCMH) recognition. The CMS Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration was designed to help FQHCs achieve NCQA Level 3 PCMH recognition and improve patient outcomes. We used a stratified random sample of 20 (out of 503) participating sites for this analysis. We developed a conceptual model of structural, cultural, and implementation factors affecting PCMH transformation based on literature and initial qualitative interview themes. We then used conventional cross-case analysis, followed by qualitative comparative analysis (QCA), a cross-case method based on Boolean logic algorithms, to systematically identify pathways (i.e., combinations of factors) associated with attaining-or not attaining-Level 3 recognition. Site-level indicators were derived from semistructured interviews with site leaders at two points in time (mid- and late-implementation) and administrative data collected prior to and during the demonstration period. The QCA results identified five distinct pathways to attaining PCMH recognition and four distinct pathways to not attaining recognition by the end of the demonstration. Across these pathways, one condition (change leader capacity) was common to all pathways for attaining recognition, and another (previous improvement or recognition experience) was absent in all pathways for not attaining recognition. In general, sites could compensate for deficiencies in one factor with capacity in others, but they needed a threshold of strengths in cultural and implementation factors to attain PCMH recognition. Future efforts at primary care transformation should take into account multiple pathways sites may pursue. Sites should be assessed on key cultural and implementation factors, in addition to structural components, in order to differentiate interventions and technical assistance. © Health Research and Educational Trust.

Transforming Care at the Bedside (TCAB): enhancing direct care and value-added care.

PubMed

Dearmon, Valorie; Roussel, Linda; Buckner, Ellen B; Mulekar, Madhuri; Pomrenke, Becky; Salas, Sheri; Mosley, Aimee; Brown, Stephanie; Brown, Ann

2013-05-01

The purpose of this study was to examine the effectiveness of a Transforming Care at the Bedside initiative from a unit perspective. Improving patient outcomes and nurses' work environments are the goals of Transforming Care at the Bedside. Transforming Care at the Bedside creates programs of change originating at the point of care and directly promoting engagement of nurses to transform work processes and quality of care on medical-surgical units. This descriptive comparative study draws on multiple data sources from two nursing units: a Transforming Care at the Bedside unit where staff tested, adopted and implemented improvement ideas, and a control unit where staff continued traditional practices. Change theory provided the framework for the study. Direct care and value-added care increased on Transforming Care at the Bedside unit compared with the control unit. Transforming Care at the Bedside unit decreased in incidental overtime. Nurses reported that the process challenged old ways of thinking and increased nursing innovations. Hourly rounding, bedside reporting and the use of pain boards were seen as positive innovations. Evidence supported the value-added dimension of the Transforming Care at the Bedside process at the unit level. Nurses recognized the significance of their input into processes of change. Transformational leadership and frontline projects provide a vehicle for innovation through application of human capital. © 2012 Blackwell Publishing Ltd.

Maximizing the Patient-Centered Medical Home (PCMH) by Choosing Words Wisely.

PubMed

Howard, Jenna; Etz, Rebecca S; Crocker, J Benjamin; Skinner, Daniel; Kelleher, Kelly J; Hahn, Karissa A; Miller, William L; Crabtree, Benjamin F

2016-01-01

Culture is transmitted through language and reflects a group's values, yet much of the current language used to describe the new patient-centered medical home (PCMH) is a carryover from the traditional, physician-centric model of care. This language creates a subtle yet powerful force that can perpetuate the status quo, despite transformation efforts. This article describes new terminology that some innovative primary care practices are using to support the transformational culture of the PCMH. Data come from the Agency for Healthcare Research and Quality-funded Working Conference for PCMH Innovation 2013, which convened 10 innovative practices and interdisciplinary content experts to discuss innovative practice redesign. Session and interview transcripts were analyzed using a grounded theory approach to identify patterns and explore their significance. Language innovations are used by 5 practices. Carefully selected terms facilitate creative reimagining of traditional roles and spaces through connotations that highlight practice goals. Participants felt that the language used was important for reinforcing substantive changes. Reworking well-established vernacular requires openness to change. True transformation does not, however, occur through a simple relabeling of old concepts. New terminology must represent values to which practices genuinely aspire, although caution is advised when using language to support cultural and clinical change. © Copyright 2016 by the American Board of Family Medicine.

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting.

PubMed

Ahmed, Sara; Ware, Patrick; Visca, Regina; Bareil, Celine; Chouinard, Maud-Christine; Desforges, Johanne; Finlayson, Roderick; Fortin, Martin; Gauthier, Josée; Grimard, Dominique; Guay, Maryse; Hudon, Catherine; Lalonde, Lyne; Lévesque, Lise; Michaud, Cecile; Provost, Sylvie; Sutton, Tim; Tousignant, Pierre; Travers, Stella; Ware, Mark; Gogovor, Amede

2015-10-15

Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation. The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis. Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event. The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

Healthcare is primary

PubMed Central

Kumar, Raman

2015-01-01

India is undergoing a rapid transformation in terms of governance, administrative reforms, newer policy develoment, and social movements. India is also considered one of the most vibrant economies in the world. The current discourse in public space is dominated by issues such as economic development, security, corruption free governance, gender equity, and women safety. Healthcare though remains a pressing need of population; seems to have taken a backseat. In the era of decreasing subsidies and cautious investment in social sectors, the 2nd National Conference on Family Medicine and Primary Care 2015 (FMPC) brought a focus on “healthcare” in India. The theme of this conference was “Healthcare is Primary.” The conference participants discussed on the theme of why healthcare should be a national priority and why strong primary care should remain at the center of healthcare delivery system. The experts recommended that India needs to strengthen the “general health system” instead of focusing on disease based vertical programs. Public health system should have capacity and skill pool to be able to deliver person centered comprehensive health services to the community. Proactive implementation of policies towards human resource in health is the need of the hour. As the draft National Health Policy 2015 is being debated, “family medicine” (academic primary care), the unfinished agenda of National Health Policy 2002, remains a priority area of implementation. PMID:26985402

An overview of future EU health systems. An insight into governance, primary care, data collection and citizens' participation.

PubMed

Quaglio, Gianluca; Figueras, Josep; Mantoan, Domenico; Dawood, Amr; Karapiperis, Theodoros; Costongs, Caroline; Bernal-Delgado, Enrique

2018-03-26

Health systems in the European Union (EU) are being questioned over their effectiveness and sustainability. In pursuing both goals, they have to conciliate coexisting, not always aligned, realities. This paper originated from a workshop entitled 'Health systems for the future' held at the European Parliament. Experts and decision makers were asked to discuss measures that may increase the effectiveness and sustainability of health systems, namely: (i) increasing citizens' participation; (ii) the importance of primary care in providing integrated services; (iii) improving the governance and (iv) fostering better data collection and information channels to support the decision making process. In the parliamentary debate, was discussed the concept that, in the near future, health systems' effectiveness and sustainability will very much depend on effective access to integrated services where primary care is pivotal, a clearer shift from care-oriented systems to health promotion and prevention, a profound commitment to good governance, particularly to stakeholders participation, and a systematic reuse of data meant to build health data-driven learning systems. Many health issues, such as future health systems in the EU, are potentially transformative and hence an intense political issue. It is policy-making leadership that will mostly determine how well EU health systems are prepared to face future challenges.

Emergence of a Policy, closure of a sector: regarding the management of penitentiary health care in Brazil.

PubMed

Batista E Silva, Martinho Braga

2016-06-01

The aim of this study is to understand recent transformations in penitentiary health care management in Brazil, during the implementation of the National Policy for Comprehensive Health Care for People Deprived of Liberty in the Prison System, and the closure of the National Sector for Penitentiary Health Care. The scientific problem investigated is the language of penitentiary health care policy. The theoretical-methodological framework adopted is Pierre Bourdieu's genetic structuralism. In this manner, we carry out an analysis of documents and public statements in search of State categories and classifications. We note the consolidation of a state classification that separates the 'penitentiary' domain from the 'prison' domain, as well as the creation of the State category of 'person deprived of liberty in the prison system'. Penitentiary health care management constitutes itself as a question of primary care.

76 FR 69166 - Airworthiness Directives; Bombardier, Inc. Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-08

...] transformer primary winding can break due to thermal fatigue. Broken transformer primary winding can prevent.... However, it was found that the same ADG GCU transformer primary winding can break due to thermal fatigue. Broken transformer primary winding can prevent the supply of power from the ADG to the essential buses...

Readiness of Primary Care Practices for Medical Home Certification

PubMed Central

Clark, Sarah J.; Sakshaug, Joseph W.; Chen, Lena M.; Hollingsworth, John M.

2013-01-01

OBJECTIVES: To assess the prevalence of medical home infrastructure among primary care practices for children and identify practice characteristics associated with medical home infrastructure. METHODS: Cross-sectional analysis of restricted data files from 2007 and 2008 of the National Ambulatory Medical Care Survey. We mapped survey items to the 2011 National Committee on Quality Assurance’s Patient-Centered Medical home standards. Points were awarded for each “passed” element based on National Committee for Quality Assurance scoring, and we then calculated the percentage of the total possible points met for each practice. We used multivariate linear regression to assess associations between practice characteristics and the percentage of medical home infrastructure points attained. RESULTS: On average, pediatric practices attained 38% (95% confidence interval 34%–41%) of medical home infrastructure points, and family/general practices attained 36% (95% confidence interval 33%–38%). Practices scored higher on medical home elements related to direct patient care (eg, providing comprehensive health assessments) and lower in areas highly dependent on health information technology (eg, computerized prescriptions, test ordering, laboratory result viewing, or quality of care measurement and reporting). In multivariate analyses, smaller practice size was significantly associated with lower infrastructure scores. Practice ownership, urban versus rural location, and proportion of visits covered by public insurers were not consistently associated with a practice’s infrastructure score. CONCLUSIONS: Medical home programs need effective approaches to support practice transformation in the small practices that provide the vast majority of the primary care for children in the United States. PMID:23382438

Clinical application of pharmacogenetics: focusing on practical issues.

PubMed

Chang, Matthew T; McCarthy, Jeanette J; Shin, Jaekyu

2015-01-01

Recent large-scale genetic-based studies have transformed the field of pharmacogenetics to identify, characterize and leverage genetic information to inform patient care. Genetic testing can be used to alter drug selection, optimize drug dosing and prevent unnecessary adverse events. As precision medicine becomes the mainstay in the clinic, it becomes critical for clinicians to utilize pharmacogenetics to guide patient care. One primary challenge is identifying patients where genetic tests that can potentially impact patient care. To address this challenge, our review highlights many practical issues clinicians may encounter: identifying candidate patients and clinical laboratories for pharmacogenetic testing, selecting highly curated resources to help asses test validity, reimbursing costs of pharmacogenetic tests, and interpreting of pharmacogenetic test results.

Developing High-Functioning Teams: Factors Associated With Operating as a "Real Team" and Implications for Patient-Centered Medical Home Development.

PubMed

Stout, Somava; Zallman, Leah; Arsenault, Lisa; Sayah, Assaad; Hacker, Karen

2017-01-01

Team-based care is a foundation of health care redesign models like the patient-centered medical home (PCMH). Yet few practices rigorously examine how the implementation of PCMH relates to teamwork. We identified factors associated with the perception of a practice operating as a real team. An online workforce survey was conducted with all staff of 12 primary care sites of Cambridge Health Alliance at different stages of PCMH transformation. Bivariate and multivariate analyses of factors associated with teamwork perceptions were conducted. In multivariate models, having effective leadership was the main factor associated with practice teamwork perceptions (odds ratio [OR], 10.49; 95% confidence interval [CI], 5.39-20.43); in addition, practicing at a site in an intermediate stage of PCMH transformation was also associated with enhanced team perceptions (OR, 2.44; 95% CI, 1.28-4.64). In a model excluding effective leadership, respondents at sites in an intermediate stage of PCMH transformation (OR, 1.95; 95% CI, 1.1-3.4) and who had higher care team behaviors (such as huddles and weekly meetings; OR, 3.41; 95% CI, 1.30-8.92), higher care team perceptions (OR, 2.65; 95% CI, 1.15-6.11), and higher job satisfaction (OR, 2.00; 95% CI, 1.02-3.92) had higher practice teamwork perceptions. This study highlights the strong association between effective leadership, care team behaviors and perceptions, and job satisfaction with perceptions that practices operate as real teams. Although we cannot infer causality with these cross-sectional data, this study raises the possibility that providing attention to these factors may be important in augmenting practice teamwork perceptions.

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 with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. 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. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs.

Transforming Training to Build the Family Physician Workforce Our Country Needs.

PubMed

Hughes, Lauren S; Tuggy, Michael; Pugno, Perry A; Peterson, Lars E; Brungardt, Stacy H; Hoekzema, Grant; Jones, Samuel; Weida, Jane; Bazemore, Andrew

2015-09-01

The Affordable Care Act has spurred significant change in the US health care system, including expansion of Medicaid and private insurance coverage to millions of Americans. As a result, the need for the medical education continuum to produce a family physician workforce that is sizable enough and highly skilled is significant. These two interdependent goals have emerged as top priorities for Family Medicine for America's Health, a new, 5-year, $21 million collaborative strategic effort of the eight US family medicine organizations to lead continued change in the US health care system. To achieve these important goals, reforms are needed across the entire educational continuum, including how we recruit, train, and help practicing family physicians refresh their skills. Such reforms must provide opportunities to acquire skills needed in new practice and payment environments, to incorporate new educational standards that reflect the public's expectations of family physicians, to collaborate with our primary care colleagues to develop effective interprofessional training, and to design educational programs that are socially accountable to the patients, families, and communities we serve. Through Family Medicine for America's Health, the discipline is well positioned to emerge as a leader in primary care workforce development and educational quality.

Michigan's fee-for-value physician incentive program reduces spending and improves quality in primary care.

PubMed

Lemak, Christy Harris; Nahra, Tammie A; Cohen, Genna R; Erb, Natalie D; Paustian, Michael L; Share, David; Hirth, Richard A

2015-04-01

As policy makers and others seek to reduce health care cost growth while improving health care quality, one approach gaining momentum is fee-for-value reimbursement. This payment strategy maintains the traditional fee-for-service arrangement but includes quality and spending incentives. We examined Blue Cross Blue Shield of Michigan's Physician Group Incentive Program, which uses a fee-for-value approach focused on primary care physicians. We analyzed the program's impact on quality and spending from 2008 to 2011 for over three million beneficiaries in over 11,000 physician practices. Participation in the incentive program was associated with approximately 1.1 percent lower total spending for adults (5.1 percent lower for children) and the same or improved performance on eleven of fourteen quality measures over time. Our findings contribute to the growing body of evidence about the potential effectiveness of models that align payment with cost and quality performance, and they demonstrate that it is possible to transform reimbursement within a fee-for-service framework to encourage and incentivize physicians to provide high-quality care, while also reducing costs. Project HOPE—The People-to-People Health Foundation, Inc.

Oregon's Medicaid Reform And Transition To Global Budgets Were Associated With Reductions In Expenditures.

PubMed

McConnell, K John; Renfro, Stephanie; Lindrooth, Richard C; Cohen, Deborah J; Wallace, Neal T; Chernew, Michael E

2017-03-01

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7 percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs. Project HOPE—The People-to-People Health Foundation, Inc.

“Hepatitis C treatment turned me around:” Psychological and Behavioral Transformation Related to Hepatitis C Treatment

PubMed Central

Peyser, D; Nahvi, S; Arnsten, JH; Litwin, AH

2016-01-01

Background Hepatitis C (HCV) is a significant public health problem that primarily affects current and former substance users. However, individuals with a history of substance use are less likely to have access to or engage in HCV care. Psychological and behavioral barriers prevent many HCV-infected individuals from initiating or engaging in HCV treatment. This study aimed to investigate the psychological and behavioral experiences of current and former substance users receiving HCV treatment within a combined methadone and primary care clinic in the United States. Methods We conducted 31 semi-structured qualitative interviews with opioid-dependent adults enrolled in an integrated HCV treatment program within a methadone maintenance clinic in the Bronx, NY. We used thematic analysis, informed by grounded theory, and inquired about perceptions of HCV before and after initiating HCV treatment, reasons for initiating HCV treatment, and the decision to participate in individual versus group HCV treatment. Results Participants described psychological and behavioral transformation over the course of HCV treatment. These included reductions in internalized stigma and shame related to HCV and addiction, increases in HCV disclosure and self-care, reductions in substance use, and new desire to help others who are living with HCV. Conclusions Integrating HCV treatment with methadone maintenance has the potential to create psychological and behavioral transformations among substance using adults, including reductions in HCV- and addiction-related shame and improvements in overall self-care. PMID:26096534

"Hepatitis C treatment turned me around:" Psychological and behavioral transformation related to hepatitis C treatment.

PubMed

Batchelder, A W; Peyser, D; Nahvi, S; Arnsten, J H; Litwin, A H

2015-08-01

Hepatitis C (HCV) is a significant public health problem that primarily affects current and former substance users. However, individuals with a history of substance use are less likely to have access to or engage in HCV care. Psychological and behavioral barriers prevent many HCV-infected individuals from initiating or engaging in HCV treatment. This study aimed to investigate the psychological and behavioral experiences of current and former substance users receiving HCV treatment within a combined methadone and primary care clinic in the United States. We conducted 31 semi-structured qualitative interviews with opioid-dependent adults enrolled in an integrated HCV treatment program within a methadone maintenance clinic in the Bronx, NY. We used thematic analysis, informed by grounded theory, and inquired about perceptions of HCV before and after initiating HCV treatment, reasons for initiating HCV treatment, and the decision to participate in individual versus group HCV treatment. Participants described psychological and behavioral transformation over the course of HCV treatment. These included reductions in internalized stigma and shame related to HCV and addiction, increases in HCV disclosure and self-care, reductions in substance use, and new desire to help others who are living with HCV. Integrating HCV treatment with methadone maintenance has the potential to create psychological and behavioral transformations among substance using adults, including reductions in HCV- and addiction-related shame and improvements in overall self-care. Copyright © 2015. Published by Elsevier Ireland Ltd.

Evaluation of patient centered medical home practice transformation initiatives.

PubMed

Crabtree, Benjamin F; Chase, Sabrina M; Wise, Christopher G; Schiff, Gordon D; Schmidt, Laura A; Goyzueta, Jeanette R; Malouin, Rebecca A; Payne, Susan M C; Quinn, Michael T; Nutting, Paul A; Miller, William L; Jaén, Carlos Roberto

2011-01-01

The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.

Understanding the organisational culture of district health services: Mahalapye and Ngamiland health districts of Botswana

PubMed Central

Mash, Robert; Phaladze, Nthabiseng

2015-01-01

Background Botswana has a shortage of health care workers, especially in primary health care. Retention and high performance of employees are closely linked to job satisfaction and motivation, which are both highest where employees’ personal values and goals are realised. Aim The aim of the study was to evaluate employees’ personal values, and the current and desired organisational culture of the district health services as experienced by the primary health care workers. Setting The study was conducted in the Ngamiland and Mahalapye health districts. Method This was a cross sectional survey. The participants were asked to select 10 values that best described their personal, current organisational and desired organisational values from a predetermined list. Results Sixty and 67 health care workers completed the survey in Mahalapye and Ngamiland districts, respectively. The top 10 prevalent organisational values experienced in both districts were: teamwork, patient satisfaction, blame, confusion, job insecurity, not sharing information and manipulation. When all the current values were assessed, 32% (Mahalapye) and 36% (Ngamiland) selected by health care workers were potentially limiting organisational effectiveness. The organisational values desired by health care workers in both districts were: transparency, professional growth, staff recognition, shared decision-making, accountability, productivity, leadership development and teamwork. Conclusions The experience of the primary health care workers in the two health districts were overwhelmingly negative, which is likely to contribute to low levels of motivation, job satisfaction, productivity and high attrition rates. There is therefore urgent need for organisational transformation with a focus on staff experience and leadership development. PMID:26842516

[Family caregiver issues: gender, privacy, and public policy perspectives].

PubMed

Lee, I; Chou, Fan-Hao; Chen, Chung-Hey

2011-04-01

Due to the phenomenon of Taiwan'saging population has made, long-term care has become an issue of increasingly emphasized importance. According to the statistics, the family takes responsibility for most long-term care duties and more than 70% of primary family caregivers are female. In the past, because of gender-based divisions of labor and gender role expectations made, it was taken for granted that females would be the socially preferred family caregivers. Those men who devoting in themselves to such work were regarded as a rare precious. As such, family care signified entailed different life experiences for males and females. Over the years, amendments to the civil code have recognized family care contributions, and the allowance for caregivers underlines that care responsibilities have shifted away from the family to society. Traditional gender divisions of labor today are significantly more blurred; family structures have become smaller in size; female labor in the workplace has increased; and ten-year long-term care plans and long-term care insurance have been successively implemented. These transformations will make labor outsourcing more and more popular and transform family care from a private problem to a pubic policy issue. In the future, family caregivers require consideration and support on a sustained basis. It is also important to improve and monitor the quality of care services. Nurses, the major professional members of long-term care teams, should be concerned over the issue of family care while providing nursing care. They should include family caregivers in the care plan so that they can make sure that patients receive comprehensive and constant care in order to enhance the overall quality of nursing care.

[The Mexican health system: does it require a transformation?].

PubMed

Chertorivski Woldenberg, Salomón; Fajardo Dolci, German

2012-01-01

National health systems represent an organized social response that enables countries to improve, maintain and enhance the health status of their citizens. These evolve and are transformed according to changes in the biological, economic, political and social components of health. In Mexico there is currently a segmented health system, consisting of a bismarckian model of social security and a social protection in health model. The latter developed to comply with the fourth constitutional article by which health is no longer described as a right linked to the employment status of the individual. Given this reality at least three alternatives seem to emerge for the future: the permanence of a mixed health system with social security and social protection institutions with a similar weight within the national health system, or its opposite, the extension of social protection as a mechanism for widespread access. Given the challenges we face, it is desirable to establish a unified health system, the aim should be that health care is universally protected, as currently happens, but is guaranteed through a much more efficient and based in primary care health care system.

Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review

PubMed Central

Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim

2016-01-01

Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician–patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients’ experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships. PMID:27789958

Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review.

PubMed

Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim

2016-01-01

Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician-patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients' experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships.

From end of life to chronic care: the provision of community home-based care for HIV and the adaptation to new health care demands in Zambia.

PubMed

Aantjes, Carolien J; Simbaya, Joseph; Quinlan, Tim K C; Bunders, Joske F G

2016-11-01

Aim We present the evolution of primary-level HIV and AIDS services, shifting from end of life to chronic care, and draw attention to the opportunities and threats for the future of Zambia's nascent chronic care system. Although African governments struggled to provide primary health care services in the context of a global economic crisis, civil society organisations (CSO) started mobilising settlement residents to respond to another crisis: the HIV and AIDS pandemic. These initiatives actively engaged patients, families and settlement residents to provide home-based care to HIV-infected patients. After 30 years, CHBC programmes continue to be appropriate in the context of changing health care needs in the population. The study took place in 2011 and 2012 and was part of a multi-country study. It used a mixed method approach involving semi-structured interviews, focus group discussions, structured interviews, service observations and a questionnaire survey. Findings Our research revealed long-standing presence of extensive mutual support amongst residents in many settlements, the invocation of cultural values that emphasise social relationships and organisation of people by CSO in care and support programmes. This laid the foundation for a locally conceived model of chronic care capable of addressing the new care demands arising from the country's changing burden of disease. However, this capacity has come under threat as the reduction in donor funding to community home-based care programmes and donor and government interventions, which have changed the nature of these programmes in the country. Zambia's health system risks losing valuable capacity for fulfilling its vision 'to bring health care as close to the family as possible' if government strategies do not acknowledge the need for transformational approaches to community participation and continuation of the brokering role by CSO in primary health care.

The Patient Protection and Affordable Care Act - The Role of the School Nurse: Position Statement.

PubMed

2015-07-01

It is the position of the National Association of School Nurses that the registered professional school nurse (hereinafter referred to as the school nurse) serves a vital role in the delivery of health care to our nation’s students within the health care system reshaped by the Patient Protection and Affordable Care Act of 2010, commonly known as the Affordable Care Act (ACA). This law presents an opportunity to transform the health care system through three primary goals: expanding access, improving quality, and reducing cost (U.S. Government Printing Office, 2010). School nurses stand at the forefront of this system change and continue to provide evidence-based, quality interventions and preventive care that, according to recent studies, actually save health care dollars (Wang et al., 2014). NASN supports the concept that school nursing services receive the same financial parity as other health care providers to improve overall health outcomes, including insurance reimbursement for services provided to students.

Fostering evidence-based quality improvement for patient-centered medical homes: Initiating local quality councils to transform primary care.

PubMed

Stockdale, Susan E; Zuchowski, Jessica; Rubenstein, Lisa V; Sapir, Negar; Yano, Elizabeth M; Altman, Lisa; Fickel, Jacqueline J; McDougall, Skye; Dresselhaus, Timothy; Hamilton, Alison B

Although the patient-centered medical home endorses quality improvement principles, methods for supporting ongoing, systematic primary care quality improvement have not been evaluated. We introduced primary care quality councils at six Veterans Health Administration sites as an organizational intervention with three key design elements: (a) fostering interdisciplinary quality improvement leadership, (b) establishing a structured quality improvement process, and (c) facilitating organizationally aligned frontline quality improvement innovation. Our evaluation objectives were to (a) assess design element implementation, (b) describe implementation barriers and facilitators, and (c) assess successful quality improvement project completion and spread. We analyzed administrative records and conducted interviews with 85 organizational leaders. We developed and applied criteria for assessing design element implementation using hybrid deductive/inductive analytic techniques. All quality councils implemented interdisciplinary leadership and a structured quality improvement process, and all but one completed at least one quality improvement project and a toolkit for spreading improvements. Quality councils were perceived as most effective when service line leaders had well-functioning interdisciplinary communication. Matching positions within leadership hierarchies with appropriate supportive roles facilitated frontline quality improvement efforts. Two key resources were (a) a dedicated internal facilitator with project management, data collection, and presentation skills and (b) support for preparing customized data reports for identifying and addressing practice level quality issues. Overall, quality councils successfully cultivated interdisciplinary, multilevel primary care quality improvement leadership with accountability mechanisms and generated frontline innovations suitable for spread. Practice level performance data and quality improvement project management support were critical. In order to successfully facilitate systematic, sustainable primary care quality improvement, regional and executive health care system leaders should engage interdisciplinary practice level leadership in a priority-setting process that encourages frontline innovation and establish local structures such as quality councils to coordinate quality improvement initiatives, ensure accountability, and promote spread of best practices.

The Future of Family Medicine: A Collaborative Project of the Family Medicine Community

PubMed Central

2004-01-01

BACKGROUND Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. METHODS A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. RESULTS The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine’s basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. CONCLUSIONS The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans. PMID:15080220

The Future of Family Medicine: a collaborative project of the family medicine community.

PubMed

Martin, James C; Avant, Robert F; Bowman, Marjorie A; Bucholtz, John R; Dickinson, John R; Evans, Kenneth L; Green, Larry A; Henley, Douglas E; Jones, Warren A; Matheny, Samuel C; Nevin, Janice E; Panther, Sandra L; Puffer, James C; Roberts, Richard G; Rodgers, Denise V; Sherwood, Roger A; Stange, Kurt C; Weber, Cynthia W

2004-01-01

Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Enhancing the Evidence for Behavioral Counseling

PubMed Central

Alcántara, Carmela; Klesges, Lisa M.; Resnicow, Ken; Stone, Amy; Davidson, Karina W.

2015-01-01

U.S. Preventive Services Task Force (USPSTF) clinical guidelines at present rarely assign the highest grade recommendation to behavioral counseling interventions for chronic disease prevention or risk reduction because of concerns about the certainty and quality of the evidence base. As a result, the broad integration of behavioral counseling interventions in primary care remains elusive. Thus, there is an urgent need for novel perspectives on how to generate the highest-quality and -certainty evidence for primary care–focused behavioral counseling interventions. As members of the Society of Behavioral Medicine (SBM)—a multidisciplinary scientific organization committed to improving population health through behavior change—we review the USPSTF mandate and current recommendations for behavioral counseling interventions, and provide a perspective for the future that calls for concerted and coordinated efforts among SBM, USPSTF, and other organizations invested in the rapid and wider uptake of beneficial, feasible, and referable primary care–focused behavioral counseling interventions. This perspective highlights five areas for further development, including: (1) behavioral counseling–focused practice-based research networks; (2) promotion of USPSTF evidence standards and the increased use of pragmatic RCT design; (3) quality control and improvement procedures for behavioral counseling training; (4) systematic research on effective primary care–based collaborative care models; and (5) methodologic innovations that capitalize on disruptive technologies and healthcare transformation. Collective efforts to improve the health of all Americans in the 21st century and beyond must ensure that effective, feasible, and referable behavioral counseling interventions are embedded in modern primary care practice. PMID:26296553

How to change organisational culture: Action research in a South African public sector primary care facility.

PubMed

Mash, Robert; De Sa, Angela; Christodoulou, Maria

2016-08-31

Organisational culture is a key factor in both patient and staff experience of the healthcare services. Patient satisfaction, staff engagement and performance are related to this experience. The department of health in the Western Cape espouses a values-based culture characterised by caring, competence, accountability, integrity, responsiveness and respect. However, transformation of the existing culture is required to achieve this vision. To explore how to transform the organisational culture in line with the desired values. Retreat Community Health Centre, Cape Town, South Africa. Participatory action research with the leadership engaged with action and reflection over a period of 18 months. Change in the organisational culture was measured at baseline and after 18 months by means of a cultural values assessment (CVA) survey. The three key leaders at the health centre also completed a 360-degree leadership values assessment (LVA) and had 6 months of coaching. Cultural entropy was reduced from 33 to 13% indicating significant transformation of organisational culture. The key driver of this transformation was change in the leadership style and functioning. Retreat health centre shifted from a culture that emphasised hierarchy, authority, command and control to one that established a greater sense of cohesion, shared vision, open communication, appreciation, respect, fairness and accountability. Transformation of organisational culture was possible through a participatory process that focused on the leadership style, communication and building relationships by means of CVA and feedback, 360-degree LVA, feedback and coaching and action learning in a co-operative inquiry group.

Strategies for Addressing the Challenges of Patient-Centered Medical Home Implementation: Lessons from Oregon.

PubMed

Gelmon, Sherril; Bouranis, Nicole; Sandberg, Billie; Petchel, Shauna

2018-01-01

Patient-centered medical homes (PCMHs) are at the forefront of the transformation of primary care as part of health systems reform. Despite robust literature describing implementation challenges, few studies describe strategies being used to overcome these challenges. This article addresses this gap through observations of exemplary PCMHs in Oregon, where the Oregon Health Authority supports and recognizes Patient-Centered Primary Care Homes (PCPCH). Twenty exemplary PCPCHs were selected using program scores, with considerations for diversity in clinic characteristics. Between 2015 and 2016, semistructured interviews and focus groups were completed with 85 key informants. Clinics reported similar challenges implementing the PCPCH model, including shifting patterns of care use, fidelity to the PCPCH model, and refining care processes. The following ten implementation strategies emerged: expanding access through care teams, preventing unnecessary emergency department visits through patient outreach, improved communication and referral tracking with outside providers, prioritization of selected program metrics, implementing patient-centered practices, developing continuous improvement capacity through committees and "champions," incorporating preventive services and chronic disease management, standardization of workflows, customizing electronic health records, and integration of mental health. Clinic leaders benefited from understanding the local context in which they were operating. Despite differences in size, ownership, geography, and population, all clinic leaders were observed to be proponents of strategies commonly associated with a "learning organization": systems thinking, personal mastery, mental models, shared vision, and team. Clinics can draw on their own characteristics, use state resources, and look to established PCMHs to build the evidence base for implementation in primary care. © Copyright 2018 by the American Board of Family Medicine.

Effectively Transforming IMC Flight into VMC Flight: An SVS Case Study

NASA Technical Reports Server (NTRS)

Glaab, Louis J.; Hughes, Monic F.; Parrish, Russell V.; Takallu, Mohammad A.

2006-01-01

A flight-test experiment was conducted using the NASA LaRC Cessna 206 aircraft. Four primary flight and navigation display concepts, including baseline and Synthetic Vision System (SVS) concepts, were evaluated in the local area of Roanoke Virginia Airport, flying visual and instrument approach procedures. A total of 19 pilots, from 3 pilot groups reflecting the diverse piloting skills of the GA population, served as evaluation pilots. Multi-variable Discriminant Analysis was applied to three carefully selected and markedly different operating conditions with conventional instrumentation to provide an extension of traditional analysis methods as well as provide an assessment of the effectiveness of SVS displays to effectively transform IMC flight into VMC flight.

Open access in the patient-centered medical home: lessons from the Veterans Health Administration.

PubMed

True, Gala; Butler, Anneliese E; Lamparska, Bozena G; Lempa, Michele L; Shea, Judy A; Asch, David A; Werner, Rachel M

2013-04-01

The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care. We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change. A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states. Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics. We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011. Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge. Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.

Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden.

PubMed

Strandberg, Eva Lena; Brorsson, Annika; André, Malin; Gröndal, Hedvig; Mölstad, Sigvard; Hedin, Katarina

2016-07-18

Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care. Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners' audit registrations. Qualitative data were collected through observations and semi-structured interviews. From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner's diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual. Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses' triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

UPMC Prescription for Wellness: A Quality Improvement Case Study for Supporting Patient Engagement and Health Behavior Change.

PubMed

Maners, Rebecca J; Bakow, Eric; Parkinson, Michael D; Fischer, Gary S; Camp, Geoffrey R

Addressing patient health and care behaviors that underlie much of chronic disease continues to challenge providers, medical practices, health systems, and insurers. Improving health and care as described by the Quadruple Aim requires innovation at the front lines of clinical care: the doctor-patient interaction and office practice. This article describes the use of Lean Six Sigma in a quality improvement (QI) effort to design an effective and scalable method for physicians to prescribe health coaching for healthy behaviors in a primary care medical home within a large integrated delivery and financing system. Building on the national Agency for Healthcare Research and Quality and Robert Wood Johnson Foundation-funded Prescription for Health multisite demonstration, this QI case study provides important lessons for transforming patient-physician-practice support systems to better address lifestyle and care management challenges critical to producing better outcomes.

Chronic disease management: the primary care perspective.

PubMed

Bragaglia, Pauline; O'Brien, Lewis

2007-01-01

This response to the essay is a "view from the trenches" by two doctors who have worked over 23 years at the Group Health Centre in Sault Ste. Marie, Ontario. We would agree wholeheartedly that reducing wait times for selected procedures will not transform our health system, although they are a start that does provide improved quality of life for a relatively small number of people. We have struggled with the care gap between known best practices and the reality of care provided, from the perspectives of both prevention and chronic disease management. This has resulted in an acute awareness of the need for an across-the-system, "bottom-up" approach to the prevention of disease and management of healthcare. Limited resources must be carefully leveraged in innovative ways if we are to eliminate this care gap, decrease morbidity and minimize expensive "rescue" procedures that make our system increasingly unaffordable.

Acceptance of lean redesigns in primary care: A contextual analysis.

PubMed

Hung, Dorothy; Gray, Caroline; Martinez, Meghan; Schmittdiel, Julie; Harrison, Michael I

Lean is a leading change strategy used in health care to achieve short-term efficiency and quality improvement while promising longer-term system transformation. Most research examines Lean intervention to address isolated problems, rather than to achieve broader systemic changes to care delivery. Moreover, no studies examine contextual influences on system-wide Lean implementation efforts in primary care. The aim of this study was to identify contextual factors most critical to implementing and scaling Lean redesigns across all primary care clinics in a large, ambulatory care delivery system. Over 100 interviews and focus groups were conducted with frontline physicians, clinical staff, and operational leaders. Data analysis was guided by a modified Consolidated Framework for Implementation Research (CFIR), a popular implementation science framework. On the basis of expert recommendations, the modified framework targets factors influencing the implementation of process redesigns. This modified framework, the CFIR-PR, informed our identification of contextual factors that most impacted Lean acceptance among frontline physicians and staff. Several domains identified by the CFIR-PR were critical to acceptance of Lean redesigns. Regarding the implementation process acceptance was influenced by time and intensity of exposure to changes, "top-down" versus "bottom-up" implementation styles, and degrees of employee engagement in developing new workflows. Important factors in the inner setting were the clinic's culture and style of leadership, along with availability of information about Lean's effectiveness. Last, implementation efforts were impacted by individual and team characteristics regarding changed work roles and related issues of professional identity, authority, and autonomy. This study underscores the need for change leaders to consider the contextual factors that surround efforts to implement Lean in primary care. As Lean redesigns are scaled across a system, special attention is warranted with respect to the implementation approach, internal clinic setting, and implications for professional roles and identities of physicians and staff.

The place of receptionists in access to primary care: Challenges in the space between community and consultation.

PubMed

Neuwelt, Pat M; Kearns, Robin A; Browne, Annette J

2015-05-01

At the point of entry to the health care system sit general practice receptionists (GPRs), a seldom studied employment group. The place of the receptionist involves both a location within the internal geography of the clinic and a position within the primary care team. Receptionists literally 'receive' those who phone or enter the clinic, and are a critical influence in their transformation from a 'person' to a 'patient'. This process occurs in a particular space: the 'waiting room'. We explore the waiting room and its dynamics in terms of 'acceptability', an under-examined aspect of access to primary care. We ask 'How do GPRs see their role with regard to patients with complex health and social needs, in light of the spatio-temporal constraints of their working environments?' We engaged receptionists as participants to explore perceptions of their roles and their workspaces, deriving narrative data from three focus groups involving 14 GPRs from 11 practices in the Northland region of New Zealand. The study employed an adapted form of grounded theory. Our findings indicate that GPRs are on the edge of the practice team, yet carry a complex role at the frontline, in the waiting space. They are de facto managers of this space; however, they have limited agency within general practice settings, due to the constraints imposed upon them by physical and organisational structures. The agency of GPRs is most evident in their ability to shape the social dynamics of the waiting space, and to frame the health care experience as positive for people whose usual experience is marginalisation. We conclude that, if well supported, receptionists have the potential to positively influence health care acceptability, and patients' access to care. Copyright © 2014 Elsevier Ltd. All rights reserved.

Enhancing assertiveness in district nurse specialist practice.

PubMed

Green, Julie

2016-08-02

District nurse (DN) care delivery has undergone substantial change in recent years due to changing demographics and service delivery demands that have called for a move of care delivery from secondary to primary care. The title District Nurse is recorded with the Nursing and Midwifery Council (NMC) on completion of the Specialist Practice Qualification in District Nursing (SPQ DN), which purports to be a 'transformational' course that prepares future caseload holders to manage their team and prioritise care delivery effectively. This article explores the need for assertiveness skills in this role in response to Australian research, and outlines the pedagogic interventions implemented during the SPQ DN course to enhance this skill. Assertiveness scores were monitored for the duration of the course and demonstrated a significant increase-a topic that is now the subject of a future, funded study.

Modeling human endothelial cell transformation in vascular neoplasias

PubMed Central

Wen, Victoria W.; MacKenzie, Karen L.

2013-01-01

Endothelial cell (EC)-derived neoplasias range from benign hemangioma to aggressive metastatic angiosarcoma, which responds poorly to current treatments and has a very high mortality rate. The development of treatments that are more effective for these disorders will be expedited by insight into the processes that promote abnormal proliferation and malignant transformation of human ECs. The study of primary endothelial malignancy has been limited by the rarity of the disease; however, there is potential for carefully characterized EC lines and animal models to play a central role in the discovery, development and testing of molecular targeted therapies for vascular neoplasias. This review describes molecular alterations that have been identified in EC-derived neoplasias, as well as the processes that underpin the immortalization and tumorigenic conversion of ECs. Human EC lines, established through the introduction of defined genetic elements or by culture of primary tumor tissue, are catalogued and discussed in relation to their relevance as models of vascular neoplasia. PMID:24046386

Dissemination and adoption of the advanced primary care model in the Maryland multi-payer patient centered medical home program.

PubMed

Khanna, Niharika; Shaya, Fadia; Chirikov, Viktor; Steffen, Ben; Sharp, David

2014-02-01

The Maryland Learning Collaborative together with the Maryland Multi-Payer Program transformed 52 medical practices into patient-centered medical homes (PCMH). The Maryland Learning Collaborative developed an Internet-based 14-question Likert scale survey to assess the impact of the PCMH model on practices and providers, concerning how this new method is affecting patient care and outcomes. The survey was sent to 339 practitioners and 52 care management teams at 18 months into the program. Sixty-seven survey results were received and analyzed. After 18 months of participation in the PCMH initiative, participants demonstrated a better understanding of the PCMH initiative, improved patient access to care, improved care coordination, and increased health information technology optimization (p > .001). The findings from the survey evaluation suggest that practice participation in the Maryland Multi-Payer Program has enhanced access to care, influenced patient outcomes, improved care coordination, and increased use of health information technology.

Evaluation of Patient Centered Medical Home Practice Transformation Initiatives

PubMed Central

Crabtree, Benjamin F.; Chase, Sabrina M.; Wise, Christopher G.; Schiff, Gordon D.; Schmidt, Laura A.; Goyzueta, Jeanette R.; Malouin, Rebecca A.; Payne, Susan M. C.; Quinn, Michael T.; Nutting, Paul A.; Miller, William L.; Jaén, Carlos Roberto

2011-01-01

Background The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. Methods Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. Results A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Conclusions Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures. PMID:21079525

[Prevalence and characterization of overactive bladder detected in a population in Madrid with self-administered OAB-V3 questionnaire in Primary Care].

PubMed

Angulo, Javier C; Calderín, María P; Fernández, Yolanda; González, Miriam; Gómez, Esther; Herreros, Maria B; Peñasco, Purificación; Zapatero, Manuela; Dorado, Juan F

2018-02-01

Determining the prevalence of symptoms suggestive of overactive bladder (OAB) in a Spanish population and evaluate the impact of these symptoms on well-being and labour productivity in this population. Transversal study. Primary health care, Madrid, Spain. Males and females >30 years. Classification by primary care physicians with the Overactive Bladder Awareness Tool abbreviated version (OAB-V3). Subjects with score ≥3 and a similarly balanced control population with score <3 were clinically investigated. History, physical examination, urinalysis, sonography, general well-being scale and the questionnaires PPBC, OAB-q y WPAI-SHP. A total 923 subjects were screened, of which 209 (22.6%), 35% males and 65% females, had probable OAB. Age distribution increased from 11.1% in 4th decade to 44.4% in 9th decade. Kappa coefficient between suspected OAB and definite diagnosis was .83. The area under ROC curve for diagnosis based on OAB-V3 questionnaire and the presence of perceived bother and coping strategies was 92%. Subjects classified by score ≥3 had worse well-being, higher PPBC score and worse parameters on total OAB-q and transformed scores for each OAB-q subscale (P<.0001). In these subjects labour productivity was not affected (P=.14) but the capacity to perform regular activities was (P<.0001). OAB-V3 is a simple questionnaire to screen OAB with good predictive accuracy in a primary care setting and reveals important implications on health related quality of life issues. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

The Cost of Sustaining a Patient-Centered Medical Home: Experience From 2 States

PubMed Central

Magill, Michael K.; Ehrenberger, David; Scammon, Debra L.; Day, Julie; Allen, Tatiana; Reall, Andreu J.; Sides, Rhonda W.; Kim, Jaewhan

2015-01-01

PURPOSE As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these “advanced primary care” functions. A key required input is personnel effort. This study’s objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards. METHODS We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions. RESULTS Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado. CONCLUSIONS Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions. PMID:26371263

The Affordable Care Act: the ethical call to transform the organizational culture.

PubMed

Piper, Llewellyn E

2014-01-01

The Patient Protection and Affordable Care Act will require health care leaders and managers to develop strategies and implement organizational tactics for their organization to survive and thrive under the federal mandates of this new health care law. Successful health care organizations and health care systems will be defined by their adaptability in the new value-based marketplace created by the Affordable Care Act. The most critical underlining challenge for this success will be the effective transformation of the organizational culture. Transformational value-based leadership is now needed to answer the ethical call for transforming the organizational culture. This article provides a model and recommendations to influence change in the most difficult leadership duty-transforming the organizational culture.

Transforming care in nursing: a concept analysis.

PubMed

Vázquez-Calatayud, Mónica; Oroviogoicoechea, Cristina; Saracibar, Maribel; Pumar-Méndez, María J

2017-04-01

Although the concept of 'Transforming care' is promising for improving health care, there is no consensus in the field as to its definition. The aim of this concept analysis is to develop a deeper understanding of the term 'Transforming care' within the nursing discipline, in order to facilitate its comprehension, implementation, and evaluation. We performed a comprehensive literature review on electronic databases such as Medline (PubMed), Cinahl (Ebsco), Cochrane Library, PsycINFO (Ovid), Web of Science, Wiley-Blackwell, ScienceDirect, and SpringerLink and used Walker and Avant's approach to analyse the concept. From the 20 studies selected for this analysis, 3 main attributes of 'Transforming care' were identified: patient-centredness, evidence-based change, and transformational leadership driven. We suggest an operational definition to facilitate the implementation of the concept in practice. Furthermore, we propose that implementation is guided by the following key ideas: (1) fostering a culture of continuous improvement; (2) encouraging bottom-up initiatives; (3) promoting patient-centred care; and (4) using transformational leadership. Lastly, the evaluation of 'Transforming care' initiatives should assess care processes and professionals' and patients' outcomes.

Health Is Primary: Family Medicine for America’s Health

PubMed Central

Phillips, Robert L.; Pugno, Perry A.; Saultz, John W.; Tuggy, Michael L.; Borkan, Jeffrey M.; Hoekzema, Grant S.; DeVoe, Jennifer E.; Weida, Jane A.; Peterson, Lars E.; Hughes, Lauren S.; Kruse, Jerry E.; Puffer, James C.

2014-01-01

PURPOSE More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to “renew the specialty to meet the needs of people and society,” some of which bore important fruit. Family Medicine for America’s Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). METHODS Family Medicine for America’s Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. RESULTS The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. CONCLUSIONS Family Medicine for America’s Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective. PMID:25352575

Health is primary: Family medicine for America's health.

PubMed

Phillips, Robert L; Pugno, Perry A; Saultz, John W; Tuggy, Michael L; Borkan, Jeffrey M; Hoekzema, Grant S; DeVoe, Jennifer E; Weida, Jane A; Peterson, Lars E; Hughes, Lauren S; Kruse, Jerry E; Puffer, James C

2014-10-01

More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective. © 2014 Annals of Family Medicine, Inc.

Work Process in Primary Health Care: action research with Community Health Workers.

PubMed

Cordeiro, Luciana; Soares, Cassia Baldini

2015-11-01

The aim of this article was to describe and analyze the work of community health workers (CHW). The main objective of study was to analyze the development process of primary health care practices related to drug consumption. The study is based on the Marxist theoretical orientation and the action research methodology, which resulted in the performance of 15 emancipatory workshops. The category work process spawned the content analysis. It exposed the social abandonment of the environment in which the CHWs work is performed. The latter had an essential impact on the identification of the causes of drug-related problems. These findings made it possible to criticize the reiterative, stressful actions that are being undertaken there. Such an act resulted in raising of the awareness and creating the means for political action. The CHWs motivated themselves to recognize the object of the work process in primary health care, which they found to be the disease or addiction in the case of drug users. They have criticized this categorization as well as discussed the social division of work and the work itself whilst recognizing themselves as mere instruments in the work process. The latter has inspired the CHW to become subjects, or co-producers of transformations of social needs.

The policy context of patient centered medical homes: perspectives of primary care providers.

PubMed

Alexander, Jeffrey A; Cohen, Genna R; Wise, Christopher G; Green, Lee A

2013-01-01

Interest in the patient centered medical home (PCMH) model has increased significantly in recent years. Despite this attention, information is limited regarding the influence of policy context on implementation of the PCMH model. Using comparative, qualitative data, we identify several key policy impediments to PCMH implementation, and propose practical guidelines for addressing these issues. Qualitative, semi-structured in-person interviews with representatives of physician organizations and primary care practices pursuing PCMH. Practitioners and staff at 16 physician practices in Michigan, as well as key leaders of physician organizations. We identified five primary policy issues cited by physicians and physician organization leaders as most impactful on their efforts to adopt PCMH: misalignment of current reimbursement schemes, administrative burden, conflicting criteria for PCMH designation, workforce policy issues, and uncertainty of health care reform. These policies were largely seen as barriers to their ability to implement PCMH. Providers' motivation to embrace PCMH, and their level of confidence regarding the results of such change, are greatly influenced by their perception of the external environment and the control they believe they have over this environment. Having policies in place that shape the path to PCMH in a manner that makes it as easy as possible for providers to accomplish the desired changes could well make the difference in whether successful transformation is achieved.

Les Nouveaux Miserables: modern victims of social asphyxia.

PubMed

Smith, D R

1995-10-01

During the past 30 years, social and economic barriers to health care services have increased for many Americans, especially for the nation's most vulnerable populations. Health status actually has declined for certain populations during this time. Meanwhile, national attention has been focused primarily on containing health care costs and on devising strategies for reforming the financing of health care rather than strategies for achieving improvements in the health status of the population. Existing methods of financing health care services, health research priorities, the increasing centralization and compartmentalization of health care services, and the recent failure of national health reform all serve to hinder this nation's progress towards developing a comprehensive and accountable health care system focused on promoting and achieving improved health as well as treating sickness. Recent changes in the health care marketplace, however, including a growing movement toward measuring the outcomes of medical treatments and an emphasis on improving the quality of services, have increased interest among payers and providers of health care services in investing in preventive services. Health maintenance organizations and other integrated health care delivery systems are beginning to devise incentives for increasing preventive care as well as for containing costs. The transformation of the nation's current medical care system into a true health care system will require innovative strategies designed to merge the existing fragmented array of services into coordinated and comprehensive systems for delivering primary and preventive health care services in community settings. The Community-Oriented Primary Care concept successfully blends these functions and has achieved measurable results in reducing health care costs and improving access to preventive services for identified populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Strengthening Multipayer Collaboration: Lessons From the Comprehensive Primary Care Initiative.

PubMed

Anglin, Grace; Tu, H A; Liao, Kristie; Sessums, Laura; Taylor, Erin Fries

2017-09-01

Policy Points: Collaboration across payers to align financial incentives, quality measurement, and data feedback to support practice transformation is critical, but challenging due to competitive market dynamics and competing institutional priorities. The Centers for Medicare & Medicaid Services or other entities convening multipayer initiatives can build trust with other participants by clearly outlining each participant's role and the parameters of collaboration at the outset of the initiative. Multipayer collaboration can be improved if participating payers employ neutral, proactive meeting facilitators; develop formal decision-making processes; seek input on decisions from practice representatives; and champion the initiative within their organizations. With increasing frequency, public and private payers are joining forces to align goals and resources for primary care transformation. However, sustaining engagement and achieving coordination among payers can be challenging. The Comprehensive Primary Care (CPC) initiative is one of the largest multipayer initiatives ever tested. Drawing on the experience of the CPC initiative, this paper examines the factors that influence the effectiveness of multipayer collaboration. This paper draws largely on semistructured interviews with CPC-participating payers and payer conveners that facilitated CPC discussions and on observation of payer meetings. We coded and analyzed these qualitative data to describe collaborative dynamics and outcomes and assess the factors influencing them. We found that several factors appeared to increase the likelihood of successful payer collaboration: contracting with effective, neutral payer conveners; leveraging the support of payer champions, and seeking input on decisions from practice representatives. The presence of these factors helped some CPC regions overcome significant initial barriers to achieve common goals. We also found that leadership from the Centers for Medicare & Medicaid Services (CMS) was key to achieving broad payer engagement in CPC, but CMS's dual role as initiative convener and participating payer at times made collaboration challenging. CMS was able to build trust with other payers by clarifying which parts of CPC could be adapted to regional contexts, deferring to other payers for these decisions, and increasing opportunities for payers to meet with CMS representatives. CPC demonstrates that when certain facilitating factors are present, payers can overcome competitive market dynamics and competing institutional priorities to align financial incentives, quality measurement, and data feedback to support practice transformation. Lessons from this large-scale, multipayer initiative may be helpful for other multipayer efforts getting under way. © 2017 Milbank Memorial Fund.

An expert system for headache diagnosis: the Computerized Headache Assessment tool (CHAT).

PubMed

Maizels, Morris; Wolfe, William J

2008-01-01

Migraine is a highly prevalent chronic disorder associated with significant morbidity. Chronic daily headache syndromes, while less common, are less likely to be recognized, and impair quality of life to an even greater extent than episodic migraine. A variety of screening and diagnostic tools for migraine have been proposed and studied. Few investigators have developed and evaluated computerized programs to diagnose headache. To develop and determine the accuracy and utility of a computerized headache assessment tool (CHAT). CHAT was designed to identify all of the major primary headache disorders, distinguish daily from episodic types, and recognize medication overuse. CHAT was developed using an expert systems approach to headache diagnosis, with initial branch points determined by headache frequency and duration. Appropriate clinical criteria are presented relevant to brief and longer-lasting headaches. CHAT was posted on a web site using Microsoft active server pages and a SQL-server database server. A convenience sample of patients who presented to the adult urgent care department with headache, and patients in a family practice waiting room, were solicited to participate. Those who completed the on-line questionnaire were contacted for a diagnostic interview. One hundred thirty-five patients completed CHAT and 117 completed a diagnostic interview. CHAT correctly identified 35/35 (100%) patients with episodic migraine and 42/49 (85.7%) of patients with transformed migraine. CHAT also correctly identified 11/11 patients with chronic tension-type headache, 2/2 with episodic tension-type headache, and 1/1 with episodic cluster headache. Medication overuse was correctly recognized in 43/52 (82.7%). The most common misdiagnoses by CHAT were seen in patients with transformed migraine or new daily persistent headache. Fifty patients were referred to their primary care physician and 62 to the headache clinic. Of 29 patients referred to the PCP with a confirmed diagnosis of migraine, 25 made a follow-up appointment, the PCP diagnosed migraine in 19, and initiated migraine-specific therapy or prophylaxis in 17. The described expert system displays high diagnostic accuracy for migraine and other primary headache disorders, including daily headache syndromes and medication overuse. As part of a disease management program, CHAT led to patients receiving appropriate diagnoses and therapy. Limitations of the system include patient willingness to utilize the program, introducing such a process into the culture of medical care, and the difficult distinction of transformed migraine.

A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults.

PubMed

Dolovich, Lisa; Oliver, Doug; Lamarche, Larkin; Agarwal, Gina; Carr, Tracey; Chan, David; Cleghorn, Laura; Griffith, Lauren; Javadi, Dena; Kastner, Monika; Longaphy, Jennifer; Mangin, Dee; Papaioannou, Alexandra; Ploeg, Jenny; Raina, Parminder; Richardson, Julie; Risdon, Cathy; Santaguida, P Lina; Straus, Sharon; Thabane, Lehana; Valaitis, Ruta; Price, David

2016-04-05

Healthcare systems are not well designed to help people maintain or improve their health. They are generally not person-focused or well-coordinated. The objective of this study is to evaluate the effectiveness of the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) approach in older adults. The overarching hypothesis is that using the Health TAPESTRY approach to achieve better integration of the health and social care systems into a person's life that centers on meeting a person's health goals and needs will result in optimal aging. This is a 12-month delayed intervention pragmatic randomized controlled trial. The study will be performed in Hamilton, Ontario, Canada in the two-site McMaster Family Health Team. Participants will include 316 patients who are 70 years of age or older. Participants will be randomized to the Health TAPESTRY approach or control group. The Health TAPESTRY approach includes intentional, proactive conversations about a person's life and health goals and health risks and then initiation of congruent tailored interventions that support achievement of those goals and addressing of risks through (1) trained volunteers visiting clients in their homes to serve as a link between the primary care team and the client; (2) the use of novel technology including a personal health record from the home to link directly with the primary healthcare team; and (3) improved processes for connections, system navigation, and care delivery among interprofessional primary care teams, community service providers, and informal caregivers. The primary outcome will be the goal attainment scaling score. Secondary outcomes include self-efficacy for managing chronic disease, quality of life, the participant perspective on their own aging, social support, access to health services, comprehensiveness of care, patient empowerment, patient-centeredness, caregiver strain, satisfaction with care, healthcare resource utilization, and cost-effectiveness. Implementation processes will also be evaluated. The main comparative analysis will take place at 6 months. Evidence of the individual elements of the Health TAPESTRY platform has been shown in isolation in the previous research. However, this study will better understand how to best integrate them to maximize the system's transformation of person-focused, primary care for older adults. ClinicalTrials.gov NCT02283723.

Values in conflict: neurology before and after the advent of managed care.

PubMed

McQuillen, M P

1997-01-01

The transformation of American medicine now taking place is fundamentally driven by money. As the pendulum swings from the excesses of fee-for-service medicine (under which system the physician was paid more for doing more), to the equally egregious excesses of managed care (according to which the physician is paid more for doing less), it is the patient--especially the vulnerable patient with a debilitating neurological disease--who stands to lose the most. A survey of the historical roots of this transformation highlights the ethical dilemmas under the course of the pendulum. The ethical principles that should guide both the profession and the business of medicine are explored in search of a common ground on which both physicians and managers can work in concert for the benefit of the patients as well as the society whom both serve. The perils that beset that search must be recognized and avoided if the commons are to be preserved. This is especially true for neurology, where care must be patient, not profit, oriented; must have quality, not cost, as its primary aim; and must not be rationed until there is a floor of universal coverage, with participation by all in allocation decisions.

Large-System Transformation in Health Care: A Realist Review

PubMed Central

Best, Allan; Greenhalgh, Trisha; Lewis, Steven; Saul, Jessie E; Carroll, Simon; Bitz, Jennifer

2012-01-01

Context An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation. Methods We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS). Findings Our rapid realist review identified five “simple rules” of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms. Conclusions Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods. PMID:22985277

The Reduction in ED and Hospital Admissions in Medical Home Practices Is Specific to Primary Care-Sensitive Chronic Conditions.

PubMed

Green, Lee A; Chang, Hsiu-Ching; Markovitz, Amanda R; Paustian, Michael L

2018-04-01

To determine whether the Patient-Centered Medical Home (PCMH) transformation reduces hospital and ED utilization, and whether the effect is specific to chronic conditions targeted for management by the PCMH in our setting. All patients aged 18 years and older in 2,218 primary care practices participating in a statewide PCMH incentive program sponsored by Blue Cross Blue Shield of Michigan (BCBSM) in 2009-2012. Quantitative observational study, jointly modeling PCMH-targeted versus other hospital admissions and ED visits on PCMH score, patient, and practice characteristics in a hierarchical multivariate model using the generalized gamma distribution. Claims data and PCMH scores held by BCBSM. Both hospital and ED utilization were reduced proportionately to PCMH score. Hospital utilization was reduced by 13.9 percent for PCMH-targeted conditions versus only 3.8 percent for other conditions (p = .003), and ED utilization by 11.2 percent versus 3.7 percent (p = .010). Hospital PMPM cost was reduced by 17.2 percent for PCMH-targeted conditions versus only 3.1 percent for other conditions (p < .001), and ED PMPM cost by 9.4 percent versus 3.6 percent (p < .001). PCMH transformation reduces hospital and ED use, and the majority of the effect is specific to PCMH-targeted conditions. © Health Research and Educational Trust.

The development of professional identity and the formation of teams in the Veterans Affairs Connecticut Healthcare System's Center of Excellence in Primary Care Education Program (CoEPCE).

PubMed

Meyer, Emily M; Zapatka, Susan; Brienza, Rebecca S

2015-06-01

The United States Department of Veterans Affairs Connecticut Healthcare System (VACHS) is one of five Centers of Excellence in Primary Care Education (CoEPCE) pilot sites. The overall goal of the CoEPCE program, which is funded by the Office of Academic Affiliations, is to develop and implement innovative approaches for training future health care providers in postgraduate education programs to function effectively in teams to provide exceptional patient care. This longitudinal study employs theoretically grounded qualitative methods to understand the effect of a combined nursing and medical training model on professional identity and team development at the VACHS CoEPCE site. The authors used qualitative approaches to understand trainees' experiences, expectations, and impressions of the program. From September 2011 to August 2012, they conducted 28 interviews of 18 trainees (internal medicine [IM] residents and nurse practitioners [NPs]) and subjected data to three stages of open, iterative coding. Major themes illuminate both the evolution of individual professional identity within both types of trainees and the dynamic process of group identity development. Results suggest that initially IM residents struggled to understand NPs' roles and responsibilities, whereas NP trainees doubted their ability to work alongside physicians. At the end of one academic year, these uncertainties disappeared, and what was originally artificial had transformed into an organic interprofessional team of health providers who shared a strong sense of understanding and trust. This study provides early evidence of successful interprofessional collaboration among NPs and IM residents in a primary care training program.

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

PubMed

Suter, Esther; Mallinson, Sara; Misfeldt, Renee; Boakye, Omenaa; Nasmith, Louise; Wong, Sabrina T

2017-07-17

We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta and Saskatchewan to understand how they inform the design and implementation of team-based primary health care service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada. We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewed relevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We compared and contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narratives prepared from the comparative analysis by offering contextual information on potential policy imperatives. Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtable event guided prioritization of policy imperatives. The concept of team-based PHC varies widely across and within the three provinces. We noted policy gaps related to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policies speak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignment of goals and policies at different system levels; (2) investment of resources for system change; (3) compensation models for all members of the team; and (4) accountability through collaborative practice metrics. Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinated approach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanisms and performance monitoring could accelerate systemic transformation by removing some well-known barriers to team-based care.

Self-perception of leadership styles and behaviour in primary health care.

PubMed

Jodar I Solà, Glòria; Gené I Badia, Joan; Hito, Pilar Delgado; Osaba, M Antonia Campo; Del Val García, Jose Luís

2016-10-12

The concept of leadership has been studied in various disciplines and from different theoretical approaches. It is a dynamic concept that evolves over time. There are few studies in our field on managers' self-perception of their leadership style. There are no pure styles, but one or another style is generally favoured to a greater or lesser degree. In the primary health care (PHC) setting, managers' leadership style is defined as a set of attitudes, behaviours, beliefs and values. The objectives of this study were to describe and learn about the self-perception of behaviours and leadership styles among PHC managers; to determine the influence of the leadership style on job satisfaction, efficiency, and willingness to work in a team; and to determine the relationship between transformational and transactional styles according age, gender, profession, type of manager years of management experience, and the type of organization. To describe leadership styles as perceived by PHC managers, a cross sectional study was performed using an 82 items-self-administered Multifactor Leadership Questionnaire (MLQ). This questionnaire measures leadership styles, attitudes and behaviour of managers. The items are grouped into three first order variables (transformational, transactional and laissez-faire) and ten second order variables (which discriminate leader behaviours). Additionally, the questionnaire evaluates organizational consequences such as extra-effort, efficiency and satisfaction. One hundred forty responses from 258 managers of 133 PHC teams in the Barcelona Health Area (response rate: 54.26 %). Most participants were nurses (61.4 %), average age was 49 years and the gender predominantly female (75 %). Globally, managers assessed themselves as equally transactional and transformational leaders (average: 3.30 points). Grouped by profession, nurses (28.57 % of participants) showed a higher transactional leadership style, over transformational leadership style, compared to physicians (3.38 points, p < 0.003). Considering gender, men obtained the lowest results in transactional style (p < 0.015). Both transactional and transformational styles correlate with efficiency and job satisfaction (r = 0.724 and r = 0.710, respectively). PHC managers' self-perception of their leadership style was transactional, focused on the maintenance of the status quo, although there was a trend in some scores towards the transformational style, mainly among nurse managers. Both styles correlate with satisfaction and willingness to strive to work better.

How to change organisational culture: Action research in a South African public sector primary care facility

PubMed Central

De Sa, Angela; Christodoulou, Maria

2016-01-01

Background Organisational culture is a key factor in both patient and staff experience of the healthcare services. Patient satisfaction, staff engagement and performance are related to this experience. The department of health in the Western Cape espouses a values-based culture characterised by caring, competence, accountability, integrity, responsiveness and respect. However, transformation of the existing culture is required to achieve this vision. Aim To explore how to transform the organisational culture in line with the desired values. Setting Retreat Community Health Centre, Cape Town, South Africa. Methods Participatory action research with the leadership engaged with action and reflection over a period of 18 months. Change in the organisational culture was measured at baseline and after 18 months by means of a cultural values assessment (CVA) survey. The three key leaders at the health centre also completed a 360-degree leadership values assessment (LVA) and had 6 months of coaching. Results Cultural entropy was reduced from 33 to 13% indicating significant transformation of organisational culture. The key driver of this transformation was change in the leadership style and functioning. Retreat health centre shifted from a culture that emphasised hierarchy, authority, command and control to one that established a greater sense of cohesion, shared vision, open communication, appreciation, respect, fairness and accountability. Conclusion Transformation of organisational culture was possible through a participatory process that focused on the leadership style, communication and building relationships by means of CVA and feedback, 360-degree LVA, feedback and coaching and action learning in a co-operative inquiry group. PMID:27608671

Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders.

PubMed

Kredo, Tamara; Abrams, Amber; Young, Taryn; Louw, Quinette; Volmink, Jimmy; Daniels, Karen

2017-08-29

Clinical practice guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa's health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level. We used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data. We conducted 37 in-depth interviews from June 2014-July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process. Our findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.

Enacting Critical Care and Transformative Leadership in Schools Highly Impacted by Poverty: An African-American Principal's Counter Narrative

ERIC Educational Resources Information Center

Wilson, Camille M.

2016-01-01

Critical notions of care and transformative educational leadership are much aligned, yet they are rarely simultaneously addressed in research. This article highlights the benefits of transformative educational leadership that enacts critical care. Critical care involves embracing and exhibiting values, dispositions and behaviours related to…

Building the Case: Changing Consumer Perceptions of the Value of Expanded Community Pharmacist Services.

PubMed

Steckowych, Kathryn; Smith, Marie; Spiggle, Susan; Stevens, Andrew; Li, Hao

2018-01-01

The role of the community pharmacist has traditionally been a medication dispenser; however, community pharmacists' responsibilities must expand to include more direct patient care services in order to transform primary care practice. Use case-based scenarios to (1) determine factors that contribute to positive and negative consumer perceptions of expanded community pharmacist patient care roles, (2) identify facilitators and barriers that contribute to consumer perceptions of the value of expanded community pharmacist patient care services, and (3) develop a successful approach and strategies for increasing consumer advocacy for the value of expanded community pharmacist patient care services. Two consumer focus groups used scenario-based guided discussions and Likert scale questionnaires to elicit consumer reactions, facilitators, and barriers to expanded community pharmacist services. Convenience, timeliness, and accessibility were common positive reactions across all 3 scenarios. Team approach to care and trust were viewed as major facilitators. Participant concerns included uncertainty about pharmacist training and qualifications, privacy, pharmacists' limited bandwidth to accept new tasks, and potential increased patient costs. Common barriers to service uptake included a lack of insurance payment and physician preference to provide the services. Consumer unfamiliarity with non-traditional community pharmacist services is likely an influencer of consumers' hesitancy to utilize such services; therefore, an opportunity exists to engage consumers and advocacy organizations in supporting expanded community pharmacist roles. This study can inform consumers, advocates, community pharmacists, primary care providers, and community-based organizations on methods to shape consumer perceptions on the value of community pharmacist expanded services.

A Chronic Disease Management Student-Faculty Collaborative Practice: Educating Students on Innovation in Health Care Delivery.

PubMed

Remus, Kristin E; Honigberg, Michael; Tummalapalli, Sri Lekha; Cohen, Laura P; Fazio, Sara; Weinstein, Amy R

2016-07-01

In the current transformative health care landscape, it is imperative that clinician educators inspire future clinicians to practice primary care in a dynamic environment. A focus on patient-centered, goal-oriented care for patients with chronic conditions is critical. In 2009, Harvard Medical School founded the Crimson Care Collaborative, a student-faculty collaborative practice (SFCP) network. With the aim of expanding clinical and educational opportunities for medical students and improving patient control of chronic disease (i.e., hypertension, obesity, and diabetes) in an innovative learning environment, in 2012, the authors developed a novel SFCP at their hospital-based academic primary care practice. In this SFCP, students learn to explore patient priorities, provide focused counseling and education, and assist patients with self-management goals during clinical visits. From 2012 to 2014, 250 student volunteers participated in the SFCP as clinicians, innovators, educators, and leaders, with between 80 and 95 medical students engaging each semester. Between January 2012 and March 2014, there were 476 urgent care or chronic disease management visits. Patients with chronic diseases were seen at least twice on average, and by 2014, chronic disease management visits accounted for approximately 74% of visits. Work is under way to create assessment tools to evaluate the practice's educa tional impact and student understanding of the current health care system, develop interdisciplinary care teams, expand efforts in registry management and broaden the patient recruitment scope, further emphasize patient engage ment and retention, and evaluate chronic disease management and patient satisfaction effectiveness.

Strengthening the Creative Transformational Leadership of Primary School Teachers

ERIC Educational Resources Information Center

Kallapadee, Yadapak; Tesaputa, Kowat; Somprach, Kanokorn

2017-01-01

This research and development aimed to: 1) study the components and indicators of creative transformational leadership of primary school teachers; 2) study the existing situation, and the desirable situation of creative transformational leadership of primary school teachers in the northeastern region of Thailand; 3) develop a program to strengthen…

Transforming care at the bedside: implementation and spread model for single-hospital and multihospital systems.

PubMed

Martin, Susan Christie; Greenhouse, Pamela K; Merryman, Tamra; Shovel, Judith; Liberi, Cindy A; Konzier, Jeannine

2007-10-01

Institute of Medicine reports provide evidence of the failings of the healthcare system in the United States and a vision of the required transformation. The Institute for Healthcare Improvement and the Robert Wood Johnson Foundation created the Transforming Care at the Bedside initiative in 2003 to develop and validate a process for transforming care in hospital medical-surgical units. The authors describe Transforming Care at the Bedside as implemented by one of Institute for Healthcare Improvement/Robert Wood Johnson's initial pilot hospitals, including promising outcomes and a model for spreading the initiative.

Expanding the role of the nurse practitioner in the deployed setting.

PubMed

Dargis, Julie; Horne, Theresa; Tillman-Ortiz, Sophie; Scherr, Diane; Yackel, Edward E

2006-08-01

Today's military is experiencing rapid advances in technology and in manpower utilization. The Army Medical Department is redesigning the structure and function of deployable hospital systems as part of this effort. The transformation of deployable hospital systems requires that a critical analysis of manpower utilization be undertaken to optimize the employment of soldier-medics. The objective of this article was to describe the use of nurse practitioners as primary care providers during deployment. The lived experiences of five nurse practitioners deployed to Operation Iraqi Freedom are presented. Data gathered during the deployment and an analysis of the literature clearly support expanded and legitimized roles for these health care professionals in future conflicts and peacekeeping operations.

Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation

PubMed Central

Makaroff, Laura; Chung, Michelle; Lin, Sue C.

2015-01-01

Over the last 50 years, the incidence of cervical cancer has dramatically decreased. However, health disparities in cervical cancer screening (CCS) persist for women from racial and ethnic minorities and those residing in rural and poor communities. For more than 45 years, federally funded health centers (HCs) have been providing comprehensive, culturally competent, and quality primary health care services to medically underserved communities and vulnerable populations. To enhance the quality of care and to ensure more women served at HCs are screened for cervical cancer, over eight HCs received funding to support patient-centered medical home (PCMH) transformation with goals to increase CCS rates. The study conducted a qualitative analysis using Atlas.ti software to describe the barriers and challenges to CCS and PCMH transformation, to identify potential solutions and opportunities, and to examine patterns in barriers and solutions proposed by HCs. Interrater reliability was assessed using Cohen's Kappa. The findings indicated that HCs more frequently described patient-level barriers to CCS, including demographic, cultural, and health belief/behavior factors. System-level barriers were the next commonly cited, particularly failure to use the full capability of electronic medical records (EMRs) and problems coordinating with external labs or providers. Provider-level barriers were least frequently cited. PMID:25685561

Transformation of Primary Hamster Brain Cells with JC Virus and Its DNA

PubMed Central

Frisque, R. J.; Rifkin, D. B.; Walker, D. L.

1980-01-01

We transformed primary hamster brain cells with four isolates of JC virus and JC virus DNA. Several properties of these transformants were characterized and compared to those of simian virus 40 transformants isolated under identical conditions. Images PMID:6251275

Health Care Reform, Care Coordination, and Transformational Leadership.

PubMed

Steaban, Robin Lea

2016-01-01

This article is meant to spur debate on the role of the professional nurse in care coordination as well as the role of nursing leaders for defining and leading to a future state. This work highlights the opportunity and benefits associated with transformation of professional nursing practice in response to the mandates of the Affordable Care Act of 2010. An understanding of core concepts and the work of care coordination are used to propose a model of care coordination based on the population health pyramid. This maximizes the roles of nurses across the continuum as transformational leaders in the patient/family and nursing relationship. The author explores the role of the nurse in a transactional versus transformational relationship with patients, leading to actualization of the nurse in care coordination. Focusing on the role of the nurse leader, the challenges and necessary actions for optimization of the professional nurse role are explored, using principles of transformational leadership.

Stakeholder Perspectives on the Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) Project.

PubMed

Ersek, Mary; Hickman, Susan E; Thomas, Anne C; Bernard, Brittany; Unroe, Kathleen T

2017-10-17

The need to reduce burdensome and costly hospitalizations of frail nursing home residents is well documented. The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project achieved this reduction through a multicomponent collaborative care model. We conducted an implementation-focused project evaluation to describe stakeholders' perspectives on (a) the most and least effective components of the intervention; (b) barriers to implementation; and (c) program features that promoted its adoption. Nineteen nursing homes participated in OPTIMISTIC. We conducted semistructured, qualitative interviews with 63 stakeholders: 23 nursing home staff and leaders, 4 primary care providers, 10 family members, and 26 OPTIMISTIC clinical staff. We used directed content analysis to analyze the data. We found universal endorsement of the value of in-depth advance care planning (ACP) discussions in reducing hospitalizations and improving care. Similarly, all stakeholder groups emphasized that nursing home access to specially trained, project registered nurses (RNs) and nurse practitioners (NPs) with time to focus on ACP, comprehensive resident assessment, and staff education was particularly valuable in identifying residents' goals for care. Challenges to implementation included inadequately trained facility staff and resistance to changing practice. In addition, the program sometimes failed to communicate its goals and activities clearly, leaving facilities uncertain about the OPTIMISTIC clinical staff's roles in the facilities. These findings are important for dissemination efforts related to the OPTIMISTIC care model and may be applicable to other innovations in nursing homes. Published by Oxford University Press on behalf of The Gerontological Society of America 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Strategic plan for geriatrics and extended care in the veterans health administration: background, plan, and progress to date.

PubMed

Shay, Kenneth; Hyduke, Barbara; Burris, James F

2013-04-01

The leaders of Geriatrics and Extended Care (GEC) in the Veterans Health Administration (VHA) undertook a strategic planning process that led to approval in 2009 of a multidisciplinary, evidence-guided strategic plan. This article reviews the four goals contained in that plan and describes VHA's progress in addressing them. The goals included transforming the healthcare system to a veteran-centric approach, achieving universal access to a panel of services, ensuring that the Veterans Affair's (VA) healthcare workforce was adequately prepared to manage the needs of the growing elderly veteran population, and integrating continuous improvement into all care enhancements. There has been substantial progress in addressing all four goals. All VHA health care has undergone an extensive transformation to patient-centered care, has enriched the services it can offer caregivers of dependent veterans, and has instituted models to better integrate VA and non-VA cares and services. A range of successful models of geriatric care described in the professional literature has been adapted to VA environments to gauge suitability for broader implementation. An executive-level task force developed a three-pronged approach for enhancing the VA's geriatric workforce. The VHA's performance measurement approaches increasingly include incentives to enhance the quality of management of vulnerable elderly adults in primary care. The GEC strategic plan was intended to serve as a road map for keeping VHA aligned with an ambitious but important long-term vision for GEC services. Although no discrete set of resources was appropriated for fulfillment of the plan's recommendations, this initial report reflects substantial progress in addressing most of its goals. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Enhancing decolonization and knowledge transfer in nursing research with non-western populations: examining the congruence between primary healthcare and postcolonial feminist approaches.

PubMed

Racine, Louise; Petrucka, Pammla

2011-03-01

This article is a call for reflection from two distinct programs of research which converge on common interests pertaining to issues of health, social justice, and globalization. One of the authors has developed a research program related to the health and well-being of non-western populations, while the other author has expanded the field of Aboriginal and international research in Canada and abroad. Based on examples drawn from our respective programs of research, we suggest conciliating the philosophy of primary healthcare to postcolonial feminism for decolonizing research and enhancing knowledge transfer with non-western populations. We contend that applying the theoretical and methodological strengths of these two approaches is a means to decolonize nursing research and to avoid western neocolonization. In conciliating primary health care and postcolonial feminism, the goal is to enhance the pragmatic relevance of postcolonial feminism to generate resistance through transformative research for achieving social justice. In tapping into the synergistic and complementary epistemological assumptions of the philosophy of primary health care and postcolonial 'feminisms', nurse researchers reinforce the anti-oppresive goals of postcolonial feminist research. Consequently, this approach may enhance both decolonization and knowledge transfer through strategies like photovoice. © 2011 Blackwell Publishing Ltd.

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 short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions. Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.

Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home

PubMed Central

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

2010-01-01

This article summarizes findings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patient-centered medical homes (PCMHs) based on these findings and an understanding of diverse efforts to transform primary care. The NDP was launched in June 2006 as the first national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys. Peer-reviewed manuscripts from the NDP provide answers to 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated? We find that although it is feasible to transform independent practices into the NDP conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefits from external support. Most practices will need additional resources for this magnitude of transformation. Recommendations focus on the need for the PCMH model to continue to evolve, for delivery system reform, and for sufficient resources for implementing personal and practice development plans. In the meantime, we find that much can be done before larger health system reform. PMID:20530397

Extended use of electronic health records by primary care physicians: Does the electronic health record artefact matter?

PubMed

Raymond, Louis; Paré, Guy; Marchand, Marie

2017-04-01

The deployment of electronic health record systems is deemed to play a decisive role in the transformations currently being implemented in primary care medical practices. This study aims to characterize electronic health record systems from the perspective of family physicians. To achieve this goal, we conducted a survey of physicians practising in private clinics located in Quebec, Canada. We used valid responses from 331 respondents who were found to be representative of the larger population. Data provided by the physicians using the top three electronic health record software products were analysed in order to obtain statistically adequate sub-sample sizes. Significant differences were observed among the three products with regard to their functional capability. The extent to which each of the electronic health record functionalities are used by physicians also varied significantly. Our results confirm that the electronic health record artefact 'does matter', its clinical functionalities explaining why certain physicians make more extended use of their system than others.

Multipayer patient-centered medical home implementation guided by the chronic care model.

PubMed

Gabbay, Robert A; Bailit, Michael H; Mauger, David T; Wagner, Edward H; Siminerio, Linda

2011-06-01

A unique statewide multipayer ini Pennsylvania was undertaken to implement the Patient-Centered Medical Home (PCMH) guided by the Chronic Care Model (CCM) with diabetes as an initial target disease. This project represents the first broad-scale CCM implementation with payment reform across a diverse range of practice organizations and one of the largest PCMH multipayer initiatives. Practices implemented the CCM and PCMH through regional Breakthrough Series learning collaboratives, supported by Improving Performance in Practice (IPIP) practice coaches, with required monthly quality reporting enhanced by multipayer infrastructure payments. Some 105 practices, representing 382 primary care providers, were engaged in the four regional collaboratives. The practices from the Southeast region of Pennsylvania focused on diabetes patients (n = 10,016). During the first intervention year (May 2008-May 2009), all practices achieved at least Level 1 National Committee for Quality Assurance (NCQA) Physician Practice Connections Patient-Centered Medical Home (PPC-PCMH) recognition. There was significant improvement in the percentage of patients who had evidence-based complications screening and who were on therapies to reduce morbidity and mortality (statins, angiotensin-converting enzyme inhibitors). In addition, there were small but statistically significant improvements in key clinical parameters for blood pressure and cholesterol levels, with the greatest absolute improvement in the highest-risk patients. Transforming primary care delivery through implementation of the PCMH and CCM supported by multipayer infrastructure payments holds significant promise to improve diabetes care.

From "retailers" to health care providers: Transforming the role of community pharmacists in chronic disease management.

PubMed

Mossialos, Elias; Courtin, Emilie; Naci, Huseyin; Benrimoj, Shalom; Bouvy, Marcel; Farris, Karen; Noyce, Peter; Sketris, Ingrid

2015-05-01

Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs-particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes. Copyright © 2015. Published by Elsevier Ireland Ltd.

Policy insights from the nutritional food market transformation model: the case of obesity prevention.

PubMed

Struben, Jeroen; Chan, Derek; Dubé, Laurette

2014-12-01

This paper presents a system dynamics policy model of nutritional food market transformation, tracing over-time interactions between the nutritional quality of supply, consumer food choice, population health, and governmental policy. Applied to the Canadian context and with body mass index as the primary outcome, we examine policy portfolios for obesity prevention, including (1) industry self-regulation efforts, (2) health- and nutrition-sensitive governmental policy, and (3) efforts to foster health- and nutrition-sensitive innovation. This work provides novel theoretical and practical insights on drivers of nutritional market transformations, highlighting the importance of integrative policy portfolios to simultaneously shift food demand and supply for successful and self-sustaining nutrition and health sensitivity. We discuss model extensions for deeper and more comprehensive linkages of nutritional food market transformation with supply, demand, and policy in agrifood and health/health care. These aim toward system design and policy that can proactively, and with greater impact, scale, and resilience, address single as well as double malnutrition in varying country settings. © 2014 New York Academy of Sciences.

Using research to transform care for women veterans: advancing the research agenda and enhancing research-clinical partnerships.

PubMed

Yano, Elizabeth M; Bastian, Lori A; Bean-Mayberry, Bevanne; Eisen, Seth; Frayne, Susan; Hayes, Patricia; Klap, Ruth; Lipson, Linda; Mattocks, Kristin; McGlynn, Geraldine; Sadler, Anne; Schnurr, Paula; Washington, Donna L

2011-01-01

The purpose of this paper is to report on the outcomes of the 2010 VA Women's Health Services Research Conference, which brought together investigators interested in pursuing research on women veterans and women in the military with leaders in women's health care delivery and policy within and outside the VA, to significantly advance the state and future direction of VA women's health research and its potential impacts on practice and policy. Building on priorities assembled in the previous VA research agenda (2004) and the research conducted in the intervening six years, we used an array of approaches to foster research-clinical partnerships that integrated the state-of-the-science with the informational and strategic needs of senior policy and practice leaders. With demonstrated leadership commitment and support, broad field-based participation, strong interagency collaboration and a push to accelerate the move from observational to interventional and implementation research, the Conference provided a vital venue for establishing the foundation for a new research agenda. In this paper, we provide the historical evolution of the emergence of women veterans' health services research and an overview of the research in the intervening years since the first VA women's health research agenda. We then present the resulting VA Women's Health Research Agenda priorities and supporting activities designed to transform care for women veterans in six broad areas of study, including access to care and rural health; primary care and prevention; mental health; post deployment health; complex chronic conditions, aging and long-term care; and reproductive health. Published by Elsevier Inc.

Transformation of Mental Health Care for U.S. Soldiers and Families During the Iraq and Afghanistan Wars: Where Science and Politics Intersect.

PubMed

Hoge, Charles W; Ivany, Christopher G; Brusher, Edward A; Brown, Millard D; Shero, John C; Adler, Amy B; Warner, Christopher H; Orman, David T

2016-04-01

The cumulative strain of 14 years of war on service members, veterans, and their families, together with continuing global threats and the unique stresses of military service, are likely to be felt for years to come. Scientific as well as political factors have influenced how the military has addressed the mental health needs resulting from these wars. Two important differences between mental health care delivered during the Iraq and Afghanistan wars and previous wars are the degree to which research has directly informed care and the consolidated management of services. The U.S. Army Medical Command implemented programmatic changes to ensure delivery of high-quality standardized mental health services, including centralized workload management; consolidation of psychiatry, psychology, psychiatric nursing, and social work services under integrated behavioral health departments; creation of satellite mental health clinics embedded within brigade work areas; incorporation of mental health providers into primary care; routine mental health screening throughout soldiers' careers; standardization of clinical outcome measures; and improved services for family members. This transformation has been accompanied by reduction in psychiatric hospitalizations and improved continuity of care. Challenges remain, however, including continued underutilization of services by those most in need, problems with treatment of substance use disorders, overuse of opioid medications, concerns with the structure of care for chronic postdeployment (including postconcussion) symptoms, and ongoing questions concerning the causes of historically high suicide rates, efficacy of resilience training initiatives, and research priorities. It is critical to ensure that remaining gaps are addressed and that knowledge gained during these wars is retained and further evolved.

Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): a protocol for a program of research.

PubMed

Hamilton, Alison B; Farmer, Melissa M; Moin, Tannaz; Finley, Erin P; Lang, Ariel J; Oishi, Sabine M; Huynh, Alexis K; Zuchowski, Jessica; Haskell, Sally G; Bean-Mayberry, Bevanne

2017-11-07

The Enhancing Mental and Physical health of Women through Engagement and Retention or EMPOWER program represents a partnership with the US Department of Veterans Health Administration (VA) Health Service Research and Development investigators and the VA Office of Women's Health, National Center for Disease Prevention and Health Promotion, Primary Care-Mental Health Integration Program Office, Women's Mental Health Services, and the Office of Patient Centered Care and Cultural Transformation. EMPOWER includes three projects designed to improve women Veterans' engagement and retention in evidence-based care for high-priority health conditions, i.e., prediabetes, cardiovascular, and mental health. The three proposed projects will be conducted in VA primary care clinics that serve women Veterans including general primary care and women's health clinics. The first project is a 1-year quality improvement project targeting diabetes prevention. Two multi-site research implementation studies will focus on cardiovascular risk prevention and collaborative care to address women Veterans' mental health treatment needs respectively. All projects will use the evidence-based Replicating Effective Programs (REP) implementation strategy, enhanced with multi-stakeholder engagement and complexity theory. Mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, and impact. Both implementation research studies will use a non-randomized stepped wedge design. EMPOWER represents a coherent program of women's health implementation research and quality improvement that utilizes cross-project implementation strategies and evaluation methodology. The EMPOWER Quality Enhancement Research Initiative (QUERI) will constitute a major milestone for realizing women Veterans' engagement and empowerment in the VA system. EMPOWER QUERI will be conducted in close partnership with key VA operations partners, such as the VA Office of Women's Health, to disseminate and spread the programs nationally. The two implementation research studies described in this protocol have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans: Trial registration NCT02991534 , registered 9 December 2016. Implementation of Tailored Collaborative Care for Women Veterans: Trial registration NCT02950961 , registered 21 October 2016.

A standardised graphic method for describing data privacy frameworks in primary care research using a flexible zone model.

PubMed

Kuchinke, Wolfgang; Ohmann, Christian; Verheij, Robert A; van Veen, Evert-Ben; Arvanitis, Theodoros N; Taweel, Adel; Delaney, Brendan C

2014-12-01

To develop a model describing core concepts and principles of data flow, data privacy and confidentiality, in a simple and flexible way, using concise process descriptions and a diagrammatic notation applied to research workflow processes. The model should help to generate robust data privacy frameworks for research done with patient data. Based on an exploration of EU legal requirements for data protection and privacy, data access policies, and existing privacy frameworks of research projects, basic concepts and common processes were extracted, described and incorporated into a model with a formal graphical representation and a standardised notation. The Unified Modelling Language (UML) notation was enriched by workflow and own symbols to enable the representation of extended data flow requirements, data privacy and data security requirements, privacy enhancing techniques (PET) and to allow privacy threat analysis for research scenarios. Our model is built upon the concept of three privacy zones (Care Zone, Non-care Zone and Research Zone) containing databases, data transformation operators, such as data linkers and privacy filters. Using these model components, a risk gradient for moving data from a zone of high risk for patient identification to a zone of low risk can be described. The model was applied to the analysis of data flows in several general clinical research use cases and two research scenarios from the TRANSFoRm project (e.g., finding patients for clinical research and linkage of databases). The model was validated by representing research done with the NIVEL Primary Care Database in the Netherlands. The model allows analysis of data privacy and confidentiality issues for research with patient data in a structured way and provides a framework to specify a privacy compliant data flow, to communicate privacy requirements and to identify weak points for an adequate implementation of data privacy. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Analysis of the enablers of capacities to produce primary health care-based reforms in Latin America: a multiple case study

PubMed Central

Báscolo, Ernesto Pablo; Yavich, Natalia; Denis, Jean-Louis

2016-01-01

Abstract Background Primary health care (PHC)-based reforms have had different results in Latin America. Little attention has been paid to the enablers of collective action capacities required to produce a comprehensive PHC approach. Objective To analyse the enablers of collective action capacities to transform health systems towards a comprehensive PHC approach in Latin American PHC-based reforms. Methods We conducted a longitudinal, retrospective case study of three municipal PHC-based reforms in Bolivia and Argentina. We used multiple data sources and methodologies: document review; interviews with policymakers, managers and practitioners; and household and services surveys. We used temporal bracketing to analyse how the dynamic of interaction between the institutional reform process and the collective action characteristics enabled or hindered the enablers of collective action capacities required to produce the envisioned changes. Results The institutional structuring dynamics and collective action capacities were different in each case. In Cochabamba, there was an ‘interrupted’ structuring process that achieved the establishment of a primary level with a selective PHC approach. In Vicente López, there was a ‘path-dependency’ structuring process that permitted the consolidation of a ‘primary care’ approach, but with limited influence in hospitals. In Rosario, there was a ‘dialectic’ structuring process that favoured the development of the capacities needed to consolidate a comprehensive PHC approach that permeates the entire system. Conclusion The institutional change processes achieved the development of a primary health care level with different degrees of consolidation and system-wide influence given how the characteristics of each collective action enabled or hindered the ‘structuring’ processes. PMID:27209640

Delivering team training to medical home staff to impact perceptions of collaboration.

PubMed

Treadwell, Janet; Binder, Brenda; Symes, Lene; Krepper, Rebecca

2015-01-01

The purpose of this study was to explore whether an evidence-based educational and experiential intervention to develop team skills in medical homes would positively affect team members' perceptions of interprofessional collaboration. The study population consisted of primary care medical home practices associated with the health plan sponsor of this research. All practices were located within the greater Houston region of Texas and had more than 500 patients. A cluster design experimental study was conducted between August 2013 and June 2014. Fifty medical home practices, 25 intervention and 25 attention control, were recruited as study sites. Results indicate that individual team members in the medical homes receiving the intervention were significantly more likely than the individual team members in the attention control groups to report higher levels of positive perception of team collaboration after the 12-week intervention. This research indicates that educating teams about interprofessional collaboration tools and supporting technique use may be an effective strategy to assist medical homes in developing collaborative environments. Case management experience in collaboration supports the role facilitating team training. Transforming culture from hierarchical to team-based care supports the case management approach of collaborative practice. In addition, role satisfaction attained through the respect and communication of team-based care delivery may influence retention within the case management profession. As case managers in primary care settings assume roles of embedded care coordinators, program leaders, and transition facilitators, an understanding of collaboration techniques is needed to support the entire care team to achieve desired outcomes.

Clinician styles of care: transforming patient care at the intersection of leadership and medicine.

PubMed

Huynh, Ho P; Sweeny, Kate

2014-11-01

A key role of clinicians is to motivate their patients to initiate and maintain beneficial health behaviors. This article integrates research on transformational leadership, clinician-patient communication, and health behavior to introduce a novel approach to understanding and improving clinicians' effectiveness as motivators. We describe three dominant clinician styles or patterned approaches to patient care that derive from leadership theory (in order of least to most effective): laissez-faire, transactional, and transformational. Additionally, we suggest potential mediators and effects of the transformational style of care. Finally, we discuss future research directions for the study of clinician styles of care. © The Author(s) 2013.

When a LIC came to town: the impact of longitudinal integrated clerkships on a rural community of healthcare practice.

PubMed

Hudson, Judith N; Thomson, Brett; Weston, Kathryn M; Knight-Billington, Patricia J

2015-01-01

Two small rural towns in Australia, where medical practitioners provide primary care to the population, including emergency, anaesthetic and obstetric services, were early adopters of an innovative year-long integrated clerkship (clinical placement) designed to foster medical student skill attainment and a commitment to underserved rural communities. Primary care vocational trainees had previously trained in the region. Engaging with the university to participate in the clerkship initiative for undergraduate medical education offered the local healthcare service an opportunity to really integrate education with service. This study sought perspectives from a multidisciplinary group of stakeholders on the impact of the longitudinal integrated clerkship (LIC) on the healthcare community. Three analysts independently analysed the transcripts arising from semi-structured interviews with a range of health care clinicians and managers (N=23). Themes were identified using inductive content analysis methodology. Four major themes emerged from the perspectives of a multi-professional group of participants from both towns: transforming a community of practice, realising the potential of the health service, investment in rural return, and sustainability. There was significant clinical exposure, skill and teaching capacity in these previously unrecognised rural placements but realising the potential of the health service needs careful management to sustain this resource. Early engagement and initial enthusiasm have produced many positive outcomes for the healthcare community, but this alone is not sufficient to sustain an increasing role for rural primary care in medical education. The study identified issues that need addressing for sustainability, namely validation, time and costs. Strategies to address these are key to continuation of LICs in small rural communities.

Appreciative Inquiry for quality improvement in primary care practices.

PubMed

Ruhe, Mary C; Bobiak, Sarah N; Litaker, David; Carter, Caroline A; Wu, Laura; Schroeder, Casey; Zyzanski, Stephen J; Weyer, Sharon M; Werner, James J; Fry, Ronald E; Stange, Kurt C

2011-01-01

To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process. Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical-record review assessed change in PSD rates. Ethnographic field notes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. The PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives, and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited 1 or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.

Appreciative Inquiry for Quality Improvement in Primary Care Practices

PubMed Central

Ruhe, Mary C.; Bobiak, Sarah N.; Litaker, David; Carter, Caroline A.; Wu, Laura; Schroeder, Casey; Zyzanski, Stephen; Weyer, Sharon M.; Werner, James J.; Fry, Ronald E.; Stange, Kurt C.

2014-01-01

Purpose To test the effect of an Appreciative Inquiry (AI) quality improvement strategy, on clinical quality management and practice development outcomes. AI enables discovery of shared motivations, envisioning a transformed future, and learning around implementation of a change process. Methods Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical record review assessed change in PSD rates. Ethnographic fieldnotes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. Results PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited one or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. Conclusions An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective. PMID:21192206

A nationwide survey of patient centered medical home demonstration projects.

PubMed

Bitton, Asaf; Martin, Carina; Landon, Bruce E

2010-06-01

The patient centered medical home has received considerable attention as a potential way to improve primary care quality and limit cost growth. Little information exists that systematically compares PCMH pilot projects across the country. Cross-sectional key-informant interviews. Leaders from existing PCMH demonstration projects with external payment reform. We used a semi-structured interview tool with the following domains: project history, organization and participants, practice requirements and selection process, medical home recognition, payment structure, practice transformation, and evaluation design. A total of 26 demonstrations in 18 states were interviewed. Current demonstrations include over 14,000 physicians caring for nearly 5 million patients. A majority of demonstrations are single payer, and most utilize a three component payment model (traditional fee for service, per person per month fixed payments, and bonus performance payments). The median incremental revenue per physician per year was $22,834 (range $720 to $91,146). Two major practice transformation models were identified--consultative and implementation of the chronic care model. A majority of demonstrations did not have well-developed evaluation plans. Current PCMH demonstration projects with external payment reform include large numbers of patients and physicians as well as a wide spectrum of implementation models. Key questions exist around the adequacy of current payment mechanisms and evaluation plans as public and policy interest in the PCMH model grows.

Call to action: A new path for improving diabetes care for Indigenous peoples, a global review.

PubMed

Harris, Stewart B; Tompkins, Jordan W; TeHiwi, Braden

2017-01-01

Diabetes has reached epidemic proportions in Indigenous populations around the globe, and there is an urgent need to improve the health and health equity of Indigenous peoples with diabetes through timely and appropriate diabetes prevention and management strategies. This review describes the evolution of the diabetes epidemic in Indigenous populations and associated risk factors, highlighting gestational diabetes and intergenerational risk, lifestyle risk factors and social determinants as having particular importance and impact on Indigenous peoples. This review further describes the impact of chronic disease and diabetes on Indigenous peoples and communities, specifically diabetes-related comorbidities and complications. This review provides continued evidence that dramatic changes are necessary to reduce diabetes-related inequities in Indigenous populations, with a call to action to support programmatic primary healthcare transformation capable of empowering Indigenous peoples and communities and improving chronic disease prevention and management. Promising strategies for transforming health services and care for Indigenous peoples include quality improvement initiatives, facilitating diabetes and chronic disease registry and surveillance systems to identify care gaps, and prioritizing evaluation to build the evidence-base necessary to guide future health policy and planning locally and on a global scale. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.

Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota–Colombia: a cross-sectional study

PubMed Central

2013-01-01

Background The high segmentation and fragmentation in the provision of services are some of the main problems of the Colombian health system. In 2004 the district government of Bogota decided to implement a Primary Health Care (PHC) strategy through the Home Health program. PHC was conceived as a model for transforming health care delivery within the network of the first-level public health care facilities. This study aims to evaluate the performance of the essential dimensions of the PHC strategy in six localities geographically distributed throughout Bogotá city. Methods The rapid assessment tool to measure PHC performance, validated in Brazil, was applied. The perception of participants (users, professionals, health managers) in public health facilities where the Home Health program was implemented was compared with the perception of participants in private health facilities not implementing the program. A global performance index and specific indices for each primary care dimension were calculated. A multivariate logistic regression analysis was conducted to determine possible associations between the performance of the PHC dimensions and the self-perceived health status of users. Results The global performance index was rated as good for all participants interviewed. In general, with the exception of professionals, the differences in most of the essential dimensions seemed to favor public health care facilities where the Home Health program was implemented. The weakest dimensions were the family focus and community orientation—rated as critical by users; the distribution of financial resources—rated as critical by health managers; and, accessibility—rated as intermediate by users. Conclusions The overall findings suggest that the Home Health program could be improving the performance of the network of the first-level public health care facilities in some PHC essential dimensions, but significant efforts to achieve its objectives and raise its visibility in the community are required. PMID:23947574

Statistical transformation and the interpretation of inpatient glucose control data from the intensive care unit.

PubMed

Saulnier, George E; Castro, Janna C; Cook, Curtiss B

2014-05-01

Glucose control can be problematic in critically ill patients. We evaluated the impact of statistical transformation on interpretation of intensive care unit inpatient glucose control data. Point-of-care blood glucose (POC-BG) data derived from patients in the intensive care unit for 2011 was obtained. Box-Cox transformation of POC-BG measurements was performed, and distribution of data was determined before and after transformation. Different data subsets were used to establish statistical upper and lower control limits. Exponentially weighted moving average (EWMA) control charts constructed from April, October, and November data determined whether out-of-control events could be identified differently in transformed versus nontransformed data. A total of 8679 POC-BG values were analyzed. POC-BG distributions in nontransformed data were skewed but approached normality after transformation. EWMA control charts revealed differences in projected detection of out-of-control events. In April, an out-of-control process resulting in the lower control limit being exceeded was identified at sample 116 in nontransformed data but not in transformed data. October transformed data detected an out-of-control process exceeding the upper control limit at sample 27 that was not detected in nontransformed data. Nontransformed November results remained in control, but transformation identified an out-of-control event less than 10 samples into the observation period. Using statistical methods to assess population-based glucose control in the intensive care unit could alter conclusions about the effectiveness of care processes for managing hyperglycemia. Further study is required to determine whether transformed versus nontransformed data change clinical decisions about the interpretation of care or intervention results. © 2014 Diabetes Technology Society.

Statistical Transformation and the Interpretation of Inpatient Glucose Control Data From the Intensive Care Unit

PubMed Central

Saulnier, George E.; Castro, Janna C.

2014-01-01

Glucose control can be problematic in critically ill patients. We evaluated the impact of statistical transformation on interpretation of intensive care unit inpatient glucose control data. Point-of-care blood glucose (POC-BG) data derived from patients in the intensive care unit for 2011 was obtained. Box–Cox transformation of POC-BG measurements was performed, and distribution of data was determined before and after transformation. Different data subsets were used to establish statistical upper and lower control limits. Exponentially weighted moving average (EWMA) control charts constructed from April, October, and November data determined whether out-of-control events could be identified differently in transformed versus nontransformed data. A total of 8679 POC-BG values were analyzed. POC-BG distributions in nontransformed data were skewed but approached normality after transformation. EWMA control charts revealed differences in projected detection of out-of-control events. In April, an out-of-control process resulting in the lower control limit being exceeded was identified at sample 116 in nontransformed data but not in transformed data. October transformed data detected an out-of-control process exceeding the upper control limit at sample 27 that was not detected in nontransformed data. Nontransformed November results remained in control, but transformation identified an out-of-control event less than 10 samples into the observation period. Using statistical methods to assess population-based glucose control in the intensive care unit could alter conclusions about the effectiveness of care processes for managing hyperglycemia. Further study is required to determine whether transformed versus nontransformed data change clinical decisions about the interpretation of care or intervention results. PMID:24876620

Transforming care: medical practice design and information technology.

PubMed

Kilo, Charles M

2005-01-01

The transformation of the medical practice is possible today because of the advancement of system design knowledge coupled with innovations in information technology (IT). Examples of such transformed care are present today, and they are creating a roadmap for others. Those efforts are also elucidating critical issues in the use of IT to advance health care quality. Connectivity, electronic integration, and knowledge management are the key functionalities emerging as levers to promote this transformation.

Transformational leadership behaviors in allied health professions.

PubMed

Wylie, David A; Gallagher, Helen L

2009-01-01

The aim of this study was to explore self-reported transformational leadership behavior profiles within the six largest allied health profession groups in the National Health Service in Scotland and to determine whether factors such as seniority of grade, locus of employment, and/or leadership training have a positive influence on transformational leadership behaviors. A postal survey comprising the shorter version of the Multifactorial Leadership Questionnaire (MLQ) and contextual demographic information was completed by 753 allied health professionals from four Health Board areas across Scotland who were randomly selected through a modified cluster sampling technique. The MLQ contains 36 items that measure nine identified leadership factors; however, only the responses to the five transformational leadership factors are reported here. The study identified significant differences in transformational leadership behaviors between individual allied health professions. Radiographers and podiatrists scored consistently lower than the other professional groups across the range of transformational behaviors. Seniority of grade significantly influenced the scores, with higher-graded staff reporting greater leadership behaviors (p < 0.001). Prior leadership training also positively influenced transformational behaviors (p < 0.001). However, locus of employment within a primary or secondary care setting or even a multidisciplinary or unidisciplinary team had no effect. This research identified significant differences in transformational leadership behaviors between individual allied health professions, indicating that some professional groups are inherently advantaged in embracing the modernization agenda. This highlights an as-yet missed opportunity for effectively targeting and evaluating multidisciplinary leadership training programs across the allied health professions.

Note: Tesla transformer damping

NASA Astrophysics Data System (ADS)

Reed, J. L.

2012-07-01

Unexpected heavy damping in the two winding Tesla pulse transformer is shown to be due to small primary inductances. A small primary inductance is a necessary condition of operability, but is also a refractory inefficiency. A 30% performance loss is demonstrated using a typical "spiral strip" transformer. The loss is investigated by examining damping terms added to the transformer's governing equations. A significant alteration of the transformer's architecture is suggested to mitigate these losses. Experimental and simulated data comparing the 2 and 3 winding transformers are cited to support the suggestion.

Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care A Cluster-Randomized Clinical Trial

PubMed Central

Liebschutz, Jane M.; Xuan, Ziming; Shanahan, Christopher W.; LaRochelle, Marc; Keosaian, Julia; Beers, Donna; Guara, George; O’Connor, Kristen; Alford, Daniel P.; Parker, Victoria; Weiss, Roger D.; Samet, Jeffrey H.; Crosson, Julie; Cushman, Phoebe A.; Lasser, Karen E.

2017-01-01

IMPORTANCE Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. OBJECTIVE To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices. INTERVENTIONS Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. MAIN OUTCOMES AND MEASURES Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language. RESULTS Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6–10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4–32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8–5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7–1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3–2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). CONCLUSIONS AND RELEVANCE A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01909076 PMID:28715535

Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial.

PubMed

Liebschutz, Jane M; Xuan, Ziming; Shanahan, Christopher W; LaRochelle, Marc; Keosaian, Julia; Beers, Donna; Guara, George; O'Connor, Kristen; Alford, Daniel P; Parker, Victoria; Weiss, Roger D; Samet, Jeffrey H; Crosson, Julie; Cushman, Phoebe A; Lasser, Karen E

2017-09-01

Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices. Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language. Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills. clinicaltrials.gov Identifier: NCT01909076.

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.

Efficient Transformation of Primary Human Mesenchymal Stromal Cells by Adenovirus Early Region 1 Oncogenes.

PubMed

Speiseder, Thomas; Hofmann-Sieber, Helga; Rodríguez, Estefanía; Schellenberg, Anna; Akyüz, Nuray; Dierlamm, Judith; Spruss, Thilo; Lange, Claudia; Dobner, Thomas

2017-01-01

Previous observations that human amniotic fluid cells (AFC) can be transformed by human adenovirus type 5 (HAdV-5) E1A/E1B oncogenes prompted us to identify the target cells in the AFC population that are susceptible to transformation. Our results demonstrate that one cell type corresponding to mesenchymal stem/stroma cells (hMSCs) can be reproducibly transformed by HAdV-5 E1A/E1B oncogenes as efficiently as primary rodent cultures. HAdV-5 E1-transformed hMSCs exhibit all properties commonly associated with a high grade of oncogenic transformation, including enhanced cell proliferation, anchorage-independent growth, increased growth rate, and high telomerase activity as well as numerical and structural chromosomal aberrations. These data confirm previous work showing that HAdV preferentially transforms cells of mesenchymal origin in rodents. More importantly, they demonstrate for the first time that human cells with stem cell characteristics can be completely transformed by HAdV oncogenes in tissue culture with high efficiency. Our findings strongly support the hypothesis that undifferentiated progenitor cells or cells with stem cell-like properties are highly susceptible targets for HAdV-mediated cell transformation and suggest that virus-associated tumors in humans may originate, at least in part, from infections of these cell types. We expect that primary hMSCs will replace the primary rodent cultures in HAdV viral transformation studies and are confident that these investigations will continue to uncover general principles of viral oncogenesis that can be extended to human DNA tumor viruses as well. It is generally believed that transformation of primary human cells with HAdV-5 E1 oncogenes is very inefficient. However, a few cell lines have been successfully transformed with HAdV-5 E1A and E1B, indicating that there is a certain cell type which is susceptible to HAdV-mediated transformation. Interestingly, all those cell lines have been derived from human embryonic tissue, albeit the exact cell type is not known yet. We show for the first time the successful transformation of primary human mesenchymal stromal cells (hMSCs) by HAdV-5 E1A and E1B. Further, we show upon HAdV-5 E1A and E1B expression that these primary progenitor cells exhibit features of tumor cells and can no longer be differentiated into the adipogenic, chondrogenic, or osteogenic lineage. Hence, primary hMSCs represent a robust and novel model system to elucidate the underlying molecular mechanisms of adenovirus-mediated transformation of multipotent human progenitor cells. Copyright © 2016 American Society for Microbiology.

The Islamic dialogue with African traditional religion: divination and health care.

PubMed

Kirby, J P

1993-02-01

In rural Africa delivering better health care is more complicated than simply offering good medical services; it must also take into account peoples' religious orientation and beliefs. Here the non-material causes of illness are at least as important as the biological or material and, in many places, one can only determine the exact nature of the problem and its corresponding remedy after the fact, through a process involving divination and sacrifice. In northern Ghana, by adapting to traditional methods of divination, Islam is gradually introducing a future perspective and expanding the possibilities of preventative action. By so doing it is bringing about a religio-epistemological transformation that is, among other things, helping people to understand and make better use of Western bio-medicine and primary health care programs. The author argues for a similar adaptation and dialogue between African traditional beliefs and Western medical institutions.

Direct current transformer

NASA Technical Reports Server (NTRS)

Khanna, S. M.; Urban, E. W. (Inventor)

1979-01-01

A direct current transformer in which the primary consists of an elongated strip of superconductive material, across the ends of which is direct current potential is described. Parallel and closely spaced to the primary is positioned a transformer secondary consisting of a thin strip of magnetoresistive material.

Organizational culture associated with provider satisfaction.

PubMed

Scammon, Debra L; Tabler, Jennifer; Brunisholz, Kimberly; Gren, Lisa H; Kim, Jaewhan; Tomoaia-Cotisel, Andrada; Day, Julie; Farrell, Timothy W; Waitzman, Norman J; Magill, Michael K

2014-01-01

Organizational culture is key to the successful implementation of major improvement strategies. Transformation to a patient-centered medical home (PCHM) is such an improvement strategy, requiring a shift from provider-centric care to team-based care. Because this shift may impact provider satisfaction, it is important to understand the relationship between provider satisfaction and organizational culture, specifically in the context of practices that have transformed to a PCMH model. This was a cross-sectional study of surveys conducted in 2011 among providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design. Measures included the Organizational Culture Assessment Instrument and the American Medical Group Association provider satisfaction survey. Providers were most satisfied with quality of care (mean, 4.14; scale of 1-5) and interactions with patients (mean, 4.12) and were least satisfied with time spent working (mean, 3.47), paperwork (mean, 3.45), and compensation (mean, 3.35). Culture profiles differed across clinics, with family/clan and hierarchical cultures the most common. Significant correlations (P ≤ .05) between provider satisfaction and clinic culture archetypes included family/clan culture negatively correlated with administrative work; entrepreneurial culture positively correlated with the Time Spent Working dimension; market/rational culture positively correlated with how practices were facing economic and strategic challenges; and hierarchical culture negatively correlated with the Relationships with Staff and Resource dimensions. Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.

The value transformation of health care: Impact on neuromuscular and electrodiagnostic medicine.

PubMed

Narayanaswami, Pushpa; Suk, Millie; Jones, Lyell K

2017-10-01

Beginning in 2017, most physicians who participate in Medicare are subject to the Medicare Access and CHIP Reauthorization Act (MACRA), the milestone legislation that signals the US health care system's transition from volume-based to value-based care. Here we review emerging trends in development of value-based healthcare systems in the US. MACRA and the resulting Quality Payment Program create 2 participation pathways, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (AAPM) pathway. Although there are several program incentives for AAPM participation, to date there have been few AAPM options for specialists. MIPS and its widening bonus and penalty window will likely be the primary participation pathway in the early years of the program. Value-based payment has the potential to reshape health care delivery in the United States, with implications for neuromuscular and electrodiagnostic (EDX) specialists. Meaningful quality measures are required for neuromuscular and EDX specialists. Muscle Nerve 56: 679-683, 2017. © 2017 Wiley Periodicals, Inc.

Promoting quality: the health-care organization from a management perspective.

PubMed

Glickman, Seth W; Baggett, Kelvin A; Krubert, Christopher G; Peterson, Eric D; Schulman, Kevin A

2007-12-01

Although agreement about the need for quality improvement in health care is almost universal, the means of achieving effective improvement in overall care is not well understood. Avedis Donabedian developed the structure-process-outcome framework in which to think about quality-improvement efforts. There is now a robust evidence-base in the quality-improvement literature on process and outcomes, but structure has received considerably less attention. The health-care field would benefit from expanding the current interpretation of structure to include broader perspectives on organizational attributes as primary determinants of process change and quality improvement. We highlight and discuss the following key elements of organizational attributes from a management perspective: (i) executive management, including senior leadership and board responsibilities (ii) culture, (iii) organizational design, (iv) incentive structures and (v) information management and technology. We discuss the relevant contributions from the business and medical literature for each element, and provide this framework as a roadmap for future research in an effort to develop the optimal definition of 'structure' for transforming quality-improvement initiatives.

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

Counsellors are prevalent in primary care settings. However, there are concerns about the clinical and cost-effectiveness of the treatments they provide, compared with alternatives such as usual care from the general practitioner, medication or other psychological therapies. To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials, controlled clinical trials and controlled patient preference trials of counselling interventions in primary care, for patients with psychological and psychosocial problems considered suitable for counselling. The original 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 to uncover further controlled trials. Contact was made with subject experts and CCDAN members in order to uncover further trials. For the updated review, searches were restricted to those databases judged to be high yield in the first version of the review: MEDLINE, EMBASE, PSYCLIT and CINAHL, the Cochrane Controlled Trials register and the CCDAN trials register. 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 2001 were included in the review. Data were extracted using a standardised data extraction sheet. The relevant data were entered into the Review Manager software. Trials were quality rated, 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. 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.

Developing an adequate "pneumatraumatology": understanding the spiritual impacts of traumatic injury.

PubMed

Bidwell, Duane R

2002-01-01

Psychosocial interventions and systematic theology are primary resources for chaplains and congregational pastors who care for victims of physical trauma. Yet these resources may not be adequate to address the spiritual impacts of trauma. This article proposes a preliminary "pneumatraumatology," drawing on early Christian asceticism and Buddhist mysticism to describe one way of understanding the spiritual impacts of traumatic injury. It also suggests possible responses to these impacts informed by narrative/constructionist perspectives and Breggemann's understanding of the dimensions of spiritual transformation in the Hebrew Bible.

Nursing Leadership in Home and Community Care: An Introduction.

PubMed

Donner, Gail

2017-01-01

There is agreement across all provinces that there is transformation needed in the area of home and community care. Yet, where is the collective voice of nurse leaders in this transformation? The guest editor calls on nurses to respond to this unique opportunity to shape the transformation of our health system, and improve care for patients and their caregivers.

Workplace clinics: a sign of growing employer interest in wellness.

PubMed

Tu, Ha T; Boukus, Ellyn R; Cohen, Genna R

2010-12-01

Interest in workplace clinics has intensified in recent years, with employers moving well beyond traditional niches of occupational health and minor acute care to offering clinics that provide a full range of wellness and primary care services. Employers view workplace clinics as a tool to contain medical costs, boost productivity and enhance companies' reputations as employers of choice. The potential for clinics to transform primary care delivery through the trusted clinician model holds promise, according to experts interviewed for a new qualitative research study from the Center for Studying Health System Change (HSC). Achieving that model is dependent on gaining employee trust in the clinic, as well as the ability to recruit and retain clinicians with the right qualities--a particular challenge in communities with provider shortages. Even when clinic operations are outsourced to vendors, initial employer involvement--including the identification of the appropriate scope and scale of clinic services--and sustained employer attention over time are critical to clinic success. Measuring the impact of clinics is difficult, and credible evidence on return on investment (ROI) varies widely, with very high ROI claims made by some vendors lacking credibility. While well-designed, well-implemented workplace clinics are likely to achieve positive returns over the long term, expecting clinics to be a game changer in bending the overall health care cost curve may be unrealistic.

Rapid Business Transformations in Health Care: A Systems Approach

ERIC Educational Resources Information Center

Shulaiba, Refaat A.

2011-01-01

The top two priorities of health care business leaders are to constantly improve the quality of health care while striving to contain and reduce the high cost of health care. The Health Care industry, similar to all businesses, is motivated to deliver innovative solutions that accelerate business transformation and increase business capabilities. …

Low-grade osteosarcoma arising from cemento-ossifying fibroma: a case report

PubMed Central

Lee, Yong Bin; Kim, Nam-Kyoo; Kim, Jae-Young

2015-01-01

Cemento-ossifying fibromas are benign tumors, and, although cases of an aggressive type have been reported, no cases of cemento-ossifying fibroma transforming into osteosarcoma have been documented previously. Low-grade osteosarcoma is a rare type of primary bone tumor, representing 1%-2% of all osteosarcomas. A 45-year-old female patient was diagnosed with cemento-ossifying fibroma, treated with mass excision several times over a period of two years and eight months, and followed up. After biopsy gathered because of signs of recurrence, she was diagnosed with low-grade osteosarcoma. The patient underwent wide excision, segmental mandibulectomy, and reconstruction with fibula free flap. The aim of this report is to raise awareness of the possibility that cemento-ossifying fibroma can transform into osteosarcoma and of the consequent necessity for careful diagnosis and treatment planning. PMID:25741469

Low-grade osteosarcoma arising from cemento-ossifying fibroma: a case report.

PubMed

Lee, Yong Bin; Kim, Nam-Kyoo; Kim, Jae-Young; Kim, Hyung Jun

2015-02-01

Cemento-ossifying fibromas are benign tumors, and, although cases of an aggressive type have been reported, no cases of cemento-ossifying fibroma transforming into osteosarcoma have been documented previously. Low-grade osteosarcoma is a rare type of primary bone tumor, representing 1%-2% of all osteosarcomas. A 45-year-old female patient was diagnosed with cemento-ossifying fibroma, treated with mass excision several times over a period of two years and eight months, and followed up. After biopsy gathered because of signs of recurrence, she was diagnosed with low-grade osteosarcoma. The patient underwent wide excision, segmental mandibulectomy, and reconstruction with fibula free flap. The aim of this report is to raise awareness of the possibility that cemento-ossifying fibroma can transform into osteosarcoma and of the consequent necessity for careful diagnosis and treatment planning.

A discussion of approaches to transforming care: contemporary strategies to improve patient safety.

PubMed

Burston, Sarah; Chaboyer, Wendy; Wallis, Marianne; Stanfield, Jane

2011-11-01

This article presents a discussion of three contemporary approaches to transforming care: Transforming Care at the Bedside, Releasing Time to Care: the Productive Ward and the work of the Studer Group(®). International studies of adverse events in hospitals have highlighted the need to focus on patient safety. The case for transformational change was identified and recently several approaches have been developed to effect this change. Despite limited evaluation, these approaches have spread and have been adopted outside their country of origin and contextual settings. Medline and CINAHL databases were searched for the years 1999-2009. Search terms included derivatives of 'transformation' combined with 'care', 'nursing', 'patient safety', 'Transforming Care at the Bedside', 'the Productive Ward' and 'Studer Group'. A comparison of the three approaches revealed similarities including: the foci of the approaches; interventions employed; and the outcomes measured. Key differences identified are the implementation models used, spread strategies and sustainability of the approaches. The approaches appear to be complementary and a hybrid of the approaches such as a blend of a top-down and bottom-up leadership strategy may offer more sustainable behavioural change. These approaches transform the way nurses do their work, how they work with others and how they view the care they provide to promote patient safety. All the approaches involve the implementation of multiple interventions occurring simultaneously to affect improvements in patient safety. The approaches are complementary and a hybrid approach may offer more sustainable outcomes. © 2011 Blackwell Publishing Ltd.

An ontological model of the practice transformation process.

PubMed

Sen, Arun; Sinha, Atish P

2016-06-01

Patient-centered medical home is defined as an approach for providing comprehensive primary care that facilitates partnerships between individual patients and their personal providers. The current state of the practice transformation process is ad hoc and no methodological basis exists for transforming a practice into a patient-centered medical home. Practices and hospitals somehow accomplish the transformation and send the transformation information to a certification agency, such as the National Committee for Quality Assurance, completely ignoring the development and maintenance of the processes that keep the medical home concept alive. Many recent studies point out that such a transformation is hard as it requires an ambitious whole-practice reengineering and redesign. As a result, the practices suffer change fatigue in getting the transformation done. In this paper, we focus on the complexities of the practice transformation process and present a robust ontological model for practice transformation. The objective of the model is to create an understanding of the practice transformation process in terms of key process areas and their activities. We describe how our ontology captures the knowledge of the practice transformation process, elicited from domain experts, and also discuss how, in the future, that knowledge could be diffused across stakeholders in a healthcare organization. Our research is the first effort in practice transformation process modeling. To build an ontological model for practice transformation, we adopt the Methontology approach. Based on the literature, we first identify the key process areas essential for a practice transformation process to achieve certification status. Next, we develop the practice transformation ontology by creating key activities and precedence relationships among the key process areas using process maturity concepts. At each step, we employ a panel of domain experts to verify the intermediate representations of the ontology. Finally, we implement a prototype of the practice transformation ontology using Protégé. Copyright © 2016 Elsevier Inc. All rights reserved.

Patient care transformation: the plan and the reality.

PubMed

Drexler, Diane; Malloch, Kathy

2006-01-01

An explosion of new hospital building has created the opportunity for nurse leaders to transform the patient care experience with evidence-based architecture, technology innovations, and new patient care delivery models. The authors share the first-year results of the creation of a hospital of the future in which staff actively participated and addressed the challenges of transforming the patient care experience. Positive results include patient satisfaction at the 99th percentile, successful integration of 63 software applications, and energized nursing staff.

Health Care Evolution Is Driving Staffing Industry Transformation.

PubMed

Faller, Marcia; Gogek, Jim

2016-01-01

The powerful transformation in the health care industry is reshaping not only patient care delivery and the business of health care but also demanding new strategies from vendors who support the health care system. These new strategies may be most evident in workforce solutions and health care staffing services. Consolidation of the health care industry has created increased demand for these types of services. Accommodating a changing workforce and related pressures resulting from health care industry transformation has produced major change within the workforce solutions and staffing services sector. The effect of the growth strategy of mergers, acquisitions, and organic development has revealed organizational opportunities such as expanding capacity for placing physicians, nurses, and allied professionals, among other workforce solutions. This article shares insights into workforce challenges and solutions throughout the health care industry.

SMART DOCS: A New Patient-Centered Outcomes and Coordinated-Care Management Approach for the Future Practice of Sleep Medicine

PubMed Central

Kushida, Clete A.; Nichols, Deborah A.; Holmes, Tyson H.; Miller, Ric; Griffin, Kara; Cardell, Chia-Yu; Hyde, Pamela R.; Cohen, Elyse; Manber, Rachel; Walsh, James K.

2015-01-01

The practice of medicine is currently undergoing a transformation to become more efficient, cost-effective, and patient centered in its delivery of care. The aim of this article is to stimulate discussion within the sleep medicine community in addressing these needs by our approach as well as other approaches to sleep medicine care. The primary goals of the Sustainable Methods, Algorithms, and Research Tools for Delivering Optimal Care Study (SMART DOCS) are: (1) to introduce a new Patient-Centered Outcomes and Coordinated-Care Management (PCCM) approach for the future practice of sleep medicine, and (2) to test the PCCM approach against a Conventional Diagnostic and Treatment Outpatient Medical Care (CONV) approach in a randomized, two-arm, single-center, long-term, comparative effectiveness trial. The PCCM approach is integrated into a novel outpatient care delivery model for patients with sleep disorders that includes the latest technology, allowing providers to obtain more accurate and rapid diagnoses and to make evidence-based treatment recommendations, while simultaneously enabling patients to have access to personalized medical information and reports regarding their diagnosis and treatment so that they can make more informed health care decisions. Additionally, the PCCM approach facilitates better communication between patients, referring primary care physicians, sleep specialists, and allied health professionals so that providers can better assist patients in achieving their preferred outcomes. A total of 1,506 patients 18 y or older will be randomized to either the PCCM or CONV approach and will be followed for at least 1 y with endpoints of improved health care performance, better health, and cost control. Clinical Trials Registration: ClinicalTrials.gov Identifier: NCT02037438. Citation: Kushida CA, Nichols DA, Holmes TH, Miller R, Griffin K, Cardell CY, Hyde PR, Cohen E, Manber R, Walsh JK. SMART DOCS: a new patient-centered outcomes and coordinated-care management approach for the future practice of sleep medicine. SLEEP 2015;38(2):315–326. PMID:25409112

Virtual nursing grand rounds and shared governance: how innovation and empowerment are transforming nursing practice at Thanh Nhan Hospital, Hanoi, Vietnam.

PubMed

Crow, Gregory L; Nguyen, Thanh; DeBourgh, Gregory A

2014-01-01

The Vietnam Nurse Project has been operating in Hanoi since 2007. Its primary purpose is to improve nursing education through curriculum development, faculty development, and the introduction of a more student-centric teaching and learning environment. The Virtual Nursing Grand Rounds component of the project is an academic-practice partnership between the Vietnam Nurse Project at the University of San Francisco School of Nursing and Health Professions and the Thanh Nhan Hospital intensive care unit. Its goal is to improve nursing practice in the Thanh Nhan Hospital intensive care unit. The Virtual Nursing Grand Rounds is a fully interactive real-time synchronous computer technology-assisted point-to-point program that provides ongoing evidence-based staff development and consultative services.

'Healthy gums do matter': A case study of clinical leadership within primary dental care.

PubMed

Moore, D; Saleem, S; Hawthorn, E; Pealing, R; Ashley, M; Bridgman, C

2015-09-25

The Health and Social Care Act 2012 heralded wide reaching reforms intended to place clinicians at the heart of the health service. For NHS general dental practice, the conduits for this clinical leadership are the NHS England local professional networks. In Greater Manchester, the local professional network has developed and piloted a clinician led quality improvement project: 'Healthy Gums DO Matter, a Practitioner's Toolkit'. Used as a case study, the project highlighted the following facilitators to clinical leadership in dentistry: supportive environment; mentoring and transformational leadership; alignment of project goals with national policy; funding allowance; cross-boundary collaboration; determination; altruism; and support from wider academic and specialist colleagues. Barriers to clinical leadership identified were: the hierarchical nature of healthcare, territorialism and competing clinical commitments.

Rotary Transformer Seals Power In

NASA Technical Reports Server (NTRS)

Studer, P. A.; Paulkovich, J.

1982-01-01

Rotary transformer originally developed for spacecraft transfers electrical power from stationary primary winding to rotating secondary without sliding contacts and very little leakage of electromagnetic radiation. Transformer has two stationary primary windings connected in parallel. Secondary, mounted on a shaft that extends out of housing, rotates between two windings of primary. Shaft of secondary is composed of electrically conducting inner and outer parts separated by an insulator. Electrical contact is made from secondary winding, through shaft, to external leads.

[Governance of PHC development in Rosario, Argentina].

PubMed

Báscolo, Ernesto; Yavich, Natalia

2010-01-01

Describing the development of PHC policy as promoted by Rosario Municipality (Argentina). A case-study was carried out during 2007 and 2008. Data was collected from secondary and primary sources (interviews, organisational census and observations). PHC development stages were identified by recognising the social norms which produced institutional change and transformation in municipal health services structure and health care and management models. The prevailing modes of governance in each stage were reconognised and characterised (clan, hierarchy and/or incentives). Four stages were identified between 1990 and 2008: 1990-1995/hierarchical mode: primary health care level organisation autonomied from hospitals. 1995-2000/ clan mode: developing of participatory managerial boards and community participation. 2000-2004/ clan mode: maturation of the "PHC movement" in competition with hospitals. 2004-2008/ clan-hierarchical mode: "movement's" crisis and constructions of norms tending towards enhancing an integrated network. Strengthening and empowering first-level health-care produced innovation favouring: the consolidation of a "PHC movement" having strong social commitment and improved services performance. The clan governance mode (regulating collective action via voluntary adhesion to shared values) was crucial for developing PHC between 1995 and 2004. Later on, the movement's fragmentation and the challenges of integrating the health system required developing hierarchical regulation mechanisms to complement the governance clan mode regulation.

Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step

PubMed Central

El Rayess, Fadya; Goldman, Roberta; Furey, Christopher; Chandran, Rabin; Goldberg, Arnold R.; Anandarajah, Gowri

2015-01-01

Background The patient-centered medical home (PCMH) is an accepted framework for delivering high-quality primary care, prompting many residencies to transform their practices into PCMHs. Few studies have assessed the impact of these changes on residents' and faculty members' PCMH attitudes, knowledge, and skills. The family medicine program at Brown University achieved Level 3 PCMH accreditation in 2010, with training relying primarily on situated learning through immersion in PCMH practice, supplemented by didactics and a few focused clinical activities. Objective To assess PCMH knowledge and attitudes after Level 3 PCMH accreditation and to identify additional educational needs. Methods We used a qualitative approach, with semistructured, individual interviews with 12 of the program's 13 postgraduate year 3 residents and 17 of 19 core faculty. Questions assessed PCMH knowledge, attitudes, and preparedness for practicing, teaching, and leading within a PCMH. Interviews were analyzed using the immersion/crystallization method. Results Residents and faculty generally had positive attitudes toward PCMH. However, many expressed concerns that they lacked specific PCMH knowledge, and felt inadequately prepared to implement PCMH principles into their future practice or teaching. Some exceptions were faculty and resident leaders who were actively involved in the PCMH transformation. Barriers included lack of time and central roles in PCMH activities. Conclusions Practicing in a certified PCMH training program, with passive PCMH roles and supplemental didactics, appears inadequate in preparing residents and faculty for practice or teaching in a PCMH. Purposeful curricular design and evaluation, with faculty development, may be needed to prepare the future leaders of primary care. PMID:26692970

The influence of a market-oriented primary care reform on family physicians' working conditions: A qualitative study in Turkey.

PubMed

Çiçeklioğlu, Meltem; Öcek, Zeliha Aslı; Turk, Meral; Taner, Şafak

2015-06-01

Turkey has undergone a 'Health transformation programme' putting emphasis on the reorganization of primary care (PC) services towards a more market-oriented system. To obtain a deep understanding of how family physicians (FPs) experienced the process of the reforms by focusing on working conditions. This phenomenological and qualitative research used maximum variation sampling and 51 FPs were interviewed in 36 in-depth and four focus-group interviews. Thematic analysis of interviews provided seven themes: (1) change in the professional identity of PC physicians (physician as businessperson); (2) transformation of the physician-patient relationship in PC (into a provider-customer relationship); (3) job description and workload; (4) interpersonal relationships; (5) remuneration of FPs, (6) uncertainty about the future and (7) exhaustion. Most FPs felt that the Family medicine model (FMM) placed more emphasis on the business function of family practice and this conflicted with their professional characteristics as physicians. FPs complained that some of their patients behaved as extremely demanding consumers. Continuously increasing responsibilities and extremely high workload were commonly reported problems. Most participants described the negative incentives in the performance scheme as a degrading method of punishment. The main factor was job insecurity caused by contract-based employment. FPs described the point at which they are with terms such as exhaustion. By increasing workload and creating uncertainty about the future and about income, the PC reforms have led to working conditions, which has led to changes in the professional attitudes of physicians and their practice of medicine.

What's in a Name? The Necessary Transformation of the Academic Medical Center in the Era of Population Health and Accountable Care.

PubMed

DiSesa, Verdi J; Kaiser, Larry R

2015-07-01

Academic medical centers (AMCs) and the physicians and other professionals who lead them need to recognize they are in a business that is making a transition from a system of "sickness" care to one of "health" care, accountable for the health of defined populations and for the value (quality divided by cost) of the services provided. This change has profound implications for how AMCs conceive themselves, how they function, and how they are paid for the work that they do. A failure to recognize how the disruption of the mission of AMCs is changing may impair them as irrevocably as other changes caused the demise of Kodak, once the world's leader in the manufacture and sale of photographic film and cameras. Leaders of academic medicine need to understand, respond to, and ultimately lead the transformation of our system of health. In this Commentary, the authors review the pressures driving these changes and potential responses to them-a process already under way. They summarize the issues in the question "Should the words 'health' and 'system' take the place of 'medical' and 'center' in our institutions' names and, more important, in how we conceive of what we do?" The authors propose the name "academic health system" to better identify primary objectives to measure success by the health of patients.

Transformation of an academic medical center: lessons learned from restructuring and downsizing.

PubMed

Woodard, B; Fottler, M D; Kilpatrick, A O

1999-01-01

This article reviews management literature on health care transformation and describes the processes, including restructuring, job redesign, and downsizing, involved in one academic medical center's experience. The article concludes with lessons learned at each of the stages of the transformation process: planning, implementation, and process continuation. Managerial implications for similar transformation efforts in other health care organizations are suggested.

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 traditional FFS model, despite higher primary care costs in some models.

RF transformer

DOEpatents

Smith, James L.; Helenberg, Harold W.; Kilsdonk, Dennis J.

1979-01-01

There is provided an improved RF transformer having a single-turn secondary of cylindrical shape and a coiled encapsulated primary contained within the secondary. The coil is tapered so that the narrowest separation between the primary and the secondary is at one end of the coil. The encapsulated primary is removable from the secondary so that a variety of different capacity primaries can be utilized with one secondary.

Transforming home health nursing with telehealth technology.

PubMed

Farrar, Francisca Cisneros

2015-06-01

Telehealth technology is an evidence-based delivery model tool that can be integrated into the plan of care for mental health patients. Telehealth technology empowers access to health care, can help decrease or prevent hospital readmissions, assist home health nurses provide shared decision making, and focuses on collaborative care. Telehealth and the recovery model have transformed the role of the home health nurse. Nurses need to be proactive and respond to rapidly emerging technologies that are transforming their role in home care. Copyright © 2015 Elsevier Inc. All rights reserved.

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.

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.

Effectiveness and costs of a vocational advice service to improve work outcomes in patients with musculoskeletal pain in primary care: a cluster randomised trial (SWAP trial ISRCTN 52269669).

PubMed

Wynne-Jones, Gwenllian; Artus, Majid; Bishop, Annette; Lawton, Sarah A; Lewis, Martyn; Jowett, Sue; Kigozi, Jesse; Main, Chris; Sowden, Gail; Wathall, Simon; Burton, A Kim; van der Windt, Danielle A; Hay, Elaine M; Foster, Nadine E

2017-10-30

Musculoskeletal pain is a common cause of work absence, and early intervention is advocated to prevent the adverse health and economic consequences of longer-term absence. This cluster randomised controlled trial investigated the effect of introducing a vocational advice service into primary care to provide occupational support. Six general practices were randomised; patients were eligible if they were consulting their general practitioner with musculoskeletal pain and were employed and struggling at work or absent from work <6 months. Practices in the intervention arm could refer patients to a vocational advisor embedded within the practice providing a case-managed stepwise intervention addressing obstacles to working. The primary outcome was number of days off work, over 4 months. Participants in the intervention arm (n = 158) had fewer days work absence compared with the control arm (n = 180) (mean 9.3 [SD 21·7] vs 14·4 [SD 27·7]) days, incidence rate ratio 0·51 (95% confidence interval 0·26, 0·99), P = 0·048). The net societal benefit of the intervention compared with best care was £733: £748 gain (work absence) vs £15 loss (health care costs). The addition of a vocational advice service to best current primary care for patients consulting with musculoskeletal pain led to reduced absence and cost savings for society. If a similar early intervention to the one tested in this trial was implemented widely, it could potentially reduce days absent over 12 months by 16%, equating to an overall societal cost saving of approximately £500 million (US $6 billion) and requiring an investment of only £10 million.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation.

PubMed

Bokhour, Barbara G; Fix, Gemmae M; Mueller, Nora M; Barker, Anna M; Lavela, Sherri L; Hill, Jennifer N; Solomon, Jeffrey L; Lukas, Carol VanDeusen

2018-03-07

Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs. We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains. Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges. Transforming healthcare systems to focus on patient-centered care and better serve the "whole" patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.

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.

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

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.

Meeting the demand of the future: a curriculum to stimulate interest in careers in primary care internal medicine

PubMed Central

Hawthorne, Mary R.; Dinh, An

2017-01-01

ABSTRACT Background: There is a growing need for primary care physicians, but only a small percentage of graduating medical students enter careers in primary care. Purpose: To assess whether a Primary Care Intraclerkship within the Medicine clerkship can significantly improve students’ attitudes by analyzing scores on pre- and post-tests. Methods: Students on the Medicine clerkship at the University of Massachusetts Medical School participated in full-day ‘intraclerkships’,to demonstrate the importance of primary care and the management of chronic illness in various primary care settings. Pre-and post-tests containing students’ self-reported, five-point Likert agreement scale evaluations to 26 items (measuring perceptions about the roles of primary care physicians in patient care and treatment) were collected before and after each session. Eleven intraclerkships with 383 students were held between June 2010 and June 2013. Responses were analyzed using the GLM Model Estimate. Results: Results from the survey analysis showed significantly more positive attitudes toward primary care in the post-tests compared to the pre-tests. Students who were satisfied with their primary care physicians were significantly more likely to show an improvement in post-test attitudes toward primary care in the areas of physicians improving the quality of patient care, making a difference in overall patient health, finding primary care as an intellectually challenging field, and in needing to collaborate with specialists. Older students were more likely than younger students to show more favorable answers on questions concerning the relative value of primary care vs. specialty care. Conclusions: A curriculum in Primary Care Internal Medicine can provide a framework to positively influence students’ attitudes toward the importance of primary care, and potentially to influence career decisions to enter careers in Primary Care Internal Medicine. Ensuring that medical students receive excellent primary care for themselves can also positively influence attitudes toward primary care. PMID:28670982

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.

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.

Service, training, mentorship: first report of an innovative education-support program to revitalize primary care social service in Chiapas, Mexico.

PubMed

Van Wieren, Andrew; Palazuelos, Lindsay; Elliott, Patrick F; Arrieta, Jafet; Flores, Hugo; Palazuelos, Daniel

2014-01-01

The Mexican mandatory year of social service following medical school, or pasantía, is designed to provide a safety net for the underserved. However, social service physicians (pasantes) are typically unpracticed, unsupervised, and unsupported. Significant demotivation, absenteeism, and underperformance typically plague the social service year. Compañeros en Salud (CES) aimed to create an education-support package to turn the pasantía into a transformative learning experience. CES recruited pasantes to complete their pasantía in CES-supported Ministry of Health clinics in rural Chiapas. The program aims to: 1) train pasantes to more effectively deliver primary care, 2) expose pasantes to central concepts of global health and social medicine, and 3) foster career development of pasantes. Program components include supportive supervision, on-site mentorship, clinical information resources, monthly interactive seminars, and improved clinic function. We report quantitative and qualitative pasante survey data collected from February 2012 to August 2013 to discuss strengths and weaknesses of this program and its implications for the pasante workforce in Mexico. Pasantes reported that their medical knowledge, and clinical and leadership skills all improved during the CES education-support program. Most pasantes felt the program had an overall positive effect on their career goals and plans, although their self-report of preparedness for the Mexican residency entrance exam (ENARM) decreased during the social service year. One hundred percent reported they were satisfied with the CES-supported pasantía experience and wished to help the poor and underserved in their careers. Education-support programs similar to the CES program may encourage graduating medical students to complete their social service in underserved areas, improve the quality of care provided by pasantes, and address many of the known shortcomings of the pasantía. Additional efforts should focus on developing a strategy to expand this education-support model so that more pasantes throughout Mexico can experience a transformative, career-building, social service year.

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.

Transformational change in health care systems: an organizational model.

PubMed

Lukas, Carol VanDeusen; Holmes, Sally K; Cohen, Alan B; Restuccia, Joseph; Cramer, Irene E; Shwartz, Michael; Charns, Martin P

2007-01-01

The Institute of Medicine's 2001 report Crossing the Quality Chasm argued for fundamental redesign of the U.S. health care system. Six years later, many health care organizations have embraced the report's goals, but few have succeeded in making the substantial transformations needed to achieve those aims. This article offers a model for moving organizations from short-term, isolated performance improvements to sustained, reliable, organization-wide, and evidence-based improvements in patient care. Longitudinal comparative case studies were conducted in 12 health care systems using a mixed-methods evaluation design based on semistructured interviews and document review. Participating health care systems included seven systems funded through the Robert Wood Johnson Foundation's Pursuing Perfection Program and five systems with long-standing commitments to improvement and high-quality care. Five interactive elements appear critical to successful transformation of patient care: (1) Impetus to transform; (2) Leadership commitment to quality; (3) Improvement initiatives that actively engage staff in meaningful problem solving; (4) Alignment to achieve consistency of organization goals with resource allocation and actions at all levels of the organization; and (5) Integration to bridge traditional intra-organizational boundaries among individual components. These elements drive change by affecting the components of the complex health care organization in which they operate: (1) Mission, vision, and strategies that set its direction and priorities; (2) Culture that reflects its informal values and norms; (3) Operational functions and processes that embody the work done in patient care; and (4) Infrastructure such as information technology and human resources that support the delivery of patient care. Transformation occurs over time with iterative changes being sustained and spread across the organization. The conceptual model holds promise for guiding health care organizations in their efforts to pursue the Institute of Medicine aims of fundamental system redesign to achieve dramatically improved patient care.

Model of care transformation: a health care system CNE's journey.

PubMed

Swick, Maureen; Doulaveris, Phyllis; Christensen, Patricia

2012-01-01

In 2001, the Institute of Medicine released the report "Crossing the Quality Chasm: A New Health System for the 21st Century." The report criticizes our health care system and argues that we are failing to provide Americans with the high-quality and affordable health care they deserve and need. While incremental progress has been made, we continue to strive for improved care quality, and our rising costs are potentially catastrophic. Consistent with the Institute of Medicine report, and its reputation for innovation, Inova Health System identified care model transformation as a system priority. Given that the organization is replacing its electronic health record and introducing advanced analytic capabilities, the opportunity to transform the model of care in tandem with core clinical platform enhancement was a compelling reason to move forward.

Digital Transformation and Disruption of the Health Care Sector: Internet-Based Observational Study.

PubMed

Herrmann, Maximilian; Boehme, Philip; Mondritzki, Thomas; Ehlers, Jan P; Kavadias, Stylianos; Truebel, Hubert

2018-03-27

Digital innovation, introduced across many industries, is a strong force of transformation. Some industries have seen faster transformation, whereas the health care sector only recently came into focus. A context where digital corporations move into health care, payers strive to keep rising costs at bay, and longer-living patients desire continuously improved quality of care points to a digital and value-based transformation with drastic implications for the health care sector. We tried to operationalize the discussion within the health care sector around digital and disruptive innovation to identify what type of technological enablers, business models, and value networks seem to be emerging from different groups of innovators with respect to their digital transformational efforts. From the Forbes 2000 and CBinsights databases, we identified 100 leading technology, life science, and start-up companies active in the health care sector. Further analysis identified projects from these companies within a digital context that were subsequently evaluated using the following criteria: delivery of patient value, presence of a comprehensive and distinctive underlying business model, solutions provided, and customer needs addressed. Our methodological approach recorded more than 400 projects and collaborations. We identified patterns that show established corporations rely more on incremental innovation that supports their current business models, while start-ups engage their flexibility to explore new market segments with notable transformations of established business models. Thereby, start-ups offer higher promises of disruptive innovation. Additionally, start-ups offer more diversified value propositions addressing broader areas of the health care sector. Digital transformation is an opportunity to accelerate health care performance by lowering cost and improving quality of care. At an economic scale, business models can be strengthened and disruptive innovation models enabled. Corporations should look for collaborations with start-up companies to keep investment costs at bay and off the balance sheet. At the same time, the regulatory knowledge of established corporations might help start-ups to kick off digital disruption in the health care sector. ©Maximilian Herrmann, Philip Boehme, Thomas Mondritzki, Jan P Ehlers, Stylianos Kavadias, Hubert Truebel. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 27.03.2018.

Digital Transformation and Disruption of the Health Care Sector: Internet-Based Observational Study

PubMed Central

Mondritzki, Thomas; Ehlers, Jan P; Kavadias, Stylianos

2018-01-01

Background Digital innovation, introduced across many industries, is a strong force of transformation. Some industries have seen faster transformation, whereas the health care sector only recently came into focus. A context where digital corporations move into health care, payers strive to keep rising costs at bay, and longer-living patients desire continuously improved quality of care points to a digital and value-based transformation with drastic implications for the health care sector. Objective We tried to operationalize the discussion within the health care sector around digital and disruptive innovation to identify what type of technological enablers, business models, and value networks seem to be emerging from different groups of innovators with respect to their digital transformational efforts. Methods From the Forbes 2000 and CBinsights databases, we identified 100 leading technology, life science, and start-up companies active in the health care sector. Further analysis identified projects from these companies within a digital context that were subsequently evaluated using the following criteria: delivery of patient value, presence of a comprehensive and distinctive underlying business model, solutions provided, and customer needs addressed. Results Our methodological approach recorded more than 400 projects and collaborations. We identified patterns that show established corporations rely more on incremental innovation that supports their current business models, while start-ups engage their flexibility to explore new market segments with notable transformations of established business models. Thereby, start-ups offer higher promises of disruptive innovation. Additionally, start-ups offer more diversified value propositions addressing broader areas of the health care sector. Conclusions Digital transformation is an opportunity to accelerate health care performance by lowering cost and improving quality of care. At an economic scale, business models can be strengthened and disruptive innovation models enabled. Corporations should look for collaborations with start-up companies to keep investment costs at bay and off the balance sheet. At the same time, the regulatory knowledge of established corporations might help start-ups to kick off digital disruption in the health care sector. PMID:29588274

Conduction-coupled Tesla transformer.

PubMed

Reed, J L

2015-03-01

A proof-of-principle Tesla transformer circuit is introduced. The new transformer exhibits the high voltage-high power output signal of shock-excited transformers. The circuit, with specification of proper circuit element values, is capable of obtaining extreme oscillatory voltages. The primary and secondary portions of the circuit communicate solely by conduction. The destructive arcing between the primary and secondary inductors in electromagnetically coupled transformers is ubiquitous. Flashover is eliminated in the new transformer as the high-voltage inductors do not interpenetrate and so do not possess an annular volume of electric field. The inductors are remote from one another. The high voltage secondary inductor is isolated in space, except for a base feed conductor, and obtains earth by its self-capacitance to the surroundings. Governing equations, for the ideal case of no damping, are developed from first principles. Experimental, theoretical, and circuit simulator data are presented for the new transformer. Commercial high-temperature superconductors are discussed as a means to eliminate the counter-intuitive damping due to small primary inductances in both the electromagnetic-coupled and new conduction-coupled transformers.

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.

In Vitro Transformation of Rat and Mouse Cells by DNA from Simian Virus 40

PubMed Central

Abrahams, P. J.; van der Eb, A. J.

1975-01-01

Primary rat kidney cells and mouse 3T3 cells can be transformed by DNA of simian virus 40 when use is made of the calcium technique (Graham and van der Eb, 1973). The transformation assay in primary rat cells is reproducible, but the dose response is not linear. PMID:166204

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.

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

PubMed

Flieger, Signe Peterson

This study explores the implementation experience of nine primary care practices becoming patient-centered medical homes (PCMH) as part of the New Hampshire Citizens Health Initiative Multi-Stakeholder Medical Home Pilot. The purpose of this study is to apply complex adaptive systems theory and relationship-centered organizations theory to explore how nine diverse primary care practices in New Hampshire implemented the PCMH model and to offer insights for how primary care practices can move from a structural PCMH to a relationship-centered PCMH. Eighty-three interviews were conducted with administrative and clinical staff at the nine pilot practices, payers, and conveners of the pilot between November and December 2011. The interviews were transcribed, coded, and analyzed using both a priori and emergent themes. Although there is value in the structural components of the PCMH (e.g., disease registries), these structures are not enough. Becoming a relationship-centered PCMH requires attention to reflection, sensemaking, learning, and collaboration. This can be facilitated by settings aside time for communication and relationship building through structured meetings about PCMH components as well as the implementation process itself. Moreover, team-based care offers a robust opportunity to move beyond the structures to focus on relationships and collaboration. (a) Recognize that PCMH implementation is not a linear process. (b) Implementing the PCMH from a structural perspective is not enough. Although the National Committee for Quality Assurance or other guidelines can offer guidance on the structural components of PCMH implementation, this should serve only as a starting point. (c) During implementation, set aside structured time for reflection and sensemaking. (d) Use team-based care as a cornerstone of transformation. Reflect on team structures and also interactions of the team members. Taking the time to reflect will facilitate greater sensemaking and learning and will ultimately help foster a relationship-centered PCMH.

Transforming Regions into High-Performing Health Systems Toward the Triple Aim of Better Health, Better Care and Better Value for Canadians.

PubMed

Bergevin, Yves; Habib, Bettina; Elicksen-Jensen, Keesa; Samis, Stephen; Rochon, Jean; Denis, Jean-Louis; Roy, Denis

2016-01-01

A study on the impact of regionalization on the Triple Aim of Better Health, Better Care and Better Value across Canada in 2015 identified major findings including: (a) with regard to the Triple Aim, the Canadian situation is better than before but variable and partial, and Canada continues to underperform compared with other industrialized countries, especially in primary healthcare where it matters most; (b) provinces are converging toward a two-level health system (provincial/regional); (c) optimal size of regions is probably around 350,000-500,000 population; d) citizen and physician engagement remains weak. A realistic and attainable vision for high-performing regional health systems is presented together with a way forward, including seven areas for improvement: 1. Manage the integrated regionalized health systems as results-driven health programs; 2. Strengthen wellness promotion, public health and intersectoral action for health; 3. Ensure timely access to personalized primary healthcare/family health and to proximity services; 4. Involve physicians in clinical governance and leadership, and partner with them in accountability for results including the required changes in physician remuneration; 5. Engage citizens in shaping their own health destiny and their health system; 6. Strengthen health information systems, accelerate the deployment of electronic health records and ensure their interoperability with health information systems; 7. Foster a culture of excellence and continuous quality improvement. We propose a turning point for Canada, from Paradigm Freeze to Paradigm Shift: from hospital-centric episodic care toward evidence-informed population-based primary and community care with modern family health teams, ensuring integrated and coordinated care along the continuum, especially for high users. We suggest goals and targets for 2020 and time-bound federal/provincial/regional working groups toward reaching the identified goals and targets and placing Canada on a rapid path toward the Triple Aim.

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

PubMed Central

Flieger, Signe Peterson

2017-01-01

Background This study explores the implementation experience of nine primary care practices becoming patient-centered medical homes (PCMH) as part of the New Hampshire Citizens Health Initiative Multi-Stakeholder Medical Home Pilot. Purpose The purpose of this study is to apply complex adaptive systems theory and relationship-centered organizations theory to explore how nine diverse primary care practices in New Hampshire implemented the PCMH model and to offer insights for how primary care practices can move from a structural PCMH to a relationship-centered PCMH. Methodology/Approach Eighty-three interviews were conducted with administrative and clinical staff at the nine pilot practices, payers, and conveners of the pilot between November and December 2011. The interviews were transcribed, coded, and analyzed using both a priori and emergent themes. Findings Although there is value in the structural components of the PCMH (e.g., disease registries), these structures are not enough. Becoming a relationship-centered PCMH requires attention to reflection, sensemaking, learning, and collaboration. This can be facilitated by settings aside time for communication and relationship building through structured meetings about PCMH components as well as the implementation process itself. Moreover, team-based care offers a robust opportunity to move beyond the structures to focus on relationships and collaboration. Practice Implications (a) Recognize that PCMH implementation is not a linear process. (b) Implementing the PCMH from a structural perspective is not enough. Although the National Committee for Quality Assurance or other guidelines can offer guidance on the structural components of PCMH implementation, this should serve only as a starting point. (c) During implementation, set aside structured time for reflection and sensemaking. (d) Use team-based care as a cornerstone of transformation. Reflect on team structures and also interactions of the team members. Taking the time to reflect will facilitate greater sensemaking and learning and will ultimately help foster a relationship-centered PCMH. PMID:26939031

Integrated Comprehensive Care - A Case Study in Nursing Leadership and System Transformation.

PubMed

Wheatley, Laura; Doyle, Winnie; Evans, Cheryl; Gosse, Carolyn; Smith, Kevin

2017-01-01

Calls for transformational change of our healthcare system are increasingly clear, persuasive and insistent. They resonate at all levels, with those who fund, deliver, provide and receive care, and they are rooted in a deep understanding that the system, as currently rigidly structured, most often lacks the necessary flexibility to comprehensively meet the needs of patients across the continuum of care. The St. Joseph's Health System (SJHS) Integrated Comprehensive Care (ICC) Program, which bundles care and funding across the hospital to home continuum, has reduced fragmentation of care, and it has delivered improved outcomes for patients, providers and the system. This case study explores the essential contribution of nursing leadership to this successful transformation of healthcare service delivery.

Paediatric musculoskeletal matters (pmm)--collaborative development of an online evidence based interactive learning tool and information resource for education in paediatric musculoskeletal medicine.

PubMed

Smith, Nicola; Rapley, Tim; Jandial, Sharmila; English, Christine; Davies, Barbara; Wyllie, Ruth; Foster, Helen E

2016-01-05

We describe the collaborative development of an evidence based, free online resource namely 'paediatric musculoskeletal matters' (pmm). This resource was developed with the aim of reaching a wide range of health professionals to increase awareness, knowledge and skills within paediatric musculoskeletal medicine, thereby facilitating early diagnosis and referral to specialist care. Engagement with stakeholder groups (primary care, paediatrics, musculoskeletal specialties and medical students) informed the essential 'core' learning outcomes to derive content of pmm. Representatives from stakeholder groups, social science and web development experts transformed the learning outcomes into a suitable framework. Target audience representatives reviewed the framework and their opinion was gathered using an online survey (n = 74) and focus groups (n = 2). Experts in paediatric musculoskeletal medicine peer reviewed the content and design. User preferences informed design with mobile, tablet and web compatible versions to facilitate access, various media and formats to engage users and the content presented in module format (i.e. Clinical assessment, Investigations and management, Limping child, Joint pain by site, Swollen joint(s) and Resources). We propose that our collaborative and evidence-based approach has ensured that pmm is user-friendly, with readily accessible, suitable content, and will help to improve access to paediatric musculoskeletal medicine education. The content is evidence-based with the design and functionality of pmm to facilitate optimal and 'real life' access to information. pmm is targeted at medical students and the primary care environment although messages are transferable to all health care professionals involved in the care of children and young people.

The power of servant leadership to transform health care organizations for the 21st-century economy.

PubMed

Schwartz, Richard W; Tumblin, Thomas F

2002-12-01

Physician leadership is emerging as a vital component in transforming the nation's health care industry. Because few physicians have been introduced to the large body of literature on leadership and organizations, we herein provide a concise review, as this literature relates to competitive health care organizations and the leaders who serve them. Although the US health care industry has transitioned to a dynamic market economy governed by a wide range of internal and external forces, health care organizations continue to be dominated by leaders who practice an outmoded transactional style of leadership and by organizational hierarchies that are inherently stagnant. In contrast, outside the health care sector, service industries have repeatedly demonstrated that transformational, situational, and servant leadership styles are most successful in energizing human resources within organizations. This optimization of intellectual capital is further enhanced by transforming organizations into adaptable learning organizations where traditional institutional hierarchies are flattened and efforts to evoke change are typically team driven and mission oriented.

The digital transformation of oral health care. Teledentistry and electronic commerce.

PubMed

Bauer, J C; Brown, W T

2001-02-01

Health care is being changed dramatically by the marriage of computers and telecommunications. Implications for hospitals and physicians already have received extensive media attention, but comparatively little has been said about the impact of information technology on dentistry. This article illustrates how the digital transformation will likely affect dentists and their patients. Based on recent experiences of hospitals and medical practices, dentists can expect to encounter revolutionary changes as a result of the digital transformation. The Internet, the World Wide Web and other developments of the information revolution will redefine patient care, referral relationships, practice management, quality, professional organizations and competition. To respond proactively to the digital transformation of oral health care, dentists must become familiar with its technologies and concepts. They must learn what new information technology can do for them and their patients and then develop creative applications that promote the profession and their approaches to care.

Translating and Transforming Care: People With Brain Injury and Caregivers Filling in a Disability Claim Form.

PubMed

Gillespie, Alex; Moore, Helen

2016-03-01

This article examines how the Disability Living Allowance claim form, used in the United Kingdom to allocate £13 billion of disability benefits, translates and transforms disability and care. Twenty-two people with acquired brain injury and their main informal caregivers (n = 44) were video-recorded filling in the disability claim form. Participants disagreed on 26% of the questions, revealing two types of problems. Translation problems arose as participants struggled to provide categorical responses to ambiguous questions and were unable to report contextual variability in care needs or divergences of perception. Transformation problems arose as participants resisted the way in which the form positioned them, forcing them to conceptualize their relationship in terms of dependency and burden. The disability claim form co-opts claimants to translate care and disability into bureaucratically predefined categories, and it transforms the care relationship that it purports to document. © The Author(s) 2015.

Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation

PubMed Central

Altschuler, Justin; Margolius, David; Bodenheimer, Thomas; Grumbach, Kevin

2012-01-01

PURPOSE Primary care faces the dilemma of excessive patient panel sizes in an environment of a primary care physician shortage. We aimed to estimate primary care panel sizes under different models of task delegation to nonphysician members of the primary care team. METHODS We used published estimates of the time it takes for a primary care physician to provide preventive, chronic, and acute care for a panel of 2,500 patients, and modeled how panel sizes would change if portions of preventive and chronic care services were delegated to nonphysician team members. RESULTS Using 3 assumptions about the degree of task delegation that could be achieved (77%, 60%, and 50% of preventive care, and 47%, 30%, and 25% of chronic care), we estimated that a primary care team could reasonably care for a panel of 1,947, 1,523, or 1,387 patients. CONCLUSIONS If portions of preventive and chronic care services are delegated to nonphysician team members, primary care practices can provide recommended preventive and chronic care with panel sizes that are achievable with the available primary care workforce. PMID:22966102

Estimating a reasonable patient panel size for primary care physicians with team-based task delegation.

PubMed

Altschuler, Justin; Margolius, David; Bodenheimer, Thomas; Grumbach, Kevin

2012-01-01

PURPOSE Primary care faces the dilemma of excessive patient panel sizes in an environment of a primary care physician shortage. We aimed to estimate primary care panel sizes under different models of task delegation to nonphysician members of the primary care team. METHODS We used published estimates of the time it takes for a primary care physician to provide preventive, chronic, and acute care for a panel of 2,500 patients, and modeled how panel sizes would change if portions of preventive and chronic care services were delegated to nonphysician team members. RESULTS Using 3 assumptions about the degree of task delegation that could be achieved (77%, 60%, and 50% of preventive care, and 47%, 30%, and 25% of chronic care), we estimated that a primary care team could reasonably care for a panel of 1,947, 1,523, or 1,387 patients. CONCLUSIONS If portions of preventive and chronic care services are delegated to nonphysician team members, primary care practices can provide recommended preventive and chronic care with panel sizes that are achievable with the available primary care workforce.

Cajal-body formation correlates with differential coilin phosphorylation in primary and transformed cell lines.

PubMed

Hearst, Scoty M; Gilder, Andrew S; Negi, Sandeep S; Davis, Misty D; George, Eric M; Whittom, Angela A; Toyota, Cory G; Husedzinovic, Alma; Gruss, Oliver J; Hebert, Michael D

2009-06-01

Cajal bodies (CBs) are nuclear structures that are thought to have diverse functions, including small nuclear ribonucleoprotein (snRNP) biogenesis. The phosphorylation status of coilin, the CB marker protein, might impact CB formation. We hypothesize that primary cells, which lack CBs, contain different phosphoisoforms of coilin compared with that found in transformed cells, which have CBs. Localization, self-association and fluorescence recovery after photobleaching (FRAP) studies on coilin phosphomutants all suggest this modification impacts the function of coilin and may thus contribute towards CB formation. Two-dimensional gel electrophoresis demonstrates that coilin is hyperphosphorylated in primary cells compared with transformed cells. mRNA levels of the nuclear phosphatase PPM1G are significantly reduced in primary cells and expression of PPM1G in primary cells induces CBs. Additionally, PPM1G can dephosphorylate coilin in vitro. Surprisingly, however, expression of green fluorescent protein alone is sufficient to form CBs in primary cells. Taken together, our data support a model whereby coilin is the target of an uncharacterized signal transduction cascade that responds to the increased transcription and snRNP demands found in transformed cells.

Cost-benefit analysis of telehealth in pre-hospital care.

PubMed

Langabeer, James R; Champagne-Langabeer, Tiffany; Alqusairi, Diaa; Kim, Junghyun; Jackson, Adria; Persse, David; Gonzalez, Michael

2017-09-01

Objective There has been very little use of telehealth in pre-hospital emergency medical services (EMS), yet the potential exists for this technology to transform the current delivery model. In this study, we explore the costs and benefits of one large telehealth EMS initiative. Methods Using a case-control study design and both micro- and gross-costing data from the Houston Fire Department EMS electronic patient care record system, we conducted a cost-benefit analysis (CBA) comparing costs with potential savings associated with patients treated through a telehealth-enabled intervention. The intervention consisted of telehealth-based consultation between the 911 patient and an EMS physician, to evaluate and triage the necessity for patient transport to a hospital emergency department (ED). Patients with non-urgent, primary care-related conditions were then scheduled and transported by alternative means to an affiliated primary care clinic. We measured CBA as both total cost savings and cost per ED visit averted, in US Dollars ($USD). Results In total, 5570 patients were treated over the first full 12 months with a telehealth-enabled care model. We found a 6.7% absolute reduction in potentially medically unnecessary ED visits, and a 44-minute reduction in total ambulance back-in-service times. The average cost for a telehealth patient was $167, which was a statistically significantly $103 less than the control group ( p < .0001). The programme produced a $928,000 annual cost savings from the societal perspective, or $2468 cost savings per ED visit averted (benefit). Conclusion Patient care enabled by telehealth in a pre-hospital environment, is a more cost effective alternative compared to the traditional EMS 'treat and transport to ED' model.

Leading from the heart: caring, love, peace, and values guiding leadership.

PubMed

Turkel, Marian C

2014-04-01

Contemporary transformational leadership focuses on authentic leadership styles, relational caring, meaningful recognition, creativity, building trust, relationships, participative decision making, dialogue with time for reflection, and innovation. The purpose of this paper is to illuminate how concepts from the unitary transformative paradigm and caring science can be integrated within nursing leadership practice, to invite nurse leaders to make these concepts explicit in their own transformational leadership journey, and to offer ways of reframing traditional organizational language. Practice exemplars are presented to highlight how tenets from caring theory are guiding the practice of nursing leadership.

Transforming a family medicine center and residency program into a federally qualified health center.

PubMed

Cousineau, Michael R; Flores, Hector; Cheng, Scott; Gates, Jerry D; Douglas, James H; Clute, Gerald B; Coan, Carl E

2013-05-01

The authors describe a family medicine center before and after a merger between the Keck School of Medicine of the University of Southern California, the California Hospital Medical Center, and the Eisner Pediatric and Family Medical Center in 2012. The merger provided new opportunities to stabilize the financial base of a clinical practice struggling financially and to enhance the training of residents and other health professionals in primary care, which motivated the partners to consider this new model. After 18 months of negotiations, they were able to convert the family medicine center and residency program into a new federally qualified health center. The benefits to this new model include an increase in both patient volume and the quality of education, supporting residency accreditation; a greater number of residents from U.S. medical schools; enhanced education and preparation of primary care physicians for practice in medically underserved communities; enhanced reimbursements and new opportunities for state, local, and federal grants; and quality improvement and new information technology. The partners overcame academic, administrative, legal, and regulatory obstacles, communication barriers, and differences in culture and expectations to achieve this merger. Keys to their success include the commitment of the leaders at the three institutions to the goals of the merger, a dedicated project manager and consultants, opportunities for new revenue sources and reimbursements, and support from a pioneering charitable foundation. The authors conclude by discussing the implications of using community health centers as the focal point for training primary care clinicians and addressing workforce shortages.

Implications of workforce and financing changes for primary care practice utilization, revenue, and cost: a generalizable mathematical model for practice management.

PubMed

Basu, Sanjay; Landon, Bruce E; Song, Zirui; Bitton, Asaf; Phillips, Russell S

2015-02-01

Primary care practice transformations require tools for policymakers and practice managers to understand the financial implications of workforce and reimbursement changes. To create a simulation model to understand how practice utilization, revenues, and expenses may change in the context of workforce and financing changes. We created a simulation model estimating clinic-level utilization, revenues, and expenses using user-specified or public input data detailing practice staffing levels, salaries and overhead expenditures, patient characteristics, clinic workload, and reimbursements. We assessed whether the model could accurately estimate clinic utilization, revenues, and expenses across the nation using labor compensation, medical expenditure, and reimbursements databases, as well as cost and revenue data from independent practices of varying size. We demonstrated the model's utility in a simulation of how utilization, revenue, and expenses would change after hiring a nurse practitioner (NP) compared with hiring a part-time physician. Modeled practice utilization and revenue closely matched independent national utilization and reimbursement data, disaggregated by patient age, sex, race/ethnicity, insurance status, and ICD diagnostic group; the model was able to estimate independent revenue and cost estimates, with highest accuracy among larger practices. A demonstration analysis revealed that hiring an NP to work independently with a subset of patients diagnosed with diabetes or hypertension could increase net revenues, if NP visits involve limited MD consultation or if NP reimbursement rates increase. A model of utilization, revenue, and expenses in primary care practices may help policymakers and managers understand the implications of workforce and financing changes.

Engaging Primary Care Practices in Studies of Improvement: Did You Budget Enough for Practice Recruitment?

PubMed

Fagnan, Lyle J; Walunas, Theresa L; Parchman, Michael L; Dickinson, Caitlin L; Murphy, Katrina M; Howell, Ross; Jackson, Kathryn L; Madden, Margaret B; Ciesla, James R; Mazurek, Kathryn D; Kho, Abel N; Solberg, Leif I

2018-04-01

The methods and costs to enroll small primary care practices in large, regional quality improvement initiatives are unknown. We describe the recruitment approach, cost, and resources required to recruit and enroll 500 practices in the Northwest and Midwest regional cooperatives participating in the Agency for Healthcare Research and Quality (AHRQ)-funded initiative, EvidenceNOW: Advancing Heart Health in Primary Care. The project management team of each cooperative tracked data on recruitment methods used for identifying and connecting with practices. We developed a cost-of-recruitment template and used it to record personnel time and associated costs of travel and communication materials. A total of 3,669 practices were contacted during the 14- to 18-month recruitment period, resulting in 484 enrolled practices across the 6 states served by the 2 cooperatives. The average number of interactions per enrolled practice was 7, with a total of 29,100 hours and a total cost of $2.675 million, or $5,529 per enrolled practice. Prior partnerships predicted recruiting almost 1 in 3 of these practices as contrasted to 1 in 20 practices without a previous relationship or warm hand-off. Recruitment of practices for large-scale practice quality improvement transformation initiatives is difficult and costly. The cost of recruiting practices without existing partnerships is expensive, costing 7 times more than reaching out to familiar practices. Investigators initiating and studying practice quality improvement initiatives should budget adequate funds to support high-touch recruitment strategies, including building trusted relationships over a long time frame, for a year or more. © 2018 Annals of Family Medicine, Inc.

46 CFR 111.50-5 - Location of overcurrent protective devices.

Code of Federal Regulations, 2014 CFR

2014-10-01

... primary side of a single phase transformer (two wire with single-voltage secondary) also protects the... secondary conductor by the secondary to primary transformer voltage ratio, and this protection meets § 111...

46 CFR 111.50-5 - Location of overcurrent protective devices.

Code of Federal Regulations, 2011 CFR

2011-10-01

... primary side of a single phase transformer (two wire with single-voltage secondary) also protects the... secondary conductor by the secondary to primary transformer voltage ratio, and this protection meets § 111...

46 CFR 111.50-5 - Location of overcurrent protective devices.

Code of Federal Regulations, 2010 CFR

2010-10-01

... primary side of a single phase transformer (two wire with single-voltage secondary) also protects the... secondary conductor by the secondary to primary transformer voltage ratio, and this protection meets § 111...

46 CFR 111.50-5 - Location of overcurrent protective devices.

Code of Federal Regulations, 2013 CFR

2013-10-01

... primary side of a single phase transformer (two wire with single-voltage secondary) also protects the... secondary conductor by the secondary to primary transformer voltage ratio, and this protection meets § 111...

46 CFR 111.50-5 - Location of overcurrent protective devices.

Code of Federal Regulations, 2012 CFR

2012-10-01

... primary side of a single phase transformer (two wire with single-voltage secondary) also protects the... secondary conductor by the secondary to primary transformer voltage ratio, and this protection meets § 111...

Psychological Science and Innovative Strategies for Informing Health Care Redesign: A Policy Brief.

PubMed

Asarnow, Joan Rosenbaum; Hoagwood, Kimberly E; Stancin, Terry; Lochman, John E; Hughes, Jennifer L; Miranda, Jeanne M; Wysocki, Tim; Portwood, Sharon G; Piacentini, John; Tynan, Douglas; Atkins, Marc; Kazak, Anne E

2015-01-01

Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health (a broad term referring to mental health, substance use, and health behavior) care in the United States. Advances in knowledge regarding effective treatment and services coupled with incentives for innovation in health and behavioral health care delivery systems make this a unique time for mobilizing our science to enhance the success of health and behavioral health care redesign. To optimize the potential of our current health care environment, a team was formed composed of leaders from the Societies of Clinical Child & Adolescent Psychology, Pediatric Psychology, and Child and Family Policy and Practice (Divisions 53, 54, and 37 of the American Psychological Association). This team was charged with reviewing the scientific and policy literature with a focus on five major issues: (a) improving access to care and reducing health disparities, (b) integrating behavioral health care within primary care, (c) preventive services, (d) enhancing quality and outcomes of care, and (e) training and workforce development. The products of that work are summarized here, including recommendations for future research, clinical, training, and policy directions. We conclude that the current emphasis on accountable care and evaluation of the outcomes of care offer numerous opportunities for psychologists to integrate science and practice for the benefit of our children, families, and nation. The dramatic changes that are occurring in psychological and behavioral health care services and payment systems also require evolution in our practice and training models.

Psychological Science and Innovative Strategies for Informing Health Care Redesign: A Policy Brief

PubMed Central

Asarnow, Joan Rosenbaum; Hoagwood, Kimberly E.; Stancin, Terry; Lochman, John E.; Hughes, Jennifer L.; Miranda, Jeanne M.; Wysocki, Tim; Portwood, Sharon G.; Piacentini, John; Tynan, Douglas; Atkins, Marc; Kazak, Anne E.

2017-01-01

Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health (a broad term referring to mental health, substance use, and health behavior) care in the United States. Advances in knowledge regarding effective treatment and services coupled with incentives for innovation in health and behavioral health care delivery systems make this a unique time for mobilizing our science to enhance the success of health and behavioral health care redesign. To optimize the potential of our current health care environment, a team was formed composed of leaders from the Societies of Clinical Child & Adolescent Psychology, Pediatric Psychology, and Child and Family Policy and Practice (Divisions 53, 54, and 37 of the American Psychological Association). This team was charged with reviewing the scientific and policy literature with a focus on five major issues: (a) improving access to care and reducing health disparities, (b) integrating behavioral health care within primary care, (c) preventive services, (d) enhancing quality and outcomes of care, and (e) training and workforce development. The products of that work are summarized here, including recommendations for future research, clinical, training, and policy directions. We conclude that the current emphasis on accountable care and evaluation of the outcomes of care offer numerous opportunities for psychologists to integrate science and practice for the benefit of our children, families, and nation. The dramatic changes that are occurring in psychological and behavioral health care services and payment systems also require evolution in our practice and training models. PMID:26430948

Transformation Education: A Vehicle for Structuring Group Care Organizations to Increase Service Quality and Effectiveness

ERIC Educational Resources Information Center

Ross, Andrew L.

2007-01-01

Transformation Education, an organizational philosophy and operating system, is designed to increase service quality and effectiveness of group care through aligning its organizational structure with its purpose. This alignment is achieved through creating a culture designed to dispense transformation rather than treatment. The author presents how…

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.

Note: Compact high voltage pulse transformer made using a capacitor bank assembled in the shape of primary.

PubMed

Shukla, Rohit; Banerjee, Partha; Sharma, Surender K; Das, Rashmita; Deb, Pankaj; Prabaharan, T; Das, Basanta; Adhikary, Biswajit; Verma, Rishi; Shyam, Anurag

2011-10-01

The experimental results of an air-core pulse transformer are presented, which is very compact (<10 Kg in weight) and is primed by a capacitor bank that is fabricated in such a way that the capacitor bank with its switch takes the shape of single-turn rectangular shaped primary of the transformer. A high voltage capacitor assembly (pulse-forming-line capacitor, PFL) of 5.1 nF is connected with the secondary of transformer. The transformer output voltage is 160 kV in its second peak appearing in less than 2 μS from the beginning of the capacitor discharge. The primary capacitor bank can be charged up to a maximum of 18 kV, with the voltage delivery of 360 kV in similar capacitive loads.

New wine in an old bottle: does alienation provide an explanation of the origins of physician discontent?

PubMed

McKinlay, John B; Marceau, Lisa

2011-01-01

We have witnessed transformational changes to the U.S. health care system over several decades. Alongside these changes is an increasing number of research reports and commentaries on physician workplace dissatisfaction and discontent. Primary care physicians, in particular, report dissatisfaction with conditions on the ground. Is there solid evidence concerning the magnitude of doctors' discontent, and how is it changing over time? Is it confined to the United States, or is it also occurring in other countries with different health care systems? Does physician discontent affect the processes, quality, and outcomes of medical care? This article addresses these questions. It considers the dimensions of physician dissatisfaction, whether there is a problem, and competing contributions to physician discontent. The authors suggest that the classic concept of alienation may build upon valuable earlier work and provide a new, coherent explanation of the workplace origins of physician discontent. Alienation theory combines both structural and psychological components associated with workplace discontent and has the potential to explain the changing position of knowledge workers (such as physicians) in the new economy.

Teaching adaptive leadership to family medicine residents: what? why? how?

PubMed

Eubank, Daniel; Geffken, Dominic; Orzano, John; Ricci, Rocco

2012-09-01

Health care reform calls for patient-centered medical homes built around whole person care and healing relationships. Efforts to transform primary care practices and deliver these qualities have been challenging. This study describes one Family Medicine residency's efforts to develop an adaptive leadership curriculum and use coaching as a teaching method to address this challenge. We review literature that describes a parallel between the skills underlying such care and those required for adaptive leadership. We address two questions: What is leadership? Why focus on adaptive leadership? We then present a synthesis of leadership theories as a set of process skills that lead to organization learning through effective work relationships and adaptive leadership. Four models of the learning process needed to acquire such skills are explored. Coaching is proposed as a teaching method useful for going beyond information transfer to create the experiential learning necessary to acquire the process skills. Evaluations of our efforts to date are summarized. We discuss key challenges to implementing such a curriculum and propose that teaching adaptive leadership is feasible but difficult in the current medical education and practice contexts.

Community pharmacy in South Africa: a changing profession in a society in transition.

PubMed

Gilbert, L

1998-09-01

The analysis of community pharmacy as a profession in transition acquires an additional dimension in South Africa, since it is inextricably linked to its social characteristics as well as to the political transformation taking place. Using data collected by means of a documentary search, interviews with key informants and a survey of community pharmacists, the paper presents the relevant societal features and explores some of the complexities associated with the existing as well as the potential future role of community pharmacy in the context of changing health services in a society in transition. It concludes that the changes in community pharmacy and the role it can play in the provision of Primary Health Care to all the people of South Africa are linked to the greater transition in society and its future health care services.

Redefining Health: Implication for Value-Based Healthcare Reform.

PubMed

Putera, Ikhwanuliman

2017-03-02

Health definition consists of three domains namely, physical, mental, and social health that should be prioritized in delivering healthcare. The emergence of chronic diseases in aging populations has been a barrier to the realization of a healthier society. The value-based healthcare concept seems in line with the true health objective: increasing value. Value is created from health outcomes which matter to patients relative to the cost of achieving those outcomes. The health outcomes should include all domains of health in a full cycle of care. To implement value-based healthcare, transformations need to be done by both health providers and patients: establishing true health outcomes, strengthening primary care, building integrated health systems, implementing appropriate health payment schemes that promote value and reduce moral hazards, enabling health information technology, and creating a policy that fits well with a community.

mHealth: Don't Forget All the Stakeholders in the Business Case.

PubMed

Petersen, Carolyn; Adams, Samantha A; DeMuro, Paul R

2015-12-31

Mobile health (mHealth) facilitates linking patient-generated data with electronic health records with clinical decision support systems. mHealth can transform health care, but to realize this potential it is important to identify the relevant stakeholders and how they might be affected. Such stakeholders include primary stakeholders, such as patients, families and caregivers, clinicians, health care facilities, researchers, payors and purchasers, employer, and miscellaneous secondary stakeholders, such as vendors, suppliers, distributors, and consultants, policy makers and legislators. The breadth and depth of the mHealth market make it possible for mHealth to have a considerable effect on people's health. However, many concerns exist, including privacy, data security, funding, and the lack of case studies demonstrating efficacy and cost-effectiveness. Many American and European initiatives to address these concerns are afoot.

The faces of group practice. The transformation and progression of physician organizations.

PubMed

Harris, D G; Smith, P J; Benedetti, S A

1992-01-01

The future will bring an increase in the economic forces which drive the succession of organizational forms. Migrating to integrated models of medical practice will become a survival technique for more and more physicians. This is a frightening prospect for individuals trained to be independent and self reliant. Fortunately, there are a variety of organizational models through which physicians can progress to ease the transition from solo to larger integrated practice forms. Regardless of the evolutionary course, successful physician organizations of the future will be primary care-based, geographically distributed, meaningfully partnered with hospital entities, equipped to accept risk, and lead by strong, business-savvy physician leaders and administrators. This organization will have the ability to flourish within a radically changing climate and will result in the delivery of measurably superior health care to its community.

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.

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.

Operational integration in primary health care: patient encounters and workflows.

PubMed

Sifaki-Pistolla, Dimitra; Chatzea, Vasiliki-Eirini; Markaki, Adelais; Kritikos, Kyriakos; Petelos, Elena; Lionis, Christos

2017-11-29

Despite several countrywide attempts to strengthen and standardise the primary healthcare (PHC) system, Greece is still lacking a sustainable, policy-based model of integrated services. The aim of our study was to identify operational integration levels through existing patient care pathways and to recommend an alternative PHC model for optimum integration. The study was part of a large state-funded project, which included 22 randomly selected PHC units located across two health regions of Greece. Dimensions of operational integration in PHC were selected based on the work of Kringos and colleagues. A five-point Likert-type scale, coupled with an algorithm, was used to capture and transform theoretical framework features into measurable attributes. PHC services were grouped under the main categories of chronic care, urgent/acute care, preventive care, and home care. A web-based platform was used to assess patient pathways, evaluate integration levels and propose improvement actions. Analysis relied on a comparison of actual pathways versus optimal, the latter ones having been identified through literature review. Overall integration varied among units. The majority (57%) of units corresponded to a basic level. Integration by type of PHC service ranged as follows: basic (86%) or poor (14%) for chronic care units, poor (78%) or basic (22%) for urgent/acute care units, basic (50%) for preventive care units, and partial or basic (50%) for home care units. The actual pathways across all four categories of PHC services differed from those captured in the optimum integration model. Certain similarities were observed in the operational flows between chronic care management and urgent/acute care management. Such similarities were present at the highest level of abstraction, but also in common steps along the operational flows. Existing patient care pathways were mapped and analysed, and recommendations for an optimum integration PHC model were made. The developed web platform, based on a strong theoretical framework, can serve as a robust integration evaluation tool. This could be a first step towards restructuring and improving PHC services within a financially restrained environment.

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 result, Switzerland previously classified as a country with low primary care strength was reclassified as country with intermediate primary care strength compared to 14 other countries. Low scored characteristics represent possible targets of future health care reforms. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan.

PubMed

Aoki, Takuya; Yamamoto, Yosuke; Ikenoue, Tatsuyoshi; Kaneko, Makoto; Kise, Morito; Fujinuma, Yasuki; Fukuhara, Shunichi

2018-05-01

To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial. To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities. This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates. Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis. We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.

Early Performance in Medicaid Accountable Care Organizations: A Comparison of Oregon and Colorado.

PubMed

McConnell, K John; Renfro, Stephanie; Chan, Benjamin K S; Meath, Thomas H A; Mendelson, Aaron; Cohen, Deborah; Waxmonsky, Jeanette; McCarty, Dennis; Wallace, Neal; Lindrooth, Richard C

2017-04-01

Several state Medicaid reforms are under way, but the relative performance of different approaches is unclear. To compare the performance of Oregon's and Colorado's Medicaid Accountable Care Organization (ACO) models. Oregon initiated its Medicaid transformation in 2012, supported by a $1.9 billion investment from the federal government, moving most Medicaid enrollees into 16 Coordinated Care Organizations, which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating 7 Regional Care Collaborative Organizations that received funding to coordinate care with providers and connect Medicaid enrollees with community services. Data spanning July 1, 2010, through December 31, 2014 (18 months before intervention and 24 months after intervention, treating 2012 as a transition year) were analyzed for 452 371 Oregon and 330 511 Colorado Medicaid enrollees, assessing changes in outcomes using difference-in-differences analyses of regional focus, primary care homes, and care coordination. Oregon's Coordinated Care Organization model was more comprehensive in its reform goals and in the imposition of downside financial risk. Regional focus, primary care homes, and care coordination in Medicaid ACOs. Performance on claims-based measures of standardized expenditures and utilization for selected services, access, preventable hospitalizations, and appropriateness of care. In a total of 782 882 Medicaid enrollees, 45.0% were male, with mean (SD) age 16.74 (14.41) years. Standardized expenditures for selected services declined in both states during the 2010-2014 period, but these decreases were not significantly different between the 2 states. Oregon's model was associated with reductions in emergency department visits (-6.28 per 1000 beneficiary-months; 95% CI, -10.51 to -2.05) and primary care visits (-15.09 visits per 1000 beneficiary-months; 95% CI, -26.57 to -3.61), improvements in acute preventable hospital admissions (-1.01 admissions per 1000 beneficiary-months; 95% CI, -1.61 to -0.42), 3 of 4 measures of access (well-child visits, ages 3-6 years, 2.69%; 95% CI, 1.20% to 4.19%; adolescent well-care visits, 6.77%; 95% CI, 5.22% to 8.32%; and adult access to preventive ambulatory care, 1.26%; 95% CI, 0.28% to 2.25%), and 1 of 4 measures of appropriateness of care (avoidance of head imaging for uncomplicated headache, 2.59%; 95% CI, 1.35% to 3.83%). Two years into implementation, Oregon's and Colorado's Medicaid ACO models exhibited similar performance on standardized expenditures for selected services. Oregon's model, marked by a large federal investment and movement to global budgets, was associated with improvements in some measures of utilization, access, and quality, but Colorado's model paralleled Oregon's on several other metrics.

Weighting Primary Care Patient Panel Size: A Novel Electronic Health Record-Derived Measure Using Machine Learning.

PubMed

Rajkomar, Alvin; Yim, Joanne Wing Lan; Grumbach, Kevin; Parekh, Ami

2016-10-14

Characterizing patient complexity using granular electronic health record (EHR) data regularly available to health systems is necessary to optimize primary care processes at scale. To characterize the utilization patterns of primary care patients and create weighted panel sizes for providers based on work required to care for patients with different patterns. We used EHR data over a 2-year period from patients empaneled to primary care clinicians in a single academic health system, including their in-person encounter history and virtual encounters such as telephonic visits, electronic messaging, and care coordination with specialists. Using a combination of decision rules and k-means clustering, we identified clusters of patients with similar health care system activity. Phenotypes with basic demographic information were used to predict future health care utilization using log-linear models. Phenotypes were also used to calculate weighted panel sizes. We identified 7 primary care utilization phenotypes, which were characterized by various combinations of primary care and specialty usage and were deemed clinically distinct by primary care physicians. These phenotypes, combined with age-sex and primary payer variables, predicted future primary care utilization with R 2 of .394 and were used to create weighted panel sizes. Individual patients' health care utilization may be useful for classifying patients by primary care work effort and for predicting future primary care usage.

Evaluating the potential for primary care to serve as a mental health home for people with schizophrenia.

PubMed

Grove, Lexie R; Olesiuk, William J; Ellis, Alan R; Lichstein, Jesse C; DuBard, C Annette; Farley, Joel F; Jackson, Carlos T; Beadles, Christopher A; Morrissey, Joseph P; Domino, Marisa Elena

2017-07-01

Primary care-based medical homes could improve the coordination of mental health care for individuals with schizophrenia and comorbid chronic conditions. The objective of this paper is to examine whether persons with schizophrenia and comorbid chronic conditions engage in primary care regularly, such that primary care settings have the potential to serve as a mental health home. We examined the annual primary care and specialty mental health service utilization of adult North Carolina Medicaid enrollees with schizophrenia and at least one comorbid chronic condition who were in a medical home during 2007-2010. Using a fixed-effects regression approach, we also assessed the effect of medical home enrollment on utilization of primary care and specialty mental health care and medication adherence. A substantial majority (78.5%) of person-years had at least one primary care visit, and 17.9% had at least one primary care visit but no specialty mental health services use. Medical home enrollment was associated with increased use of primary care and specialty mental health care, as well as increased medication adherence. Medical home enrollees with schizophrenia and comorbid chronic conditions exhibited significant engagement in primary care, suggesting that primary-care-based medical homes could serve a care coordination function for persons with schizophrenia. Copyright © 2017 Elsevier Inc. All rights reserved.

Mediating the effects of work-life conflict between transformational leadership and health-care workers' job satisfaction and psychological wellbeing.

PubMed

Munir, Fehmidah; Nielsen, Karina; Garde, Anne H; Albertsen, Karen; Carneiro, Isabella G

2012-05-01

To explore the mediating effects of work-life conflict between transformational leadership and job satisfaction and psychological wellbeing. The importance of work-life balance for job satisfaction and wellbeing among health-care employees is well-recognized. Evidence shows that transformational leadership style is linked to psychological wellbeing. It is possible that transformational leadership is also associated with employees' perceptions of work-life conflict, thereby influencing their job satisfaction and wellbeing. A longitudinal design was used where staff working within Danish elderly care completed a questionnaire at baseline and 18-month follow-up (N=188). Regression analyses showed that transformational leadership style was directly associated with perceptions of work-life conflict, job satisfaction and psychological wellbeing. Work-life conflict mediated between transformational leadership and wellbeing, but not job satisfaction. The findings suggest transformational leadership style may improve perceptions of work-life balance and employee wellbeing. Managers should adopt transformational leadership styles to reduce work-life conflict and enhance the wellbeing of their staff. © 2011 Blackwell Publishing Ltd.

Harnessing the privatisation of China's fragmented health-care delivery.

PubMed

Yip, Winnie; Hsiao, William

2014-08-30

Although China's 2009 health-care reform has made impressive progress in expansion of insurance coverage, much work remains to improve its wasteful health-care delivery. Particularly, the Chinese health-care system faces substantial challenges in its transformation from a profit-driven public hospital-centred system to an integrated primary care-based delivery system that is cost effective and of better quality to respond to the changing population needs. An additional challenge is the government's latest strategy to promote private investment for hospitals. In this Review, we discuss how China's health-care system would perform if hospital privatisation combined with hospital-centred fragmented delivery were to prevail--population health outcomes would suffer; health-care expenditures would escalate, with patients bearing increasing costs; and a two-tiered system would emerge in which access and quality of care are decided by ability to pay. We then propose an alternative pathway that includes the reform of public hospitals to pursue the public interest and be more accountable, with public hospitals as the benchmarks against which private hospitals would have to compete, with performance-based purchasing, and with population-based capitation payment to catalyse coordinated care. Any decision to further expand the for-profit private hospital market should not be made without objective assessment of its effect on China's health-policy goals. Copyright © 2014 Elsevier Ltd. All rights reserved.

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

Transforming Identities through Transforming Care: How People with Learning Disabilities Experience Moving out of Hospital

ERIC Educational Resources Information Center

Head, Annabel; Ellis-Caird, Helen; Rhodes, Louisa; Parkinson, Kathie

2018-01-01

Background: People with learning disabilities are moving out of hospitals as part of the Transforming Care programme, although thus far their views on how they have experienced this have not been researched. Materials and Methods: A qualitative design was used to explore how people with learning disabilities experienced moving as part of…

Excessive workload, uncertain career opportunities and lack of funding are important barriers to recruiting and retaining primary care medical researchers: a qualitative interview study.

PubMed

Thomsen, Janus Laust; Jarbøl, Dorthe; Søndergaard, Jens

2006-10-01

Research activity in primary care has been steadily increasing, but is still insufficient and more researchers are needed. Many initiatives have been launched to recruit and retain primary care researchers, but only little is known about barriers and facilitators to a research career in primary care. To examine barriers and facilitators to recruiting and retaining primary care medical researchers. Semi-structured interviews with 33 primary care medical researchers, all medical doctors. We used a phenomenological approach to analysing the interviews. Important barriers to pursuing a research career in primary care were heavy workload, isolation at work, short-term funding and low salary. Important facilitators to attracting and retaining primary care researchers were the desire and opportunity to improve primary care, the flexible working conditions, the career opportunities, including the possibility of combining university-based research with clinical work and a friendly and competent research environment. Better strategies for recruiting and retaining researchers are a prerequisite for the development of primary care, and in future the main emphasis should be on working conditions, networking and mentoring. Studies including those primary care physicians who have chosen not to do research are highly needed.

Addressing disparities and achieving equity: cultural competence, ethics, and health-care transformation.

PubMed

Betancourt, Joseph R; Corbett, James; Bondaryk, Matthew R

2014-01-01

The passage of health-care reform and current efforts in payment reform signal the beginning of a significant transformation of the US health-care system. An entire new set of structures is being developed to facilitate increased access to care that is cost-effective and of high quality. As described in The Institute of Medicine report "Crossing the Quality Chasm," our nation is charting a path toward quality health care that aims to be safe, efficient, effective, timely, patient-centered, and equitable. As our health-care system rapidly undergoes dramatic transformation, several truths-and challenges-remain. First, racial and ethnic disparities in health care persist and are a clear sign of inequality in quality. Second, although the root causes for these disparities are complex, there exists a well-developed set of evidence-based approaches to address them; among these is improving the cultural competence of health-care providers and the health-care system. Third, as part of our care redesign, we must assure that we are prepared to meet the ethical challenges ahead and reassert the importance of equity, fairness, and caring as key building blocks of a new care delivery system. As we move ahead, it is critical to assure that our health-care system is culturally competent and has the capacity to deliver high-quality care for all, while eliminating disparities and assuring equity. Disparities are unjust, unethical, costly, and unacceptable-and integrating strategies to achieve equity as part of our health-care system's transformation will give us an incredible opportunity to comprehensively address them.

Physician specialty and the quality of medical care experiences in the context of the Taiwan national health insurance system.

PubMed

Tsai, Jenna; Shi, Leiyu; Yu, Wei-Lung; Hung, Li-Mei; Lebrun, Lydie A

2010-01-01

Based on a recent patient survey from Taiwan, where there is universal health insurance coverage and unrestricted physician choice, this study examined the relationship between physician specialty and the quality of primary medical care experiences. We assessed ambulatory patients' experiences with medical care using the Primary Care Assessment Tool, representing 7 primary care domains: first contact (ie, accessibility and utilization); longitudinality (ie, ongoing care); coordination (ie, referrals and information systems); comprehensiveness (ie, services available and provided); family centeredness; community orientation; and cultural competence. Having a primary care physician was significantly associated with patients reporting higher quality of primary care experiences. Specifically, relative to specialty care physicians, primary care physicians enhanced accessibility, achieved better community orientation and cultural competence, and provided more comprehensive services. In an area with universal health insurance and unrestricted physician choice, ambulatory patients of primary care physicians rated their medical care experiences as superior to those of patients of specialists. In addition to providing health insurance coverage, promoting primary care should be included as a health policy to improve patients' quality of ambulatory medical care experiences.

Productivity vs. training in primary care: analysis of hospitals and health centers in New York City.

PubMed

DeLia, Derek; Cantor, Joel C; Duck, Elaine

2002-01-01

This paper examines the indirect costs of primary care residency in terms of ambulatory care site productivity and the influence of graduate medical education (GME) subsidies on the employment of primary care residents. Using a sample of hospitals and health centers in New York City (NYC), we find that most facilities employ significantly more primary care residents relative to nonresident primary care physicians than would be dictated by cost-minimizing behavior in the production of primary care. We also find evidence that New York's GME subsidy encourages the "overemployment" of residents, while the Medicare GME subsidy does not. We conclude that the trade-off between productivity and teaching is more serious in primary care than in inpatient settings, and that facilities heavily involved in ambulatory care teaching will be at a competitive disadvantage if GME subsidies are not targeted specifically for primary care.

Cajal-body formation correlates with differential coilin phosphorylation in primary and transformed cell lines

PubMed Central

Hearst, Scoty M.; Gilder, Andrew S.; Negi, Sandeep S.; Davis, Misty D.; George, Eric M.; Whittom, Angela A.; Toyota, Cory G.; Husedzinovic, Alma; Gruss, Oliver J.; Hebert, Michael D.

2009-01-01

Summary Cajal bodies (CBs) are nuclear structures that are thought to have diverse functions, including small nuclear ribonucleoprotein (snRNP) biogenesis. The phosphorylation status of coilin, the CB marker protein, might impact CB formation. We hypothesize that primary cells, which lack CBs, contain different phosphoisoforms of coilin compared with that found in transformed cells, which have CBs. Localization, self-association and fluorescence recovery after photobleaching (FRAP) studies on coilin phosphomutants all suggest this modification impacts the function of coilin and may thus contribute towards CB formation. Two-dimensional gel electrophoresis demonstrates that coilin is hyperphosphorylated in primary cells compared with transformed cells. mRNA levels of the nuclear phosphatase PPM1G are significantly reduced in primary cells and expression of PPM1G in primary cells induces CBs. Additionally, PPM1G can dephosphorylate coilin in vitro. Surprisingly, however, expression of green fluorescent protein alone is sufficient to form CBs in primary cells. Taken together, our data support a model whereby coilin is the target of an uncharacterized signal transduction cascade that responds to the increased transcription and snRNP demands found in transformed cells. PMID:19435804

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.

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 patterns of collaboration and integration will be presented.

The impact of electronic health records on workflow and financial measures in primary care practices.

PubMed

Fleming, Neil S; Becker, Edmund R; Culler, Steven D; Cheng, Dunlei; McCorkle, Russell; da Graca, Briget; Ballard, David J

2014-02-01

To estimate a commercially available ambulatory electronic health record's (EHR's) impact on workflow and financial measures. Administrative, payroll, and billing data were collected for 26 primary care practices in a fee-for-service network that rolled out an EHR on a staggered schedule from June 2006 through December 2008. An interrupted time series design was used. Staffing, visit intensity, productivity, volume, practice expense, payments received, and net income data were collected monthly for 2004-2009. Changes were evaluated 1-6, 7-12, and >12 months postimplementation. Data were accessed through a SQLserver database, transformed into SAS®, and aggregated by practice. Practice-level data were divided by full-time physician equivalents for comparisons across practices by month. Staffing and practice expenses increased following EHR implementation (3 and 6 percent after 12 months). Productivity, volume, and net income decreased initially but recovered to/close to preimplementation levels after 12 months. Visit intensity did not change significantly, and a secular trend offset the decrease in payments received. Expenses increased and productivity decreased following EHR implementation, but not as much or as persistently as might be expected. Longer term effects still need to be examined. © Health Research and Educational Trust.

What blocks health visitors from taking on a leadership role?

PubMed

Hyett, Erika

2003-07-01

Current government documents in the United Kingdom call for all nurses to take on a greater leadership role. This paper critically considers some of the management factors that block one group of specialist nurses (health visitors) from fulfilling their leadership role. Health visitors have a key role to play in meeting the public health targets of local primary care trusts, known as local health improvement plans. But to take on a greater public health role, health visitors need to move away from working independently within separate general practitioner surgeries and to work in teams which share the vision and goals of the primary care trusts. The paper explores different styles of management that promote transformational leadership and relate to practice. It is suggested that use of the Servant-Leader model of management should encourage the empowerment of staff, and through empowerment health visitors should be able to instigate change and become more innovative in their practice. Persistent recruitment and retention problems have resulted in little time being available to focus on the effectiveness of services. The future management of health visitors will be to primarily run the service while supporting staff in accessing and influencing those in power.

[Adherence to the Ongoing Education Program for family doctors in a southeastern Brazilian state].

PubMed

d'Ávila, Luciana Souza; Assis, Lucília Nunes de; Melo, Marilene Barros de; Brant, Luiz Carlos

2014-02-01

Ongoing Health Education is a strategy for transformation of health practices, though the adherence of professionals is one of the challenges facing its implementation. Thus, the objective of this study was to investigate the factors associated with adherence of family doctors to the Ongoing Education Program in a southeastern Brazilian state from the perception of supervisors. It is a cross-sectional and quantitative study with the use of online questionnaires. Data were analyzed using the chi-square test with ongoing correction to determine the association between structure, topics, activities and difficulties of the supervisors working in Ongoing Health Education, difficulties of the physicians in Primary Health Care (PHC) and poor and good adherence to the program. Excellent medical participation was statistically related to the adequacy of physical space (p = 0.001), a multidisciplinary approach (p = 0.035) and epidemiological aspects (p = 0.043). Low adherence was associated with the inadequacy of the physical structure, difficulty understanding the methodology, less time in a supervisory position, multiple workdays, among others. A good adherence to Ongoing Health Education is a possibility for collective reconstruction of the everyday work of physicians in Primary Health Care.

Linking Nurses' Clinical Leadership to Patient Care Quality: The Role of Transformational Leadership and Workplace Empowerment.

PubMed

Boamah, Sheila

2018-03-01

Background While improving patient safety requires strong nursing leadership, there has been little empirical research that has examined the mechanisms by which leadership influences patient safety outcomes. Aim To test a model examining relationships among transformational leadership, structural empowerment, staff nurse clinical leadership, and nurse-assessed adverse patient outcomes. Methods A cross-sectional survey was conducted with a randomly selected sample of 378 registered nurses working in direct patient care in acute care hospitals across Ontario, Canada. Structural equation modeling was used to test the hypothesized model. Results The model had an acceptable fit, and all paths were significant. Transformational leadership was significantly associated with decreased adverse patient outcomes through structural empowerment and staff nurse clinical leadership. Discussion This study highlights the importance of transformational leadership in creating empowering practice environments that foster high-quality care. The findings indicate that a more complete understanding of what drives desired patient outcomes warrants the need to focus on how to empower nurses and foster clinical leadership practices at the point of care. Conclusion In planning safety strategies, managers must demonstrate transformational leadership behaviors in order to modify the work environment to create better defenses for averting adverse events.

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.

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.

Low current extended duration spark ignition system

DOEpatents

Waters, Stephen Howard; Chan, Anthony Kok-Fai

2005-08-30

A system for firing a spark plug is disclosed. The system includes a timing controller configured to send a first timing signal and a second timing signal. The system also includes an ignition transformer having a primary winding and a secondary winding and a spark-plug that is operably associated with the secondary winding. A first switching element is disposed between the timing controller and the primary winding of the ignition transformer. The first switching element controls a supply of power to the primary winding based on the first timing signal. Also, a second switching element is disposed between the timing controller and the primary winding of the ignition transformer. The second switching element controls the supply of power to the primary winding based on the second timing signal. A method for firing a spark plug is also disclosed.

RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care.

PubMed

Engel, Charles C; Oxman, Thomas; Yamamoto, Christopher; Gould, Darin; Barry, Sheila; Stewart, Patrice; Kroenke, Kurt; Williams, John W; Dietrich, Allen J

2008-10-01

U.S. military ground forces report high rates of war-related traumatic stressors, posttraumatic stress disorder (PTSD), and depression following deployment in support of recent armed conflicts in Iraq and Afghanistan. Affected service members do not receive needed mental health services in most cases, and they frequently report stigma and significant structural barriers to mental health services. Improvements in primary care may help address these issues, and evidence supports the effectiveness of a systems-level collaborative care approach. To test the feasibility of systems-level collaborative care for PTSD and depression in military primary care. We named our collaborative care model "Re-Engineering Systems of Primary Care for PTSD and Depression in the Military" (RESPECT-Mil). Key elements of RESPECT-Mil care include universal primary care screening for PTSD and depression, brief standardized primary care diagnostic assessment for those who screen positive, and use of a nurse "care facilitator" to ensure continuity of care for those with unmet depression and PTSD treatment needs. The care facilitator assists primary care providers with follow-up, symptom monitoring, and treatment adjustment and enhances the primary care interface with specialty mental health services. We report assessments of feasibility of RESPECT-Mil implementation in a busy primary care clinic supporting Army units undergoing frequent Iraq, Afghanistan, and other deployments. Thirty primary care providers (family physicians, physician assistants, and nurse practitioners) were trained in the model and in the care of depression and PTSD. The clinic screened 4,159 primary care active duty patient visits: 404 screens (9.7%) were positive for depression, PTSD, or both. Sixty-nine patients participated in collaborative care for 6 weeks or longer, and the majority of these patients experienced clinically important improvement in PTSD and depression. Even although RESPECT-Mil participation was voluntary for providers, only one refused participation. No serious adverse events were noted. Collaborative care is an evidence-based approach to improving the quality of primary care treatment of anxiety and depression. Our version of collaborative care for PTSD and depression, RESPECT-Mil, is feasible, safe, and acceptable to military primary care providers and patients, and participating patients frequently showed clinical improvements. Efforts to implement and evaluate collaborative care approaches for mental disorders in populations at high risk for psychiatric complications of military service are warranted.

Transforming to a computerized system for nursing care: organizational success within Magnet idealism.

PubMed

Lindgren, Carolyn L; Elie, Leslie G; Vidal, Elizabeth C; Vasserman, Alex

2010-01-01

In reaching the goal for standardized, quality care, a not-for-profit healthcare system consisting of seven institutional entities is transforming nursing practice guidelines, patient care workflow, and patient documents into electronic, online, real-time modalities for use across departments and all healthcare delivery entities of the system. Organizational structure and a strategic plan were developed for the 2-year Clinical Transformation Project. The Siemens Patient Care Document System was adopted and adapted to the hospitals' documentation and information needs. Two fast-track sessions of more than 100 nurses and representatives from other health disciplines were held to standardize assessments, histories, care protocols, and interdisciplinary plans of care for the top 10 diagnostic regulatory groups. Education needs of the users were addressed. After the first year, a productive, functional system is evidenced. For example, the bar-coded Medication Administration Check System is in full use on the clinical units of one of the hospitals, and the other institutional entities are at substantial stages of implementation of Patient Care Documentation System. The project requires significant allocation of personnel and financial resources for a highly functional informatics system that will transform clinical care. The project exemplifies four of the Magnet ideals and serves as a model for others who may be deciding about launching a similar endeavor.

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.

Care Model Design for E-Health: Integration of Point-of-Care Testing at Dutch General Practices.

PubMed

Verhees, Bart; van Kuijk, Kees; Simonse, Lianne

2017-12-21

Point-of-care testing (POCT)-laboratory tests performed with new mobile devices and online technologies outside of the central laboratory-is rapidly outpacing the traditional laboratory test market, growing at a rate of 12 to 15% each year. POCT impacts the diagnostic process of care providers by yielding high efficiency benefits in terms of turnaround time and related quality improvements in the reduction of errors. However, the implementation of this disruptive eHealth technology requires the integration and transformation of diagnostic services across the boundaries of healthcare organizations. Research has revealed both advantages and barriers of POCT implementations, yet to date, there is no business model for the integration of POCT within general practice. The aim of this article is to contribute with a design for a care model that enables the integration of POCT in primary healthcare. In this research, we used a design modelling toolkit for data collection at five general practices. Through an iterative design process, we modelled the actors and value transactions, and designed an optimized care model for the dynamic integration of POCTs into the GP's network of care delivery. The care model design will have a direct bearing on improving the integration of POCT through the connectivity and norm guidelines between the general practice, the POC technology, and the diagnostic centre.

Care Model Design for E-Health: Integration of Point-of-Care Testing at Dutch General Practices

PubMed Central

Verhees, Bart; van Kuijk, Kees

2017-01-01

Point-of-care testing (POCT)—laboratory tests performed with new mobile devices and online technologies outside of the central laboratory—is rapidly outpacing the traditional laboratory test market, growing at a rate of 12 to 15% each year. POCT impacts the diagnostic process of care providers by yielding high efficiency benefits in terms of turnaround time and related quality improvements in the reduction of errors. However, the implementation of this disruptive eHealth technology requires the integration and transformation of diagnostic services across the boundaries of healthcare organizations. Research has revealed both advantages and barriers of POCT implementations, yet to date, there is no business model for the integration of POCT within general practice. The aim of this article is to contribute with a design for a care model that enables the integration of POCT in primary healthcare. In this research, we used a design modelling toolkit for data collection at five general practices. Through an iterative design process, we modelled the actors and value transactions, and designed an optimized care model for the dynamic integration of POCTs into the GP’s network of care delivery. The care model design will have a direct bearing on improving the integration of POCT through the connectivity and norm guidelines between the general practice, the POC technology, and the diagnostic centre. PMID:29267224

Ethical aspects of transformational leadership.

PubMed

Cassidy, V R; Koroll, C J

1994-10-01

The requirements of leadership in the current environment of health care reform necessitate a clear distinction between leadership and management, an alteration in traditional leadership roles, and an evaluation of the knowledge and skills needed to address the ethical issues that arise from such reform. Transformational leadership is well suited to the current climate in health care because of the manner in which it actively embraces and encourages innovation and change. The article explores the elements of transformational leadership, describes the need for transformational leaders to be cognizant of the ethical aspects of their roles, and outlines the responsibilities of transformational leaders as moral agents.

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.

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

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.

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.

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.

Helping the Student with Diabetes Succeed: A Guide for School Personnel

MedlinePlus

... People With or at Risk for Diabetes Practice Transformation Why Transform Defining Quality Care Team-Based Care ... with leading diabetes, pediatric medicine, health professional, and education experts, the guide offers a coordinated team approach ...

Patient Experience with the Patient-Centered Medical Home in Michigan's Statewide Multi-Payer Demonstration: A Cross-Sectional Study.

PubMed

Sarinopoulos, Issidoros; Bechel-Marriott, Diane L; Malouin, Jean M; Zhai, Shaohui; Forney, Jason C; Tanner, Clare L

2017-11-01

The literature on patient-centered medical homes (PCMHs) and patient experience is somewhat mixed. Government and private payers are promoting multi-payer PCMH initiatives to align requirements and resources and to enhance practice transformation outcomes. To this end, the multipayer Michigan Primary Care Transformation (MiPCT) demonstration project was carried out. To examine whether the PCMH is associated with a better patient experience, and whether a mature, multi-payer PCMH demonstration is associated with even further improvement in the patient experience. This is a cross-sectional comparison of adults attributed to MiPCT PCMH, non-participating PCMH, and non-PCMH practices, statistically controlling for potential confounders, and conducted among both general and high-risk patient samples. Responses came from 3893 patients in the general population and 4605 in the high-risk population (response rates of 31.8% and 34.1%, respectively). The Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey, with PCMH supplemental questions, was administered in January and February 2015. MiPCT general and high-risk patients reported a significantly better experience than non-PCMH patients in most domains. Adjusted mean differences were as follows: access (0.35**, 0.36***), communication (0.19*, 0.18*), and coordination (0.33**, 0.35***), respectively (on a 10-point scale, with significance indicated by: *= p<0.05, **= p<0.01, and ***= p<0.001). Adjusted mean differences in overall provider ratings were not significant. Global odds ratios were significant for the domains of self-management support (1.38**, 1.41***) and comprehensiveness (1.67***, 1.61***). Non-participating PCMH ratings fell between MiPCT and non-PCMH across all domains and populations, sometimes attaining statistical significance. PCMH practices have more positive patient experiences across domains characteristic of advanced primary care. A mature multi-payer model has the strongest, most consistent association with a better patient experience, pointing to the need to provide consistent expectations, resources, and time for practice transformation. Our results held for a general population and a high-risk population which has much more contact with the healthcare system.

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

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.

Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians?

PubMed

Langton, Julia M; Wong, Sabrina T; Johnston, Sharon; Abelson, Julia; Ammi, Mehdi; Burge, Fred; Campbell, John; Haggerty, Jeannie; Hogg, William; Wodchis, Walter P; McGrail, Kimberlyn

2016-11-01

Primary care services form the foundation of modern healthcare systems, yet the breadth and complexity of services and diversity of patient populations may present challenges for creating comprehensive primary care information systems. Our objective is to develop regional-level information on the performance of primary care in Canada. A scoping review was conducted to identify existing initiatives in primary care performance measurement and reporting across 11 countries. The results of this review were used by our international team of primary care researchers and clinicians to propose an approach for regional-level primary care reporting. We found a gap between conceptual primary care performance measurement frameworks in the peer-reviewed literature and real-world primary care performance measurement and reporting activities. We did not find a conceptual framework or analytic approach that could readily form the foundation of a regional-level primary care information system. Therefore, we propose an approach to reporting comprehensive and actionable performance information according to widely accepted core domains of primary care as well as different patient population groups. An approach that bridges the gap between conceptual frameworks and real-world performance measurement and reporting initiatives could address some of the potential pitfalls of existing ways of presenting performance information (i.e., by single diseases or by age). This approach could produce meaningful and actionable information on the quality of primary care services. Copyright © 2016 Longwoods Publishing.

Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians?

PubMed Central

Langton, Julia M.; Wong, Sabrina T.; Johnston, Sharon; Abelson, Julia; Ammi, Mehdi; Burge, Fred; Campbell, John; Haggerty, Jeannie; Hogg, William; Wodchis, Walter P.

2016-01-01

Objective: Primary care services form the foundation of modern healthcare systems, yet the breadth and complexity of services and diversity of patient populations may present challenges for creating comprehensive primary care information systems. Our objective is to develop regional-level information on the performance of primary care in Canada. Methods: A scoping review was conducted to identify existing initiatives in primary care performance measurement and reporting across 11 countries. The results of this review were used by our international team of primary care researchers and clinicians to propose an approach for regional-level primary care reporting. Results: We found a gap between conceptual primary care performance measurement frameworks in the peer-reviewed literature and real-world primary care performance measurement and reporting activities. We did not find a conceptual framework or analytic approach that could readily form the foundation of a regional-level primary care information system. Therefore, we propose an approach to reporting comprehensive and actionable performance information according to widely accepted core domains of primary care as well as different patient population groups. Conclusions: An approach that bridges the gap between conceptual frameworks and real-world performance measurement and reporting initiatives could address some of the potential pitfalls of existing ways of presenting performance information (i.e., by single diseases or by age). This approach could produce meaningful and actionable information on the quality of primary care services. PMID:28032823

Health Care System Transformation and Integration: A Call to Action for Public Health.

PubMed

Wiley, Lindsay F; Matthews, Gene W

2017-03-01

Restructured health care reimbursement systems and new requirements for nonprofit hospitals are transforming the U.S. health system, creating opportunities for enhanced integration of public health and health care goals. This article explores the role of public health practitioners and lawyers in this moment of transformation. We argue that the population perspective and structural strategies that characterize public health can add value to the health care system but could get lost in translation as changes to tax requirements and payment systems are rapidly implemented. We urge public health leaders to take a more active role in hospital assessments of community health needs and evaluation of the patient outcomes for which providers are accountable.

Employee effort - reward balance and first-level manager transformational leadership within elderly care.

PubMed

Keisu, Britt-Inger; Öhman, Ann; Enberg, Birgit

2018-03-01

Negative aspects, staff dissatisfaction and problems related to internal organisational factors of working in elderly care are well-known and documented. Much less is known about positive aspects of working in elderly care, and therefore, this study focuses on such positive factors in Swedish elderly care. We combined two theoretical models, the effort-reward imbalance model and the Transformational Leadership Style model. The aim was to estimate the potential associations between employee-perceived transformational leadership style of their managers, and employees' ratings of effort and reward within elderly care work. The article is based on questionnaires distributed at on-site visits to registered nurses, occupational therapists, physiotherapists (high-level education) and assistant nurses (low-level education) in nine Swedish elderly care facilities. In order to grasp the positive factors of work in elderly care, we focused on balance at work, rather than imbalance. We found a significant association between employees' effort-reward balance at work and a transformational leadership style among managers. An association was also found between employees' level of education and their assessments of the first-level managers. We conclude that the first-level manager is an important actor for achieving a good workplace within elderly care, since she/he influences employees' psychosocial working environment. We also conclude that there are differences and inequalities, in terms of well-being, effort and reward at the work place, between those with academic training and those without, in that the former group to a higher degree evaluated their first-level manager to perform a transformational leadership style, which in turn is beneficial for their psychosocial work environment. Consequently, this (re)-produce inequalities in terms of well-being, effort and reward among the employees at the work place. © 2017 Nordic College of Caring Science.

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

PubMed

Gale, Randall C; Asch, Steven M; Taylor, Thomas; Nelson, Karin M; Luck, Jeff; Meredith, Lisa S; Helfrich, Christian D

2015-04-19

Like other transformative healthcare initiatives, patient-centered medical home (PCMH) implementation requires substantial investments of time and resources. Even though PCMH and PCMH-like models are being implemented by multiple provider practices and health systems, little is known about what facilitates their implementation. The purpose of this study was to assess which PCMH-implementation resources are most widely used, by whom, and which resources primary care personnel find most helpful. This study is an analysis of data from a cross-sectional survey of primary care personnel in the Veterans Health Administration in 2012, in which respondents were asked to rate whether they were aware of and accessed PCMH-implementation resources, and to rate their helpfulness. Logistic regression was used to produce odds ratios for the outcomes (1) resource use and (2) resource helpfulness. Respondents were nested within clinics, nested, in turn, within 135 parent hospitals. Teamlet huddles were the most widely accessed (80.4% accessed) and most helpful (90.4% rated helpful) resource; quality-improvement methods to conduct small tests of change were the least frequently accessed (42.4% accessed) resource though two-thirds (66.7%) of users reported as helpful. Supervisors were significantly more likely (ORs, 1.46 to 1.86) to use resources than non-supervisors but were less likely to rate the majority (8 out of 10) of resources as "somewhat/very helpful" than non-supervisors (ORs, 0.72 to 0.84). Longer-tenured employees tended to rate resources as more helpful. These findings are the first in the PCMH literature that we are aware of that systematically assesses primary care staff's access to and the helpfulness of PCMH implementation resources. Supervisors generally reported greater access to resources, relative to non-supervisors, but rated resources as less helpful, suggesting that information about them may not have been optimally disseminated. Knowing what resources primary care staff use and find helpful can inform administrators' and policymakers' investments in PCMH-implementation resources. The implications of our model extend beyond just PCMH implementation but also to considerations when providing implementation resources for other complex quality-improvement initiatives.

Helping Families Improve: An Evaluation of Two Primary Care Approaches to Parenting Support in the Netherlands

ERIC Educational Resources Information Center

de Graaf, Ireen; Onrust, Simone; Haverman, Merel; Janssens, Jan

2009-01-01

The present study evaluated two primary care parenting interventions. First, we evaluated the most widely used Dutch practices for primary care parenting support. Second, we assessed the applicability of the Primary Care Triple P approach, which is now being utilized in a wide variety of primary care settings. Both interventions target parents of…

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.

Influence of income, hours worked, and loan repayment on medical students' decision to pursue a primary care career.

PubMed

Rosenthal, M P; Diamond, J J; Rabinowitz, H K; Bauer, L C; Jones, R L; Kearl, G W; Kelly, R B; Sheets, K J; Jaffe, A; Jonas, A P

To assess the specialty plans of current fourth-year medical students and, for those not choosing primary care specialties, to investigate the potential effect that changes in key economic or lifestyle factors could have in attracting such students to primary care. A survey study was sent to 901 fourth-year medical students in the 1993 graduating classes of six US medical schools. Comparisons were made between students choosing and not choosing primary care specialties. For the non-primary care students, we also evaluated whether alteration of income, hours worked, or loan repayment could attract them to primary care careers. Of the 688 responses (76% response rate), primary care specialties were chosen by 27% of the students and non-primary care specialties by 73%. One quarter (25%) of the non-primary care students indicated they would change to primary care for one of the following factors: income (10%), hours worked (11%), or loan repayment (4%). For students whose debt was $50,000 or greater, the loan repayment option became much more important than for students with lesser debt. In all, a total of 45% (n = 313) of the students indicated either they were planning to enter primary care (n = 188) or they would change to a primary care specialty (n = 125) with appropriate adjustments in income, hours worked, or loan repayment. Significant changes in economic and lifestyle factors could have a direct effect on the ability to attract students to primary care. Including such changes as part of health system reform, especially within the context of a supportive medical school environment, could enable the United States to approach a goal of graduating 50% generalist physicians.

Linear transformer and primary low-inductance switch and capacitor modules for fast charging of PFL

NASA Astrophysics Data System (ADS)

Bykov, Yu A.; Krastelev, E. G.; Popov, G. V.; Sedin, A. A.; Feduschak, V. F.

2017-05-01

A step-up linear pulse transformer and a modular primary powering system were developed for fast (≈350 ns) charging of a pulse forming line (PFL) of a high-current electron accelerator. The linear transformer is assembled of a set of 20 inductors with circular ferromagnetic cores and one-turn primary windings. The secondary turn is formed by housing tube walls and a voltage adder with a film-glycerol insulation installed inside of the inductors. The primary powering system assembles 10 modules, each of them is a low-inductance site of two capacitors of 0,35 µF and one gas switch mounted at the same enclosure. The total stored energy is 5.5 kJ at the charging voltage of 40 kV. According to test results, the equivalent parameters at the output of the transformer are the next: a capacity - 17.5 nF, an inductance - 2 µH, a resistance - 3.2 Ohms.

Direct procurement of wound management products.

PubMed

Jenkins, Trevor

2014-03-01

This article describes a collaborative project between Bedfordshire Community Health Services and Primary Care Trusts/Clinical Commissioning Groups to improve provision of dressings to nurses for the patients they treat. Commissioners have facilitated a transformational approach and encouraged development of efficient systems of increased cost-effectiveness rather than a transactional approach based on opportunistic cost improvement plans. Reconfiguration to direct procurement from GP prescribing has reduced wastage, released nurse time from processes to spend on clinical contact time with patients, increased efficiency, and reduced prescription workload for GPs, all without adverse effects on expenditure. Establishing a wound care products formulary placed control under the nurses treating patients and facilitated decision-making based on cost-effectiveness in clinical use. Nurses now manage 60% of expenditure in the local community health economy, and this is increasing. Relationships with the dressings manufacturing industry have also changed in a positive, constructive direction.

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

Patient profile, referral sources, and consultant utilization in a primary care sports medicine clinic.

PubMed

Butcher, J D; Zukowski, C W; Brannen, S J; Fieseler, C; O'Connor, F G; Farrish, S; Lillegard, W A

1996-12-01

Sports medicine has matured as a focused discipline within primary care with the number of primary care sports medicine physicians growing annually. The practices of these physicians range from "part-time" sports medicine as a part of a broader practice in their primary specialty, to functioning as a full-time team physician for a university or college. Managed care organizations are increasingly incorporating primary care sports medicine providers into their organizations. The optimal role of these providers in a managed care system has not been described. A descriptive analysis was made of patient contacts in a referral-based, free-standing primary care sports medicine clinic associated with a large managed care system. This study describes patient information including demographic data, referral source, primary diagnosis, specialized diagnostic testing, and subsequent specialty consultation. A total of 1857 patient contacts were analyzed. New patients were referred from a full range of physicians both primary care (family practice, internal medicine, pediatrics, and emergency physicians) and other specialists, with family practice clinic providers (physicians, physician assistants, and nurse practitioners) accounting for the largest percentage of new referrals. The majority of patient visits were for orthopedic injuries (95.4%); the most frequently involved injury sites were: knee (26.5%), shoulder (18.2%), back (14.3%), and ankle (10%). The most common types of injury were: tendinitis (21.3%), chronic anterior knee pain (10.6%), and ligament sprains (9.9%). Specialized testing was requested for 8% of all patients. The majority of patients were treated at the Ft Belvoir Sports Medicine Clinic by primary care sports medicine physicians without further specialty referral. Primary care sports medicine physicians offer an intermediate level of care for patients while maintaining a practice in their primary care specialty. This dual practice is ideal in the managed care setting. This study demonstrates the complementary nature of primary care sports medicine and orthopedics, with the primary care sports medicine physician reducing the demand on orthopedists for nonsurgical treatment. This study also demonstrates the need for revision in the orthopedic curriculum for primary care physicians.

A clinical prediction rule for detecting major depressive disorder in primary care: the PREDICT-NL study.

PubMed

Zuithoff, Nicolaas P A; Vergouwe, Yvonne; King, Michael; Nazareth, Irwin; Hak, Eelko; Moons, Karel G M; Geerlings, Mirjam I

2009-08-01

Major depressive disorder often remains unrecognized in primary care. Development of a clinical prediction rule using easily obtainable predictors for major depressive disorder in primary care patients. A total of 1046 subjects, aged 18-65 years, were included from seven large general practices in the center of The Netherlands. All subjects were recruited in the general practice waiting room, irrespective of their presenting complaint. Major depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Text Revision edition criteria was assessed with the Composite International Diagnostic Interview. Candidate predictors were gender, age, educational level, being single, number of presented complaints, presence of non-somatic complaints, whether a diagnosis was assigned, consultation rate in past 12 months, presentation of depressive complaints or prescription of antidepressants in past 12 months, number of life events in past 6 months and any history of depression. The first multivariable logistic regression model including only predictors that require no confronting depression-related questions had a reasonable degree of discrimination (area under the receiver operating characteristic curve or concordance-statistic (c-statistic) = 0.71; 95% Confidence Interval (CI): 0.67-0.76). Addition of three simple though more depression-related predictors, number of life events and history of depression, significantly increased the c-statistic to 0.80 (95% CI: 0.76-0.83). After transforming this second model to an easily to use risk score, the lowest risk category (sum score < 5) showed a 1% risk of depression, which increased to 49% in the highest category (sum score > or = 30). A clinical prediction rule allows GPs to identify patients-irrespective of their complaints-in whom diagnostic workup for major depressive disorder is indicated.

Increased Health Information Technology Adoption and Use Among Small Primary Care Physician Practices Over Time: A National Cohort Study.

PubMed

Rittenhouse, Diane R; Ramsay, Patricia P; Casalino, Lawrence P; McClellan, Sean; Kandel, Zosha K; Shortell, Stephen M

2017-01-01

Implementation and meaningful use of health information technology (HIT) has been shown to facilitate delivery system transformation, yet implementation is far from universal. This study examined correlates of greater HIT implementation over time among a national cohort of small primary care practices in the United States. We used data from a 40-minute telephone panel survey of 566 small primary care practices having 8 or fewer physicians to investigate adoption and use of HIT in 2007-2010 and 2012-2013. We used generalized estimating equations (GEE) to estimate the association of practice characteristics and external incentives with the adoption and use of HIT. We studied 18 measures of HIT functionalities, including record keeping, clinical decision support, patient communication, and health information exchange with hospitals and pharmacies. Overall, use of 16 HIT functionalities increased significantly over time, whereas use of 2 decreased significantly. On average, compared with physician-owned practices, hospital-owned practices used 1.48 (95% CI, 1.07-1.88; P <.001) more HIT processes. And relative to smaller practices, practices with 3 to 8 physicians used 2.49 (95% CI, 2.26-2.72; P <.001) more HIT processes. Participation in pay-for-performance programs, participation in public reporting of clinical quality data, and a larger proportion of revenue from Medicare were also associated with greater adoption and use of HIT. The new Medicare Access and CHIP Reauthorization Act (MACRA) will provide payment incentives and technical support to speed HIT adoption and use by small practices. We found that external incentives were, indeed, positively associated with greater adoption and use of HIT. Our findings also support a strategy of targeting assistance to smaller physician practices and those that are physician owned. © 2017 Annals of Family Medicine, Inc.

Journey toward a patient-centered medical home: readiness for change in primary care practices.

PubMed

Wise, Christopher G; Alexander, Jeffrey A; Green, Lee A; Cohen, Genna R; Koster, Christina R

2011-09-01

Information is limited regarding the readiness of primary care practices to make the transformational changes necessary to implement the patient-centered medical home (PCMH) model. Using comparative, qualitative data, we provide practical guidelines for assessing and increasing readiness for PCMH implementation. We used a comparative case study design to assess primary care practices' readiness for PCMH implementation in sixteen practices from twelve different physician organizations in Michigan. Two major components of organizational readiness, motivation and capability, were assessed. We interviewed eight practice teams with higher PCMH scores and eight with lower PCMH scores, along with the leaders of the physician organizations of these practices, yielding sixty-six semistructured interviews. The respondents from the higher and lower PCMH scoring practices reported different motivations and capabilities for pursuing PCMH. Their motivations pertained to the perceived value of PCMH, financial incentives, understanding of specific PCMH requirements, and overall commitment to change. Capabilities that were discussed included the time demands of implementation, the difficulty of changing patients' behavior, and the challenges of adopting health information technology. Enhancing the implementation of PCMH within practices included taking an incremental approach, using data, building a team and defining roles of its members, and meeting regularly to discuss the implementation. The respondents valued external organizational support, regardless of its source. The respondents from the higher and lower PCMH scoring practices commented on similar aspects of readiness-motivation and capability-but offered very different views of them. Our findings suggest the importance of understanding practice perceptions of the motivations for PCMH and the capability to undertake change. While this study identified some initial approaches that physician organizations and practices have used to prepare for practice redesign, we need much more information about their effectiveness. © 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.

Effects of floodgates operation on nitrogen transformation in a lake based on structural equation modeling analysis.

PubMed

Zhu, Longji; Zhou, Haixuan; Xie, Xinyu; Li, Xueke; Zhang, Duoying; Jia, Liming; Wei, Qingbin; Zhao, Yue; Wei, Zimin; Ma, Yingying

2018-08-01

Floodgates operation is one of the primary means of flood control in lake development. However, knowledge on the linkages between floodgates operation and nitrogen transformation during the flood season is limited. In this study, water samples from six sampling sites along Lake Xingkai watershed were collected before and after floodgates operation. The causal relationships between environmental factors, bacterioplankton community composition and nitrogen fractions were determined during flood season. We found that concentrations of nitrogen fractions decreased significantly when the floodgates were opened, while the concentrations of total nitrogen (TN) and NO 3 - increased when the floodgates had been shut for a period. Further, we proposed a possible mechanism that the influence of floodgates operation on nitrogen transformation was largely mediated through changes in dissolved organic matter, dissolved oxygen and bacterioplankton community composition as revealed by structural equation modeling (SEM). We conclude that floodgates operation has a high risk for future eutrophication of downstream watershed, although it can reduce nitrogen content temporarily. Therefore, the environmental impacts of floodgates operation should be carefully evaluated before the floodwaters were discharged into downstream watershed. Copyright © 2018. Published by Elsevier B.V.

Town and Gown Differences Among the 100 Largest Medical Groups in the United States.

PubMed

Welch, W Pete; Bindman, Andrew B

2016-07-01

The authors undertook a study to determine whether large academic and community-based medical groups differ in terms of their financial stake in Medicare Advantage or Medicare Accountable Care Organizations (ACOs) and whether their participation in these alternative payment models is related to their size, specialty mix, and Medicare physician market share in their local area. The authors used the 2013 Medicare Data on Provider Practice and Specialty database and a national database of ACOs to conduct a cross-sectional descriptive study of the 100 largest medical groups in the United States. Medical groups were categorized as academic or community based on matches of their name with a list of U.S. medical schools or the results of a series of Internet search procedures. Sixty-eight of the 100 largest groups were academic, and 32 were community based. On average, community-based groups had more than twice the percentage of primary care physicians as academic groups (mean, 38.4%; 95% CI, 34.7%-42.0%; vs. 18.3%; 95% CI, 17.0%-19.6%). Community groups were significantly (P < .001) more likely than academic groups to have a financial stake in a Medicare ACO or Medicare Advantage plan, but this difference was no longer significant when the percentage of primary care physicians in the group was added to the model. The specialty mix within academic medical groups may hinder their ability to transform themselves into organizations that can manage the financial responsibilities of caring for a patient population through a Medicare ACO or Medicare Advantage.

Growth of Regional Acute Stroke Systems of Care in the United States in the First Decade of the 21st Century

PubMed Central

Song, Sarah; Saver, Jeffrey

2012-01-01

Background and Purpose States and counties in the US began implementing regional systems of acute stroke care in the first decade of the 21st century, whereby emergency medical services (EMS) systems preferentially route acute stroke patients directly to primary stroke centers (PSCs). The pace, geographic range, and population reach of regional stroke system implementation has not been previously delineated. Methods Review of legislative archives, internet and media reports, consultation with American Heart Association/American Stroke Association and Centers for Disease Control staff, and phone interviews with state public health and emergency medical service officials from each of the fifty states. Results The first counties to adopt regional regulations supporting routing of acute stroke patients to PSCs were in Alabama and Texas in 2000; the first states were Florida and Massachusetts in 2004. By 2010, 16 states had state-level legislation or regulations to enable EMS routing to PSCs, as did counties in 3 additional states. The US population covered by routing protocols increased substantially in the latter half of the decade, from 1.5% in 2000, to 53% of the U.S. population by the end of 2010. Conclusions The first decade of the 21st century witnessed a remarkable structural transformation in acute stroke care - by the end of 2010, over half of all Americans were living in states/counties with EMS routing protocols supporting the direct transport of acute stroke patients to primary stroke centers. Additional efforts are needed to extend regional stroke systems of care to the rest of the US. PMID:22669404

Work satisfaction and future career intentions of experienced nurses transitioning to primary health care employment.

PubMed

Ashley, Christine; Peters, Kath; Brown, Angela; Halcomb, Elizabeth

2018-02-12

To explore registered nurses' reflections on transitioning from acute to primary health care employment, and future career intentions. Reforms in primary health care have resulted in increasing demands for a skilled primary health care nursing workforce. To meet shortfalls, acute care nurses are being recruited to primary health care employment, yet little is known about levels of satisfaction and future career intentions. A sequential mixed methods study consisting of a survey and semi-structured interviews with nurses who transition to primary health care. Most reported positive experiences, valuing work/life balance, role diversity and patient/family interactions. Limited orientation and support, loss of acute skills and inequitable remuneration were reported negatively. Many respondents indicated an intention to stay in primary health care (87.3%) and nursing (92.6%) for the foreseeable future, whilst others indicated they may leave primary health care as soon as convenient (29.6%). Our findings provide guidance to managers in seeking strategies to recruit and retain nurses in primary health care employment. To maximize recruitment and retention, managers must consider factors influencing job satisfaction amongst transitioning nurses, and the impact that nurses' past experiences may have on future career intentions in primary health care. © 2018 John Wiley & Sons Ltd.

Transformational leadership in nursing: a concept analysis.

PubMed

Fischer, Shelly A

2016-11-01

To analyse the concept of transformational leadership in the nursing context. Tasked with improving patient outcomes while decreasing the cost of care provision, nurses need strategies for implementing reform in health care and one promising strategy is transformational leadership. Exploration and greater understanding of transformational leadership and the potential it holds is integral to performance improvement and patient safety. Concept analysis using Walker and Avant's (2005) concept analysis method. PubMed, CINAHL and PsychINFO. This report draws on extant literature on transformational leadership, management, and nursing to effectively analyze the concept of transformational leadership in the nursing context. This report proposes a new operational definition for transformational leadership and identifies model cases and defining attributes that are specific to the nursing context. The influence of transformational leadership on organizational culture and patient outcomes is evident. Of particular interest is the finding that transformational leadership can be defined as a set of teachable competencies. However, the mechanism by which transformational leadership influences patient outcomes remains unclear. Transformational leadership in nursing has been associated with high-performing teams and improved patient care, but rarely has it been considered as a set of competencies that can be taught. Also, further research is warranted to strengthen empirical referents; this can be done by improving the operational definition, reducing ambiguity in key constructs and exploring the specific mechanisms by which transformational leadership influences healthcare outcomes to validate subscale measures. © 2016 John Wiley & Sons Ltd.

Rolled-up transformer structure for a radiofrequency integrated circuit (RFIC)

DOEpatents

Li, Xiuling; Huang, Wen

2016-05-03

A rolled-up transformer structure comprises a multilayer sheet having a rolled configuration comprising multiple turns about a longitudinal axis. The multilayer sheet comprises more than one conductive pattern layer on a strain-relieved layer, including a first conductive film and a second conductive film separated from the first conductive film in a thickness direction. The first conductive film comprises an even number of primary conductive strips, where each primary conductive strip has a length extending in the rolling direction, and the second conductive film comprises an even number of secondary conductive strips, where each secondary conductive strip has a length extending in the rolling direction. In the rolled configuration, turns of the primary conductive strips and turns of the secondary conductive strips wrap around the longitudinal axis. The primary conductive strips serve as a primary winding and the secondary conductive strips serve as a secondary winding of the rolled-up transformer structure.

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 a career in primary care.

[Transforming gene in human esophageal carcinoma tissue].

PubMed

Jiang, W

1988-09-01

The transforming gene in human esophageal carcinoma (HEC) tissues collected from Lin-xian county, a high incidence area of esophageal cancer was studied. Eight primary HEC tissues were used as sources for the preparation of DNA. High molecular weight DNAs were separately added to NIH 3T3 cells by the calcium phosphate coprecipitation method. Of the 8 HEC tissues examined, 3 DNAs showed transforming activity and produced secondary transformants. The use of uncloned NIH 3T3 cells resulted in the appearances of non-transforming. The efficiency of primary transfection foci was low (0.025--0.05 focus per ug of DNA). In the secondary transfection, the efficiency was increased (0.30 focus per ug of DNA). The primary and secondary transformants were capable of forming colonies in soft agar (0.33%) in contrast to the control NIH 3T3 cells, which did not show any anchorage-independent growth. About 1 X 10(6) cells of the cloned secondary transformants were injected subcutaneously into athymic BALB/c nude mice. The mice developed large tumors (approximately 20-30 mm in diameter) within 5--15 days after injection. No tumor developed in mice injected with control NIH 3T3 cells even after 2 months. The transforming DNA had a linkage to the Alu sequence, indicating that a common human DNA fragment is conserved in the tumors. H-ras was found in the transforming DNA using Southern blot assay.

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...

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...

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...

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...

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...

Identification of physicians providing comprehensive primary care in Ontario: a retrospective analysis using linked administrative data.

PubMed

Schultz, Susan E; Glazier, Richard H

2017-12-19

Given the changing landscape of primary care, there may be fewer primary care physicians available to provide a broad range of services to patients of all age groups and health conditions. We sought to identify physicians with comprehensive primary care practices in Ontario using administrative data, investigating how many and what proportion of primary care physicians provided comprehensive primary care and how this changed over time. We identified the pool of active primary care physicians in linked population-based databases for Ontario from 1992/93 to 2014/15. After excluding those who saw patients fewer than 44 days per year, we identified physicians as providing comprehensive care if more than half of their services were for core primary care and if these services fell into at least 7 of 22 activity areas. Physicians with 50% or less of their services for core primary care but with more than 50% in a single location or type of service were identified as being in focused practice. In 2014/15, there were 12 891 physicians in the primary care pool: 1254 (9.7%) worked fewer than 44 days per year, 1619 (12.6%) were in focused practice, and 1009 (7.8%) could not be classified. The proportion in comprehensive practice ranged from 67.5% to 74.9% between 1992/93 and 2014/15, with a peak in 2002/03 and relative stability from 2009/10 to 2014/15. Over this period, there was an increase of 8.8% in population per comprehensive primary care physician. We found that just over two-thirds of primary care physicians provided comprehensive care in 2014/15, which indicates that traditional estimates of the primary care physician workforce may be too high. Although implementation will vary by setting and available data, this approach is likely applicable elsewhere. Copyright 2017, Joule Inc. or its licensors.

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 in multidisciplinary care planning is warranted. PMID:18681977

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

PubMed Central

Harris, Mark F; Advocat, Jenny; Crabtree, Benjamin F; Levesque, Jean-Frederic; Miller, William L; Gunn, Jane M; Hogg, William; Scott, Cathie M; Chase, Sabrina M; Halma, Lisa; Russell, Grant M

2016-01-01

Context A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood. Objective To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices. Design Collaborative synthesis of 12 mixed methods studies. Setting Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec). Methods We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context. Results There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups. Conclusion The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level. PMID:26889085

Disease management projects and the Chronic Care Model in action: baseline qualitative research

PubMed Central

2012-01-01

Background Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in the Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in the Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams. Methods Eleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project directors and managers were interviewed. The interviews focused on each project’s chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders’ action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework. Results This analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved. Conclusions At the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader’s point of view. PMID:22578251

Disease management projects and the Chronic Care Model in action: baseline qualitative research.

PubMed

Walters, Bethany Hipple; Adams, Samantha A; Nieboer, Anna P; Bal, Roland

2012-05-11

Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in The Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in The Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams. Eleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project directors and managers were interviewed. The interviews focused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders' action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework. This analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved. At the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader's point of view.

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.

Learning from malpractice claims about negligent, adverse events in primary care in the United States

PubMed Central

Phillips, R; Bartholomew, L; Dovey, S; Fryer, G; Miyoshi, T; Green, L

2004-01-01

Background: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. Methods: Physician Insurers Association of America malpractice claims data (1985–2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. Results: Of 49 345 primary care claims, 26 126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). Conclusions: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations. PMID:15069219

Towards efficient use of research resources: a nationwide database of ongoing primary care research projects in the Netherlands.

PubMed

Kortekaas, Marlous F; van de Pol, Alma C; van der Horst, Henriëtte E; Burgers, Jako S; Slort, Willemjan; de Wit, Niek J

2014-04-01

PURPOSE. Although in the last decades primary care research has evolved with great success, there is a growing need to prioritize the topics given the limited resources available. Therefore, we constructed a nationwide database of ongoing primary care research projects in the Netherlands, and we assessed if the distribution of research topics matched with primary care practice. We conducted a survey among the main primary care research centres in the Netherlands and gathered details of all ongoing primary care research projects. We classified the projects according to research topic, relation to professional guidelines and knowledge deficits, collaborative partners and funding source. Subsequently, we compared the frequency distribution of clinical topics of research projects to the prevalence of problems in primary care practice. We identified 296 ongoing primary care research projects from 11 research centres. Most projects were designed as randomized controlled trial (35%) or observational cohort (34%), and government funded mostly (60%). Thematically, most research projects addressed chronic diseases, mainly cardiovascular risk management (8%), depressive disorders (8%) and diabetes mellitus (7%). One-fifth of the projects was related to defined knowledge deficits in primary care guidelines. From a clinical primary care perspective, research projects on dermatological problems were significantly underrepresented (P = 0.01). This survey of ongoing projects demonstrates that primary care research has a firm basis in the Netherlands, with a strong focus on chronic disease. The fit with primary care practice can improve, and future research should address knowledge deficits in professional guidelines more.

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.

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.

From complexity to reality: providing useful frameworks for defining systems of care.

PubMed

Levison-Johnson, Jody; Wenz-Gross, Melodie

2010-02-01

Because systems of care are not uniform across communities, there is a need to better document the process of system development, define the complexity, and describe the development of the structures, processes, and relationships within communities engaged in system transformation. By doing so, we begin to identify the necessary and sufficient components that, at minimum, move us from usual care within a naturally occurring system to a true system of care. Further, by documenting and measuring the degree to which key components are operating, we may be able to identify the most successful strategies in creating system reform. The theory of change and logic model offer a useful framework for communities to begin the adaptive work necessary to effect true transformation. Using the experience of two system of care communities, this new definition and the utility of a theory of change and logic model framework for defining local system transformation efforts will be discussed. Implications for the field, including the need to further examine the natural progression of systems change and to create quantifiable measures of transformation, will be raised as new challenges for the evolving system of care movement.

Five key pillars of an analytics center of excellence, which are required to manage populations and transform organizations into the next era of health care.

PubMed

Reichert, Jim; Furlong, Gerry

2014-01-01

Acute care facilities are experiencing fiscal challenges as noted by decreasing admissions and lower reimbursement creating an unsustainable fiscal environment as we move into the next era of health care. This situation necessitates a strategy to move away from acting solely on hunches and instinct to using analytics to become a truly data-driven organization that identifies opportunities within patient populations to improve the quality and efficiency of care across the continuum. A brief overview of knowledge management philosophies will be provided and how it is used to enable organizations to leverage data, information, and knowledge for operational transformation leading to improved outcomes. This article outlines the 5 key pillars of an Analytics Center of Excellence; governance, organizational structure, people, process, and technology, that are foundational to the development of this strategy. While culture is the most important factor to achieve organizational transformation and improved care delivery, it is the 5 pillars of the ACoE that will enable the culture shift necessary to become a truly data-driven organization and thus achieve transformation into the next era of health care.

Minding the gap and overlap: a literature review of fragmentation of primary care for chronic dialysis patients.

PubMed

Wang, Virginia; Diamantidis, Clarissa J; Wylie, JaNell; Greer, Raquel C

2017-08-29

Care coordination is a challenge for patients with kidney disease, who often see multiple providers to manage their associated complex chronic conditions. Much of the focus has been on primary care physician (PCP) and nephrologist collaboration in the early stages of chronic kidney disease, but less is known about the co-management of the patients in the end-stage of renal disease. We conducted a systematic review and synthesis of empirical studies on primary care services for dialysis patients. Systematic literature search of MEDLINE/PubMED, CINAHL, and EmBase databases for studies, published until August 2015. Inclusion criteria included publications in English, empirical studies involving human subjects (e.g., patients, physicians), conducted in US and Canadian study settings that evaluated primary care services in the dialysis patient population. Fourteen articles examined three major themes of primary care services for dialysis patients: perceived roles of providers, estimated time in providing primary care, and the extent of dialysis patients' use of primary care services. There was general agreement among providers that PCPs should be involved but time, appropriate roles, and miscommunication are potential barriers to good primary care for dialysis patients. Although many dialysis patients report having a PCP, the majority rely on primary care from their nephrologists. Studies using administrative data found lower rates of preventive care services than found in studies relying on provider or patient self-report. The extant literature revealed gaps and opportunities to optimize primary care services for dialysis patients, foreshadowing the challenges and promise of Accountable Care / End-Stage Seamless Care Organizations and care coordination programs currently underway in the United States to improve clinical and logistical complexities of care for this commonly overlooked population. Studies linking the relationship between providers and patients' receipt of primary care to outcomes will serve as important comparisons to the nascent care models for ESRD patients, whose value is yet to be determined.

The Norrtaelje model: a unique model for integrated health and social care in Sweden.

PubMed

Bäck, Monica Andersson; Calltorp, Johan

2015-01-01

Many countries organise and fund health and social care separately. The Norrtaelje model is a Swedish initiative that transformed the funding and organisation of health and social care in order to better integrate care for older people with complex needs. In Norrtaelje model, this transformation made it possible to bringing the team together, to transfer responsibility to different providers, to use care coordinators, and to develop integrated pathways and plans around transitions in and out of hospital and from nursing homes to hospital. The Norrtaelje model operates in the context of the Swedish commitment to universal coverage and public programmes based on tax-funded resources that are pooled and redistributed to citizens on the basis of need. The experience of Norrtaelje model suggests that one way to promote integration of health and social care is to start with a transformation that aligns these two sectors in terms of high level organisation and funding. This transformation then enables the changes in operations and management that can be translated into changes in care delivery. This "top-down" approach must be in-line with national priorities and policies but ultimately is successful only if the culture, resource allocation and management are changed throughout the local system.

Neoliberal Justice and the Transformation of the Moral: The Privatization of the Right to Health Care in Colombia.

PubMed

Abadía-Barrero, César Ernesto

2016-03-01

Neoliberal reforms have transformed the legislative scope and everyday dynamics around the right to health care from welfare state social contracts to insurance markets administered by transnational financial capital. This article presents experiences of health care-seeking treatment, judicial rulings about the right to health care, and market-based health care legislation in Colombia. When insurance companies deny services, citizens petition the judiciary to issue a writ affirming their right to health care. The judiciary evaluates the finances of all relevant parties to rule whether a service should be provided and who should be responsible for the costs. A 2011 law claimed that citizens who demand, physicians who prescribe, and judges who grant uncovered services use the system's limited economic resources and undermine the state's capacity to expand coverage to the poor. This article shows how the consolidation of neoliberal ideology in health care requires the transformation of moral values around life. © 2015 by the American Anthropological Association.

Michigan Pharmacists Transforming Care and Quality: Developing a Statewide Collaborative of Physician Organizations and Pharmacists to Improve Quality of Care and Reduce Costs.

PubMed

Choe, Hae Mi; Lin, Alexandra Tungol; Kobernik, Kathleen; Cohen, Marc; Wesolowicz, Laurie; Qureshi, Nabeel; Leyden, Tom; Share, David A; Darland, Rozanne; Spahlinger, David A

2018-04-01

Inappropriate drug use, increasing complexity of drug regimens, continued pressure to control costs, and focus on shared accountability for clinical measures drive the need to leverage the medication expertise of pharmacists in direct patient care. A statewide strategy based on the collaboration of pharmacists and physicians regarding patient care was developed to improve disease state management and medication-related outcomes. Blue Cross Blue Shield of Michigan (BCBSM) partnered with Michigan Medicine to develop and implement a statewide provider-payer program called Michigan Pharmacists Transforming Care and Quality (MPTCQ), which integrates pharmacists within physician practices throughout the state of Michigan. As the MPTCQ Coordinating Center, Michigan Medicine established an infrastructure integrating clinical pharmacists into direct patient care within patient-centered medical home (PCMH) practices and provides direction and guidance for quality and process improvement across physician organizations (POs) and their affiliated physician practices. The primary goal of MPTCQ is to improve patient care and outcomes related to Medicare star ratings and HEDIS measures through integration of clinical pharmacists into direct patient care. The short-term goal is to adopt and modify Michigan Medicine's integrated pharmacist practice model at participating POs, with the long-term goal of developing a sustainable model of pharmacist integration at each PO to improve patient care and outcomes. Initially, pharmacists are delivering disease management (diabetes, hypertension, and hyperlipidemia) and comprehensive medication review services with future plans to expand clinical services. In 2015, 10 POs participated in year 1 of the program. In collaboration with the MPTCQ Coordinating Center, each PO identified 1 "pharmacist transformation champion" (PTC). The PTC implemented the integrated pharmacist model at 2 or 3 practice sites with at least 2 practicing physicians per site. MPTCQ is a unique collaboration between a large academic institution, physician organizations, a payer, and a statewide coordinating center to improve patient care and address medication-related challenges by integrating pharmacists into a PCMH network. Pharmacists can actively provide their medication expertise to physicians and patients and optimize quality measure performance. This project was funded by Blue Cross Blue Shield of Michigan. Choe and Spahlinger are employees of Michigan Medicine. Tungol Lin, Kobernik, Cohen, Qureshi, Leyden, and Darland are employees of Blue Cross Blue Shield of Michigan. At the time of manuscript preparation, Share and Wesolowicz were employees of Blue Cross Blue Shield of Michigan. Study concept and design were primarily contributed by Choe, along with the other authors. Choe, Tungol Lin, and Kobernik collected data, and data interpretation was performed by Choe, Tungol Lin, Cohen, and Wesolowicz. The manuscript was written primarily by Choe, along with Tungol Lin and assisted by Kobernik, Cohen, Leyden, and Qureshi. The manuscript was revised by Leyden, Spahlinger, Share, and Darland. Material from this manuscript was previously presented as an education session at the 2016 AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 19-22, 2016; San Francisco, California.

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.

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.

Contact With Mental Health and Primary Care Providers Before Suicide: A Review of the Evidence

PubMed Central

Luoma, Jason B.; Martin, Catherine E.; Pearson, Jane L.

2016-01-01

Objective This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide. Method The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects. Results Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults. Conclusions While it is not known to what degree contact with mental health care and primary care providers can prevent suicide, the majority of individuals who die by suicide do make contact with primary care providers, particularly older adults. Given that this pattern is consistent with overall health-service-seeking, alternate approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men. PMID:12042175

Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics

PubMed Central

Liu, Chuan-Fen; Chapko, Michael; Bryson, Chris L; Burgess, James F; Fortney, John C; Perkins, Mark; Sharp, Nancy D; Maciejewski, Matthew L

2010-01-01

Objective To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. Data Sources/Study Setting VA administrative and Medicare claims data from 2001 to 2004. Study Design Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. Principal Findings A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3–4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). Conclusions Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care. PMID:20831716

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

Can managed care plans control health care costs?

PubMed

Zwanziger, J; Melnick, G A

1996-01-01

The health insurance sector has been transformed in the past fifteen years, with managed care replacing indemnity insurance as the norm. This transformation was intended to change the nature of competition in the health care system so that market forces could be used to control costs. Empirical studies have shown that this objective has been met, as areas with high managed care penetration have tended to have much lower rates of increase in their costs. Creating a more efficient health care system will require additional efforts to produce useful measures of quality and to maintain competitive markets.

Health Care Transformation: A Strategy Rooted in Data and Analytics.

PubMed

Koster, John; Stewart, Elizabeth; Kolker, Eugene

2016-02-01

Today's consumers purchasing any product or service are armed with information and have high expectations. They expect service providers and payers to know about their unique needs. Data-driven decisions can help organizations meet those expectations and fulfill those needs.Health care, however, is not strictly a retail relationship-the sacred trust between patient and doctor, the clinician-patient relationship, must be preserved. The opportunities and challenges created by the digitization of health care are at the crux of the most crucial strategic decisions for academic medicine. A transformational vision grounded in data and analytics must guide health care decisions and actions.In this Commentary, the authors describe three examples of the transformational force of data and analytics to improve health care in order to focus attention on academic medicine's vital role in guiding the needed changes.

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

Primary care characteristics and their association with health screening in a low-socioeconomic status public rental-flat population in Singapore- a mixed methods study.

PubMed

Wee, Liang En; Cher, Wen Qi; Sin, David; Li, Zong Chen; Koh, Gerald Choon-Huat

2016-02-06

In Singapore, subsidized primary care is provided by centralized polyclinics; since 2000, policies have allowed lower-income Singaporeans to utilize subsidies at private general-practitioner (GP) clinics. We sought to determine whether proximity to primary care, subsidised primary care, or having regular primary care associated with health screening participation in a low socioeconomic-status public rental-flat community in Singapore. From 2009-2014, residents in five public rental-flat enclaves (N = 936) and neighboring owner-occupied precincts (N = 1060) were assessed for participation in cardiovascular and cancer screening. We then evaluated whether proximity to primary care, subsidised primary care, or having regular primary care associated with improved adherence to health screening. We also investigated attitudes to health screening using qualitative methodology. In the rental flat population, for cardiovascular screening, regular primary care was independently associated with regular diabetes screening (adjusted odds ratio, aOR = 1.59, CI = 1.12-2.26, p = 0.009) and hyperlipidemia screening (aOR = 1.82, CI = 1.10-3.04, p = 0.023). In the owner-occupied flats, regular primary care was independently associated with regular hypertension screening (aOR = 9.34 (1.82-47.85, p = 0.007), while subsidized primary care was associated with regular diabetes screening (aOR = 2.94, CI = 1.04-8.31, p = 0.042). For cancer screening, in the rental flat population, proximity to primary care was associated with less participation in regular colorectal cancer screening (aOR = 0.42, CI = 0.17-0.99, p = 0.049) and breast cancer screening (aOR = 0.29, CI = 0.10-0.84, p = 0.023). In the owner-occupied flat population, for gynecological cancer screening, usage of subsidized primary care and proximity to primary care was associated with higher rates of breast cancer and cervical cancer screening; however, being on regular primary care followup was associated with lower rates of mammography (aOR = 0.10, CI = 0.01-0.75, p = 0.025). On qualitative analysis, patients were discouraged from screening by distrust in the doctor-patient relationship; for cancer screening in particular, patients were discouraged by potential embarrassment. Regular primary care was independently associated with regular participation in cardiovascular screening in both low-SES and higher-SES communities. However, for cancer screening, in the low-SES community, proximity to primary care was associated with less participation in regular screening, while in the higher-SES community, regular primary care was associated with lower screening participation; possibly due to embarrassment regarding screening modalities.

Minding the Gap: Factors Associated With Primary Care Coordination of Adults in 11 Countries.

PubMed

Penm, Jonathan; MacKinnon, Neil J; Strakowski, Stephen M; Ying, Jun; Doty, Michelle M

2017-03-01

Care coordination has been identified as a key strategy in improving the effectiveness, safety, and efficiency of the US health care system. Our objective was to determine whether population or health care system issues are associated with primary care coordination gaps in the United States and other high-income countries. We analyzed data from the 2013 Commonwealth Fund International Health Policy (IHP) survey with multivariate logistic regression analysis. Respondents were adult primary care patients from 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and the United States. Poor primary care coordination was defined as participants reporting at least 3 gaps in the coordination of care out of a maximum of 5. Analyses were based on 13,958 respondents. The rate of poor primary care coordination was 5.2% (724/13,958 respondents) overall and highest in the United States, at 9.8% (137/1,395 respondents). Multivariate regression analysis among all respondents found that they were less likely to experience poor primary care coordination if their primary care physician often or always knew their medical history, spent sufficient time, involved them, and explained things well (odds ratio = 0.6 for each). Poor primary care coordination was more likely to occur among patients with chronic conditions (odds ratios = 1.4-2.1 depending on number) and patients younger than 65 years (odds ratios = 1.6-2.3 depending on age-group). Among US respondents, insurance status, health status, household income, and sex were not associated with poor primary care coordination. The United States had the highest rate of poor primary care coordination among the 11 high-income countries evaluated. An established relationship with a primary care physician was significantly associated with better care coordination, whereas being chronically ill or younger was associated with poorer care coordination. © 2017 Annals of Family Medicine, Inc.

Minding the Gap: Factors Associated With Primary Care Coordination of Adults in 11 Countries

PubMed Central

Penm, Jonathan; MacKinnon, Neil J.; Strakowski, Stephen M.; Ying, Jun; Doty, Michelle M.

2017-01-01

PURPOSE Care coordination has been identified as a key strategy in improving the effectiveness, safety, and efficiency of the US health care system. Our objective was to determine whether population or health care system issues are associated with primary care coordination gaps in the United States and other high-income countries. METHODS We analyzed data from the 2013 Commonwealth Fund International Health Policy (IHP) survey with multivariate logistic regression analysis. Respondents were adult primary care patients from 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and the United States. Poor primary care coordination was defined as participants reporting at least 3 gaps in the coordination of care out of a maximum of 5. RESULTS Analyses were based on 13,958 respondents. The rate of poor primary care coordination was 5.2% (724/13,958 respondents) overall and highest in the United States, at 9.8% (137/1,395 respondents). Multivariate regression analysis among all respondents found that they were less likely to experience poor primary care coordination if their primary care physician often or always knew their medical history, spent sufficient time, involved them, and explained things well (odds ratio = 0.6 for each). Poor primary care coordination was more likely to occur among patients with chronic conditions (odds ratios = 1.4–2.1 depending on number) and patients younger than 65 years (odds ratios = 1.6–2.3 depending on age-group). Among US respondents, insurance status, health status, household income, and sex were not associated with poor primary care coordination. CONCLUSIONS The United States had the highest rate of poor primary care coordination among the 11 high-income countries evaluated. An established relationship with a primary care physician was significantly associated with better care coordination, whereas being chronically ill or younger was associated with poorer care coordination. PMID:28289109

Chronic Myeloproliferative Neoplasms: a Collaborative Approach

PubMed Central

Pieri, Lisa; Guglielmelli, Paola; Vannucchi, Alessandro M.

2010-01-01

The classic chronic myeloproliferative neoplasms (MPN) include different entities that pose significant challenges for their optimal diagnosis, treatment and overall management. Polycythemia Vera and Essential Thrombocythemia are the most common among chronic myeloproliferative neoplasms (MPNs); major causes of morbidity and mortality are represented by arterial and venous thrombosis, as well as evolution to myelofibrosis or transformation to acute leukemia. However, survival is only minimally affected. Therapy aims at reducing the rate of thrombosis without increasing the risk of hematologic transformation which could be caused by exposure to cytotoxic drugs. On the other hand, survival is significantly reduced in primary myelofibrosis, and the clinical manifestations may be disabling. In the absence of therapies with the potential of curing the disease, a careful risk-oriented approach is employed for stratifying patients to the most appropriate, currently available, therapeutic options. In this brief review, we will discuss some of the key issues that can arise along the clinical course of MPNs and require an integrated, strictly patient-oriented, approach. PMID:21415968

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions.

PubMed

McAlister, Finlay A; Bakal, Jeffrey A; Green, Lee; Bahler, Brad; Lewanczuk, Richard

2018-03-12

Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. Adults receiving care within a primary care network ( n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care ( n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96-0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93-0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03-1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07-1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. Care within a primary care network was associated with fewer emergency department visits and fewer hospital days. © 2018 Joule Inc. or its licensors.

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions

PubMed Central

Bakal, Jeffrey A.; Green, Lee; Bahler, Brad; Lewanczuk, Richard

2018-01-01

BACKGROUND: Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. METHODS: We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. RESULTS: Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96–0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93–0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03–1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07–1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. INTERPRETATION: Care within a primary care network was associated with fewer emergency department visits and fewer hospital days. PMID:29530868

Effectiveness of Problem-Solving Therapy for Older, Primary Care Patients with Depression: Results from the IMPACT Project

ERIC Educational Resources Information Center

Arean, Patricia; Hegel, Mark; Vannoy, Steven; Fan, Ming-Yu; Unuzter, Jurgen

2008-01-01

Purpose: We compared a primary-care-based psychotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psychotherapy in treating late-life major depression and dysthymia. Design and Methods: The data here are from the IMPACT study, which compared collaborative care within a primary care clinic to care as usual in…

Education in the Wake of Healthcare Reform: Increasing Primary Care Usage by Individuals Currently Reliant upon Emergency Departments for Care

ERIC Educational Resources Information Center

Tannebaum, Michael; Wilkin, Holley A.; Keys, Jobia

2014-01-01

Background: The Affordable Care Act (ACA) was introduced, in part, to increase access to primary care, which has been shown to provide patients with myriad health benefits. Objective: To increase primary care usage by understanding the beliefs about primary and emergency care most salient to those whose healthcare-seeking practices may be impacted…

The leadership labyrinth: leveraging the talents of women to transform health care.

PubMed

McDonagh, Kathryn J; Paris, Nancy M

2013-01-01

Women have had a transformative influence on the health care field as highly effective leaders known to produce superior results. Women make up the vast majority of the health care workforce as well as health care graduates. Women also make most health care decisions on behalf of their families. Yet, despite this omnipresence in health care, there is a dearth of women in chief executive and governance roles. A lack of leadership development and succession planning in health care and other obstacles to career progression make it challenging for women to advance to top leadership levels. The traditional linear career ladder that has existed in health care is not conducive to women's advancement. Women have taken a different pathway to career development referred to as the leadership labyrinth. This is a development process leading to wisdom and insights essential for today's health care challenges. This crucial stage in the evolution of health care calls for new models of care and leadership. The most abundant resource at risk of being overlooked is the optimal engagement of women. Women leaders are the backbone of the health care workforce but have yet to be strategically deployed in key leadership positions. The talents of women leaders can be a significant factor in the transformation of health care.

Interventions for prevention of childhood obesity in primary care: a qualitative study

PubMed Central

Bourgeois, Nicole; Brauer, Paula; Simpson, Janis Randall; Kim, Susie; Haines, Jess

2016-01-01

Background: Preventing childhood obesity is a public health priority, and primary care is an important setting for early intervention. Authors of a recent national guideline have identified a need for effective primary care interventions for obesity prevention and that parent perspectives on interventions are notably absent from the literature. Our objective was to determine the perspectives of primary care clinicians and parents of children 2-5 years of age on the implementation of an obesity prevention intervention within team-based primary care to inform intervention implementation. Methods: We conducted focus groups with interprofessional primary care clinicians (n = 40) and interviews with parents (n = 26). Participants were asked about facilitators and barriers to, and recommendations for implementing a prevention program in primary care. Data were recorded and transcribed, and we used directed content analysis to identify major themes. Results: Barriers existed to addressing obesity-related behaviours in this age group and included a gap in well-child primary care between ages 18 months and 4-5 years, lack of time and sensitivity of the topic. Trust and existing relationships with primary care clinicians were facilitators to program implementation. Offering separate programs for parents and children, and addressing both general parenting topics and obesity-related behaviours were identified as desirable. Interpretation: Despite barriers to addressing obesity-related behaviours within well-child primary care, both clinicians and parents expressed interest in interventions in primary care settings. Next steps should include pilot studies to identify feasible strategies for intervention implementation. PMID:27398363

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.

Ozonation of the oxybenzone, octinoxate, and octocrylene UV-filters: Reaction kinetics, absorbance characteristics, and transformation products.

PubMed

Hopkins, Zachary R; Snowberger, Sebastian; Blaney, Lee

2017-09-15

UV-filters (UVFs) are active ingredients in personal care products that protect skin from exposure to UV light. Environmentally-relevant concentrations of UVFs have recently been linked to toxicity in aquatic organisms, necessitating research into improved UVF removal in water/wastewater treatment. Here, we investigated ozonation of the three most commonly employed UVFs: octinoxate (OMC), octocrylene (OC), and oxybenzone (OXY). Specific second-order rate constants for UVF reaction with ozone were identified as follows: OMC, 5.25×10 4 M -1 s -1 ; OC, 1.58M -1 s -1 ; OXY (neutral), 3.80×10 2 M -1 s -1 ; and, OXY (anion), 1.51×10 6 M -1 s -1 . These kinetic parameters indicated that OMC and OXY undergo significant (2-log or greater) transformation for typical ozone exposures in disinfection processes; however, minimal oxidation is expected for OC. UV absorbance mapping was employed to characterize the loss of UVF activity (i.e., absorbance across the UV-A, UV-B, and UV-C ranges) during ozonation. These 4-dimensional maps also confirmed ozone attack mechanisms, namely reaction at phenolate (OXY) and olefin (OMC, OC) groups. Primary transformation products from these reactions were identified for all three UVFs of concern. For OC and OXY, the benzophenone structure is conserved, suggesting that transformation products retain toxicity concerns. Copyright © 2017 Elsevier B.V. All rights reserved.

Enhancing success in transition service coordinators: use of transformational leadership.

PubMed

Rearick, Ellen

2007-01-01

The lifespan of children with special healthcare needs has been extended because of improved technology and medical advances. Successful transition to the adult arena of healthcare, social services, and education by adolescents with special healthcare needs (ASHCN) is lacking. The transition service coordinator (TSC) is a multifaceted role of advanced practice nursing that provides highly specialized transition services to adolescents with special healthcare needs. The use of key concepts from the transformational leadership theory may improve healthcare outcomes. This article applies to pediatric and adult primary care and case management services that serve adolescents with special healthcare needs. Employing key concepts of transformational leadership theory will enhance the success of the TSC to improve both collaboration among stakeholders in the transitional team and young adults' transition to the world of adult services. Enhanced communication resulting in improved sharing of information, understanding of the stakeholder roles, and provision of formal linkages between pediatric and adult medical providers is a significant outcome affecting the ASHCN. Improved collaboration will produce a smooth transition for the ASHCN to the world of adult social services education, and employment. Incorporating the transformational leadership dimensions of idealized influence, inspirational motivation intellectual stimulation, and individualized consideration will enhance the ability of the TSC to improve collaboration among stakeholders in the transitional team and the quality of services for the ASHCN.

Joint principles: Integrating behavioral health care into the patient-centered medical home.

PubMed

2014-06-01

The Patient-centered Medical Home (PCMH) is an innovative, improved, and evolving approach to providing primary care that has gained broad acceptance in the United States. The Joint Principles of the PCMH, formulated and endorsed in February 2007, are sound and describe the ideal toward which we aspire. However, there is an element running implicitly through these joint principles that is difficult to achieve yet indispensable to the success of the entire PCMH concept. The incorporation of behavioral health care has not always been included as practices transform to accommodate to the PCMH ideals. This is an alarming development because the PCMH will be incomplete and ineffective without the full incorporation of this element, and retrofitting will be much more difficult than prospectively integrating into the original design of the PCMH. Therefore we offer a complementary set of joint principles that recognizes the centrality of behavioral health care as part of the PCMH. This document follows the order and language of the original joint principles while emphasizing what needs to be addressed to insure incorporation of the essential behavioral elements. It is intended to supplement and not replace the original Joint Principles document, which still stands.

Early appraisal of China's huge and complex health-care reforms.

PubMed

Yip, Winnie Chi-Man; Hsiao, William C; Chen, Wen; Hu, Shanlian; Ma, Jin; Maynard, Alan

2012-03-03

China's 3 year, CN¥850 billion (US$125 billion) reform plan, launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by 2020. The government's undertaking of systemic reform and its affirmation of its role in financing health care together with priorities for prevention, primary care, and redistribution of finance and human resources to poor regions are positive developments. Accomplishing nearly universal insurance coverage in such a short time is commendable. However, transformation of money and insurance coverage into cost-effective services is difficult when delivery of health care is hindered by waste, inefficiencies, poor quality of services, and scarcity and maldistribution of the qualified workforce. China must reform its incentive structures for providers, improve governance of public hospitals, and institute a stronger regulatory system, but these changes have been slowed by opposition from stakeholders and lack of implementation capacity. The pace of reform should be moderated to allow service providers to develop absorptive capacity. Independent, outcome-based monitoring and evaluation by a third-party are essential for mid-course correction of the plans and to make officials and providers accountable. Copyright © 2012 Elsevier Ltd. All rights reserved.

Perspective: united we stand, divided we fall: the case for a single primary care specialty in the United States.

PubMed

Halvorsen, John G

2008-05-01

Primary care as an academic discipline and key component of the U.S. health care system faces a threatened future, despite numerous studies in the United States and cross-nationally that substantiate its health-promoting benefits. The United States remains the only Western industrialized nation that delivers primary care through three major disciplines rather than as a single specialty. This fragmented model may contribute to the fact that the United States does not have a primary-care-based health care system and that the U.S. population demonstrates poorer health outcomes than do those countries whose health systems are based on primary care and managed by a single primary care specialty. Fragmentation also creates confusion about primary care's identity, diminishes its influence because it does not speak with a common voice, and creates competition for academic and professional status, resources, curricular priority, research and training program funding, patients, and reimbursement. A large, single-specialty body of primary physicians could eliminate much duplication and competition and demonstrate greater political influence with academia, government agencies, insurers, and corporate America. A single specialty that incorporates the strengths of the three primary care disciplines would expand the clinical scope of primary care and could serve as a potent enabling force to lead health system reform. It would also produce measurable benefits for medical student and graduate medical education, health system design and service delivery, and primary care research. The author outlines a plan of action, involving all stakeholders, to initiate and achieve the single-specialty goal.

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.

Factors associated with final year nursing students' desire to work in the primary health care setting: Findings from a national cross-sectional survey.

PubMed

Bloomfield, Jacqueline G; Aggar, Christina; Thomas, Tamsin H T; Gordon, Christopher J

2018-02-01

Registered nurses are under-represented in the primary health care setting both internationally and in Australia, and this shortage is predicted to worsen. To address the increasingly complex healthcare needs of an ageing population, it is vital to develop and sustain a primary health care nursing workforce, yet attracting nurses is challenging. In Australia, registered nurses graduating from university typically commence their careers in hospital-based transition to professional practice programs. Similar programs in primary health care settings may be a valuable strategy for developing the primary health care nursing workforce, yet little is known about nursing students desire to work in this setting, factors that influence this, or their expectations of primary health care-focused transition to professional practice programs. This study sought to identify factors associated with final year nursing students' desire to work in primary health care setting including demographic factors, expectations of future employment conditions, and job content. It also explored expectations of graduate transition programs based in primary health care. A cross-sectional survey design comprising a quantitative online survey. 14 Australian universities from all states/territories, both rural and urban. 530 final-year nursing students. Binary logistic regression identifying factors contributing to desire to work in primary health care. The desire of nursing students to work in primary health care is associated with older age, greater perceived value of employment conditions including flexibility, and less perceived importance of workplace support. Collaborative efforts from primary health care nurses, health professionals, academics and policy makers are needed to attract new graduate nurses to primary health care. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

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 provider, primary care is increasingly teamwork, and the role of nurses and other (new) professions in primary care is developing constantly. The composition and coordination of teams are two components of one of the major complexities to address: how to provide individualised care with standardisation at organisation the level. (Lack of) Coordination with specialist care remains a widespread problem and needs attention from policy makers and practitioners alike. Alignment with home care and social services remains a challenge in all countries, not least because of the different funding arrangements between the services. Further priorities for research and development are summarised.

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.

Comparing Quality of Public Primary Care between Hong Kong and Shanghai Using Validated Patient Assessment Tools

PubMed Central

Wei, Xiaolin; Li, Haitao; Yang, Nan; Wong, Samuel Y. S.; Owolabi, Onikepe; Xu, Jianguang; Shi, Leiyu; Tang, Jinling; Li, Donald; Griffiths, Sian M.

2015-01-01

Objectives Primary care is the key element of health reform in China. The objective of this study was to compare patient assessed quality of public primary care between Hong Kong, a city with established primary care environment influenced by its colonial history, and Shanghai, a city leading primary care reform in Mainland China; and to measure the equity of care in the two cities. Methods Cross sectional stratified random sampling surveys were conducted in 2011. Data were collected from 1,994 respondents in Hong Kong and 811 respondents in Shanghai. A validated Chinese version of the primary care assessment tool was employed to assess perceived quality of primary care with respect to socioeconomic characteristics and health status. Results We analyzed 391 and 725 respondents in Hong Kong and Shanghai, respectively, who were regular public primary care users. Respondents in Hong Kong reported significant lower scores in first contact accessibility (1.59 vs. 2.15), continuity of care (2.33 vs. 3.10), coordination of information (2.84 vs. 3.64), comprehensiveness service availability (2.43 vs. 3.31), comprehensiveness service provided (2.11 vs. 2.40), and the total score (23.40 vs. 27.40), but higher scores in first contact utilization (3.15 vs. 2.54) and coordination of services (2.67 vs. 2.40) when compared with those in Shanghai. Respondents with higher income reported a significantly higher total primary care score in Hong Kong, but not in Shanghai. Conclusions Respondents in Shanghai reported better quality of public primary care than those in Hong Kong, while quality of public primary care tended to be more equitable in Shanghai. PMID:25826616

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.

Transforming pedagogy in nursing education: a caring learning environment for adult students.

PubMed

Bankert, Esther G; Kozel, Victoria V

2005-01-01

This article is an account of a project involving nursing faculty and adult learners. Their purpose was to generate interactive and collaborative pedagogies. Reflection and dialogue were used to explore how the educational experience can be transformed into an engaging and caring learning environment for adult students. Principles derived from humanistic nursing and caring, reflection, and teaching and learning guided this project.

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.

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

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.

Integrated primary care: patient perceptions and the role of mental health stigma.

PubMed

Miller-Matero, Lisa R; Khan, Shehryar; Thiem, Rachel; DeHondt, Tiffany; Dubaybo, Hala; Moore, Daniel

2018-06-19

Some patients are more willing to see a behavioral health provider within primary care. The purpose of this study was to evaluate the patients' perspectives of having access to a psychologist within primary care and to investigate whether mental health stigma affected preferences. In total, 36 patients completed questionnaires after seeing a psychologist in primary care. Patients were satisfied with having a primary care psychologist involved in their care. Most patients were more likely to see the psychologist in primary care and those who preferred this indicated higher levels of mental health stigma. The overarching theme for why patients saw a psychologist in primary care was convenience. Mental health stigma may also have played a role. Results suggest that providing integrated services may reach patients who may not have otherwise sought services in a behavioral health clinic. Findings from this study encourage the continued integration of behavioral health services.

Endurance, resistance and resilience in the South African health care system: case studies to demonstrate mechanisms of coping within a constrained system.

PubMed

Eyles, John; Harris, Bronwyn; Fried, Jana; Govender, Veloshnee; Munyewende, Pascalia

2015-09-29

South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system's realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients' narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.

Primary care teams in Ireland: a qualitative mapping review of Irish grey and published literature.

PubMed

O'Sullivan, M; Cullen, W; MacFarlane, A

2015-03-01

The Irish government published its primary care strategy, Primary Care: A New Direction in 2001. Progress with the implementation of Primary care teams is modest. The aim of this paper is to map the Irish grey literature and peer-reviewed publications to determine what research has been carried out in relation to primary care teams, the reform process and interdisciplinary working in primary care in Ireland. This scoping review employed three methods: a review of Web of Science, Medline and Embase databases, an email survey of researchers across academic institutions, the HSE and independent researchers and a review of Lenus and the Health Well repository. N = 123 outputs were identified. N = 14 were selected for inclusion. A thematic analysis was undertaken. Common themes identified were resources, GP participation, leadership, clarity regarding roles in primary care teams, skills and knowledge for primary care team working, communication and community. There is evidence of significant problems that disrupt team formation and functioning that warrants more comprehensive research.

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

Disease-specific clinical pathways - are they feasible in primary care? A mixed-methods study.

PubMed

Grimsmo, Anders; Løhre, Audhild; Røsstad, Tove; Gjerde, Ingunn; Heiberg, Ina; Steinsbekk, Aslak

2018-06-01

To explore the feasibility of disease-specific clinical pathways when used in primary care. A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. Primary care and specialist care collaborating to manage care coordination. Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care. In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.

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)

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.

Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT): the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT).

PubMed

Jeon, Ki-Yeob

2011-01-01

It is well known that countries with well-structured primary care have better health outcomes, better health equity and reduced healthcare costs. This study aimed to culturally modify and validate the US consumer form of the short Primary Care Assessment Tool (PCAT) in primary care in the Republic of Korea (hereafter referred to as Korea). The Korean consumer form of the short PCAT (KC PCAT) was cross-culturally modified from the original version using a standardised transcultural adaptation method. A pre-test version of the KC PCAT was formulated by replacement of four items and modification of a further four items from the 37 items of the original consumer form of the short PCAT at face value evaluation meetings. Pilot testing was done with a convenience sample of 15 responders at two different sites. Test-retest showed high reliability. To validate the KC PCAT, 606 clients participated in a survey carried out in Korea between February and May 2006. Internal consistency reliability, test-retest reliability and factor analysis were conducted in order to test validity. Psychometric testing was carried out on 37 items of the KC PCAT to make the KS PCAT which has 30 items and has seven principal domains: first contact utilisation, first contact accessibility, ongoing accountable care (ongoing care and coordinated rapport care), integrated care (patient-centred care with integration between primary and specialty care or between different specialties), comprehensive care, community-oriented care and culturally-oriented care. Component factors of the verified KS PCAT explained 58.28% of the total variance in the total item scores of primary care. The verified KS PCAT has been characterised by the seven classic domains of primary care with minor modifications. This may provide clues concerning differences in expectations for primary care in the Korean population as compared with that of the US. The KS PCAT is a reliable and valid tool for the evaluation of the quality of primary care in Korea. It will be used to identify any aspects of primary care linked to better or worse health outcomes, and to provide evidence-based evaluations of or recommendations for Korean healthcare policy. cross-cultural adaptation, Korean Standard Primary Care Assessment Tool, Primary Care Assessment Tool, quality of primary care.

Reflections from organization science on the development of primary health care research networks.

PubMed

Fenton, E; Harvey, J; Griffiths, F; Wild, A; Sturt, J

2001-10-01

In the UK, policy changes in primary health care research and development have led to the establishment of primary care research networks. These organizations aim to increase research culture, capacity and evidence base in primary care. As publicly funded bodies, these networks need to be accountable. Organizational science has studied network organizations including why and how they develop and how they function most effectively. This paper draws on organizational science to reflect on why primary care research networks appear to be appropriate for primary care research and how their structures and processes can best enable the achievement of their aims.

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.

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

Switching power supply

DOEpatents

Mihalka, A.M.

1984-06-05

The invention is a repratable capacitor charging, switching power supply. A ferrite transformer steps up a dc input. The transformer primary is in a full bridge configuration utilizing power MOSFETs as the bridge switches. The transformer secondary is fed into a high voltage, full wave rectifier whose output is connected directly to the energy storage capacitor. The transformer is designed to provide adequate leakage inductance to limit capacitor current. The MOSFETs are switched to the variable frequency from 20 to 50 kHz to charge a capacitor from 0.6 kV. The peak current in a transformer primary and secondary is controlled by increasing the pulse width as the capacitor charges. A digital ripple counter counts pulses and after a preselected desired number is reached an up-counter is clocked.

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.

A Nationwide Survey of Patient Centered Medical Home Demonstration Projects

PubMed Central

Bitton, Asaf; Martin, Carina

2010-01-01

Background The patient centered medical home has received considerable attention as a potential way to improve primary care quality and limit cost growth. Little information exists that systematically compares PCMH pilot projects across the country. Design Cross-sectional key-informant interviews. Participants Leaders from existing PCMH demonstration projects with external payment reform. Measurements We used a semi-structured interview tool with the following domains: project history, organization and participants, practice requirements and selection process, medical home recognition, payment structure, practice transformation, and evaluation design. Results A total of 26 demonstrations in 18 states were interviewed. Current demonstrations include over 14,000 physicians caring for nearly 5 million patients. A majority of demonstrations are single payer, and most utilize a three component payment model (traditional fee for service, per person per month fixed payments, and bonus performance payments). The median incremental revenue per physician per year was $22,834 (range $720 to $91,146). Two major practice transformation models were identified—consultative and implementation of the chronic care model. A majority of demonstrations did not have well-developed evaluation plans. Conclusion Current PCMH demonstration projects with external payment reform include large numbers of patients and physicians as well as a wide spectrum of implementation models. Key questions exist around the adequacy of current payment mechanisms and evaluation plans as public and policy interest in the PCMH model grows. Electronic supplementary material The online version of this article (doi:10.1007/s11606-010-1262-8) contains supplementary material, which is available to authorized users. PMID:20467907

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.

Possible Sources of Bias in Primary Care Electronic Health Record Data Use and Reuse.

PubMed

Verheij, Robert A; Curcin, Vasa; Delaney, Brendan C; McGilchrist, Mark M

2018-05-29

Enormous amounts of data are recorded routinely in health care as part of the care process, primarily for managing individual patient care. There are significant opportunities to use these data for other purposes, many of which would contribute to establishing a learning health system. This is particularly true for data recorded in primary care settings, as in many countries, these are the first place patients turn to for most health problems. In this paper, we discuss whether data that are recorded routinely as part of the health care process in primary care are actually fit to use for other purposes such as research and quality of health care indicators, how the original purpose may affect the extent to which the data are fit for another purpose, and the mechanisms behind these effects. In doing so, we want to identify possible sources of bias that are relevant for the use and reuse of these type of data. This paper is based on the authors' experience as users of electronic health records data, as general practitioners, health informatics experts, and health services researchers. It is a product of the discussions they had during the Translational Research and Patient Safety in Europe (TRANSFoRm) project, which was funded by the European Commission and sought to develop, pilot, and evaluate a core information architecture for the learning health system in Europe, based on primary care electronic health records. We first describe the different stages in the processing of electronic health record data, as well as the different purposes for which these data are used. Given the different data processing steps and purposes, we then discuss the possible mechanisms for each individual data processing step that can generate biased outcomes. We identified 13 possible sources of bias. Four of them are related to the organization of a health care system, whereas some are of a more technical nature. There are a substantial number of possible sources of bias; very little is known about the size and direction of their impact. However, anyone that uses or reuses data that were recorded as part of the health care process (such as researchers and clinicians) should be aware of the associated data collection process and environmental influences that can affect the quality of the data. Our stepwise, actor- and purpose-oriented approach may help to identify these possible sources of bias. Unless data quality issues are better understood and unless adequate controls are embedded throughout the data lifecycle, data-driven health care will not live up to its expectations. We need a data quality research agenda to devise the appropriate instruments needed to assess the magnitude of each of the possible sources of bias, and then start measuring their impact. The possible sources of bias described in this paper serve as a starting point for this research agenda. ©Robert A Verheij, Vasa Curcin, Brendan C Delaney, Mark M McGilchrist. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 29.05.2018.

Equations For Rotary Transformers

NASA Technical Reports Server (NTRS)

Salomon, Phil M.; Wiktor, Peter J.; Marchetto, Carl A.

1988-01-01

Equations derived for input impedance, input power, and ratio of secondary current to primary current of rotary transformer. Used for quick analysis of transformer designs. Circuit model commonly used in textbooks on theory of ac circuits.

Evaluation of Policy Options for Increasing the Availability of Primary Care Services in Rural Washington State.

PubMed

Friedberg, Mark W; Martsolf, Grant R; White, Chapin; Auerbach, David I; Kandrack, Ryan; Reid, Rachel O; Butcher, Emily; Yu, Hao; Hollands, Simon; Nie, Xiaoyu

2017-01-01

The Washington State legislature has recently considered several policy options to address a perceived shortage of primary care physicians in rural Washington. These policy options include opening the new Elson S. Floyd College of Medicine at Washington State University in 2017; increasing the number of primary care residency positions in the state; expanding educational loan-repayment incentives to encourage primary care physicians to practice in rural Washington; increasing Medicaid payment rates for primary care physicians in rural Washington; and encouraging the adoption of alternative models of primary care, such as medical homes and nurse-managed health centers, that reallocate work from physicians to nurse practitioners (NPs) and physician assistants (PAs). RAND Corporation researchers projected the effects that these and other policy options could have on the state's rural primary care workforce through 2025. They project a 7-percent decrease in the number of rural primary care physicians and a 5-percent decrease in the number of urban ones. None of the policy options modeled in this study, on its own, will offset this expected decrease by relying on physicians alone. However, combinations of these strategies or partial reallocation of rural primary care services to NPs and PAs via such new practice models as medical homes and nurse-managed health centers are plausible options for preserving the overall availability of primary care services in rural Washington through 2025.

Five keys to real transformation in health care.

PubMed

Senzon, Simon A

2011-11-01

Transformation in health care requires a deeply holistic approach. Natural leaders of such a transformation are the complementary and alternative medicine practitioners who already share a vision of wellness, prevention, and optimal human function. Central to this shared vision is lifestyle change for patients and practitioners. Yet, to change a lifestyle is to change a self. Assisting individuals to transform their very sense of self in order to live healthier, more fulfilling lives centered on flourishing requires several important keys. Visionary and unified leaders are the first key. Structural support through coordination of health clinics locally and nationally is the second key. This can be optimized by utilizing initiatives of the new Affordable Health Care Act, because it provides a potential impetus for deep structural changes. An expanded evidence base for multifactorial approaches to wellness lifestyles is the third key. A reorganizational orientation with an emphasis on the right timing of transformation is the fourth key. The fifth key is an Integral map, which brings together the personal, behavioral, cultural, and social domains. By utilizing such a map, one ensures that no aspect of the transformative revolution at hand slips away due to any misplaced focus, such as emphasizing only on the things we can see with our eyes. By embracing the essence of transformation in terms of a wholeness to all reality, an evolutionary unifying field with interior depth and exterior expression, health care is redefined more authentically. © Mary Ann Liebert, Inc.

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…

Analysis of the Concept of Primary Care for Children and Adolescents: A Policy Research Brief.

ERIC Educational Resources Information Center

Johansen, Anne S.; And Others

This document examines the 10 essential attributes of primary health care contained in the U.S. Maternal and Child Health Bureau's definition of primary care. Primary care for children and adolescents is personal health care delivered in the context of family, culture, and community; the range of services meets all but the most uncommon health…

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.

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.

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.

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 professionals in their research. Resources should be distributed equitably, taking into account demography, geography and the health needs of patients in Scotland. The strategy and its components must be seen as a whole. The Scottish School of Primary Care will stimulate and co-ordinate both research and training programmes. DRDPs will become research active and will participate in School-led training and research, and will contribute to research programmes. Comprehensive funding for training and career development will ensure that staff have the skills to participate in both DRDPs and in the School's activities. Thus, inadequate commitment to any one component of the strategy will mean that other components will be less successful. Commitment to all three components will maximise the chances of success.