It ‘makes you feel more like a person than a patient’: patients’ experiences receiving home‐based primary care (HBPC) in Ontario,Canada

The lack of effective systems to appropriately manage the health and social care of frail older adults – especially among those who become homebound – is becoming all the more apparent. Home‐based primary care (HBPC) is increasingly being promoted as a promising model that takes into account the accessibility needs of frail older adults, ensuring that they receive more appropriate primary and community care. There remains a paucity of literature exploring patients' experiences with HBPC programmes. The purpose of this study was to explore the experiences of patients accessing HBPC delivered by interprofessional teams, and their perspectives on the facilitators and barriers to this model of care in Ontario, Canada. Using certain grounded theory principles, we conducted an inductive qualitative content analysis of in‐depth patient interviews (n = 26) undertaken in the winter of 2013 across seven programme sites exploring the lived experiences and perspectives of participants receiving HBPC. Themes emerged in relation to patients' perceptions regarding the preference for and necessity of HBPC, the promotion of better patient care afforded by the model in comparison to office‐based care, and the benefits of and barriers to HBPC service provision. Underlying patterns also surfaced related to patients' feelings and emotions about their quality of life and satisfaction with HBPC services. We argue that HBPC is well positioned to serve frail homebound older adults, ensuring that patients receive appropriate primary and community care – which the office‐based alternative provides little guarantee – and that they will be cared for, pointing to a model that may not only lead to greater patient satisfaction but also likely contributes to bettering the quality of life of a highly vulnerable population.     

The Impact of Home-Based Primary Care on Outcomes Among Older Adults in South Korea

ObjectivesAlthough Korea issued a law and developed benefits of National Health Insurance (NHI) to enable the provision of home-based primary care (HBPC) along with implementation of a pilot project for community care for older adults in August 2019, the outcomes of HBPC services were not surveyed in Korea. This study aimed to assess the outcomes of HBPC among older adults.DesignAnalyses were conducted using data from the National Health Insurance Service in connection with administrative survey data. Difference-in-differences analysis was performed using a generalized estimating equation and Cox proportional hazards model.Setting and ParticipantsOverall, 538 older adults who used HBPC services in a pilot project for community care and 2059 propensity score–matched older individuals who did not use HBPC services in Korea were included.MethodsThe length of home stay, total costs of NHI, hospitalizations, and admission to long-term care (LTC) facilities were measured as outcomes, and the outcomes of the participants were compared to those of the control group.ResultsThe findings indicated an increase of 8.3 days (95% CI 2.1-14.5) in the length of home stay and a reduction of US$1241 (95% CI −2342 to −139) in total costs of NHI among older adults who used HBPC services compared to the control group. The odds ratio for rates of hospitalization among older adults who utilized HBPC services was 0.77 (95% CI 0.60-0.98) and the hazard ratio for the admission of LTC facilities was 0.12 (95% CI 0.04-0.32) in comparison to the control group.Conclusions and ImplicationsThe HBPC intervention has resulted in an increased length of home stay and reduced total costs, hospitalizations, and admission to LTC facilities among Korean older adults. In the future, new HBPC models must be developed to provide interprofessional team–based HBPC services with a standardized protocol of service provision.     

Feasibility of using an alcohol-screening and health education system with older primary care patients

BACKGROUND: This study evaluated the feasibility of a combined alcohol-screening and health education system for elderly patients METHODS: The Computerized Alcohol-Related Problems Survey (CARPS) was evaluated in primary care practices among 106 current drinkers, 60 years and older. The CARPS contains (1) a self-administered screening survey; (2) software to scan or hand-enter survey responses; (3) software to process data and electronically generate reports of patients' drinking risks; (4) health education; and (5) a database useful for clinical and quality improvement purposes. RESULTS: Nearly all study participants were able to complete the CARPS while waiting for a prescheduled appointment with their physician. There were 44% of patients who were hazardous and 9% who were harmful drinkers. About 20% of men and 26% of women were binge drinkers. Most (85%) patients agreed that alcohol is an important topic, 67% reported learning new information, 78% had never discussed drinking with a physician, and 31% intended to do so. After reviewing CARPS data, physicians concluded that alcohol use in the elderly is an important quality improvement topic. CONCLUSIONS: Combined screening and health education systems appear feasible for use in practice if they deal with pertinent health problems such as alcohol use. Their data can encourage discussions between physicians and patients and might be used for quality improvement activities.     

Provision of Home-Based Primary Care to Individuals With Intellectual and/or Developmental Disability Is Associated With a Lower Hospitalization Rate Than a Traditional Primary Care Model

ObjectivesThe objective of this study was to determine if providing home-based primary care (HBPC) to individuals with intellectual and/or developmental disabilities (IDD) was associated with a lower hospitalization rate than a control group receiving traditional primary care.Design and InterventionIndividuals with IDD living in supported residential settings in Ohio were offered HBPC. Individuals electing HBPC made up the intervention group. Those who did not opt for HBPC continued to receive traditional primary care services and made up the control group. Hospitalizations were tracked in both groups.Setting and ParticipantsThe 757 study participants had IDD diagnoses and received residential support services throughout the study period.MethodsAnnualized hospitalization rate was determined in both groups and was compared using generalized estimating equations while controlling for patients’ age and hospitalization rate in the year prior to the study.ResultsThe results showed that group membership had a significant effect on the hospitalization rate (Wald χ² = 20.71, P < .01). Being in the control group was associated with a 2.12-fold increase in annual hospitalization rate for a given patient. The overall population hospitalization rate was 329 hospitalizations per 1000 per year in the HBPC-receiving individuals and 619 hospitalizations per 1000 per year in the control group.Conclusions and ImplicationsWe found that individuals with IDD receiving HBPC were hospitalized at a lower rate than a control group receiving traditional primary care. Expanding access to HBPC may be a worthwhile priority for organizations that support individuals with IDD.     

Home-based primary care in the VA setting, with a focus on Birmingham, Alabama

The Veterans Administration Hospital-Based Home Care Program provides comprehensive primary care to homebound veterans. Unlike Medicare-funded home care, it is not oriented to episodic provision of skilled nursing care, but rather to long-term primary care in the home. The interdisciplinary composition of HBPC teams allows for innovative approaches to care and coordinated implementation of treatment plans. Outcomes assessment of care provided through HBPC has been positive, suggesting an overall improvement in function and decrease in health care costs among those using the HBPC Program. The HBPC Program offers a tested model of primary home care within a "managed care" model. Its positive features should be considered by those initiating managed primary home care within the private sector.     

Preconception Healthcare: What Women Know and Believe

Objectives: The objectives of this study were to determine if women realize the importance of optimizing their health prior to a pregnancy, whether the pregnancy is planned or not; and to evaluate their knowledge level and beliefs about preconception healthcare. Additionally, we sought to understand how and when women wanted to receive information on preconception health. Methods: A survey study was performed using consecutive patients presenting to primary care practices for an annual well-woman exam. Patients were recruited based on appointment type and willingness to complete the survey at the time of their appointment, but prior to being seen by the physician. Results: A total of 499 women completed the survey. Nearly all women (98.6%) realized the importance of optimizing their health prior to a pregnancy, and realized the best time to receive information about preconception health is before conception. The vast majority of patients surveyed (95.3%) preferred to receive information about preconception health from their primary care physician. Only 39% of women could recall their physician ever discussing this topic. The population studied revealed some significant knowledge deficiencies about factors that may threaten the health of mother or fetus. Conclusions: A majority of women do understand the importance of optimizing their health prior to conception, and look to their Primary care physician as their preferred source for such information. Study participants demonstrated deficiencies in their knowledge of risk factors that impact maternal and fetal health suggesting that physicians are not addressing preconception healthcare during routine care.     

Occupational Justice as a Quality Indicator for Occupational Therapy Services

ABSTRACT

Although a key concept in occupational therapy theoretical documents, the issue of occupational justice continues to be elusive to the everyday practitioner. The purpose of this article is to outline a quality improvement project focused on the incorporation of occupational justice concepts into daily treatment. For the purposes of this quality improvement project, occupational justice was explored through practitioners' perceptions of clients' preparation to face societal, physical, and political barriers based on the occupational therapy services they received. Project participants were able to identify current utilization of these concepts, barriers to utilizing concepts, and potential avenues for incorporation of occupational justice into daily practice. This project demonstrates that quality improvement activities, driven by practitioners providing direct care, can enrich occupational therapy programs and lead to the inclusion of social justice practices in occupational therapy services.     

Factors Associated With Hospitalization by Veterans in Home-Based Primary Care

ObjectivesThis study examined the extent to which program site-based and Veteran characteristics were associated with potentially avoidable hospitalizations or other hospitalization of Veterans enrolled in the Veterans Affairs (VA) Home-Based Primary Care (HBPC).DesignRetrospective claims-based study.Setting and ParticipantsHBPC programs that responded to a national survey of HBPC programs (n = 189) in fiscal year (FY) 2016 were studied. Veterans in the analysis cohort were identified as having been enrolled in VA-HBPC in FY2016 who had not received care by VA-HBPC within 1 year prior to their first HBPC enrollment in FY2016 (N = 8497).MethodsMultinomial logistic regression analysis with 5 outcome categories within the 6 months following the first HBPC enrollment date: (1) any potentially avoidable hospitalizations for ambulatory care–sensitive conditions (ACSC) as identified by AHRQ Prevention Quality Indicator (PQI), (2) any other hospitalizations for non-ACSC conditions, (3) died during study period, (4) discharged from HBPC, or (5) remained at home with HBPC. Average marginal effects (AME) of veteran-level and VA-HBPC-level covariates are reported for each of the outcome categories.ResultsMore frail Veterans and Veterans 85 years old or older were more likely to have potentially preventable ACSC hospitalizations (AME = 5.4%, 1.8%, respectively). Veterans who were younger than 75 years, functionally impaired, bed-bound, or frail were more likely to have non-ACSC hospitalization (AME = 3.0%, 2.2%, 3.5%, and 9.0%, respectively). Veterans with low frailty index scores were less likely to have non-ACSC hospitalizations (AME = ?17.1%). Six-month hospitalization patterns were not associated with reported HBPC site characteristics.Conclusions and ImplicationsWithin the framework of the national VA HBPC program, variations in the structural model used at HBPC sites are not significantly associated with hospitalizations. Tailoring of HBPC care, based on individual patient factors and clinical judgment rather than standard protocols, may be central to the success of HBPC in reducing ACSC hospitalizations.     

Sustained Improvement in Pediatricians' ADHD Practice Behaviors in the Context of a Community-Based Quality Improvement Initiative

The long-term sustainability of a quality improvement project was examined. The ADHD Collaborative was designed to assist community-based pediatricians in adhering to the American Academy of Pediatrics evidence-based assessment and treatment guidelines for attention deficit hyperactivity disorder (ADHD). Patient chart reviews were completed out to 2 years post training for 14 practices (N = 38 pediatricians), who received the ADHD Collaborative intervention to assess whether improvements made immediately post training were sustained. Pediatricians maintained significant improvements in their use of evidence-based assessment and treatment practices for a period of 2 years. The majority of the improvements occurred quickly, within 6 months of training. Pediatricians focused most of their continuous quality improvement (CQI) efforts on improving follow-up care for their patients with ADHD. Systematic monitoring and follow up of ADHD patients who were prescribed medication improved considerably from pre-training (10%) to 6 months (49%), and pediatricians continued to make gradual improvements in follow-up care (62% at the 2-year follow up). Systematic intervention efforts with a focus on CQI are effective at improving and sustaining quality of ADHD care. More work is needed to determine how to disseminate, support, and deliver this and similar intervention models to the many physicians who may benefit.     

You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital

The majority of dying patients continue to receive care in acute, tertiary settings. This has generated the development of hospital-based palliative care (HBPC). The Symptom Management and Palliative Care Program (SMPCP) at LAC+USC Medical Center provides HBPC. The SMPCP operates as an interdisciplinary consultative service, assessing inpatients, and documenting recommendations for primary physicians. Over a 28-month period the SMPCP provided clinical recommendations, education, and research for patients, family members, and hospital staff Demographic, clinical, psychosocial, financial, and outcome information was collected on 265 patients. The SMPCP documented the attainment of defined quality end-points, including pain control within 24 hours, a Do Not Resuscitate (DNR) discussion with patient and family within 72 hours, and control of nausea and vomiting within 24 hours. Team members also documented impediments to implementing recommendations and the success of interventions to overcome impediments. Results indicated that the SMPCP achieved a high rate of quality end-point attainment when impediments were not present. The most significant impediments resulted from behaviors by primary physicians. The SMPCP's ability to overcome barrier behaviors improved the rate of end-point attainment, confirming the importance of palliative care at the end of life.     

Clinical microsystems, part 2. Learning from micro practices about providing patients the care they want and need

BACKGROUND: Usual medical care in the United States is frequently not a satisfying experience for either patients or primary care physicians. Whether primary care can be saved and its quality improved is a subject of national concern. An increasing number of physicians are using microsystem principles to radically redesign their practices. Small, independent practices-micro practices-are often able to incorporate into a few people the frontline attributes of successful microsystems such as clear leadership, patient focus, process improvement, performance patterns, and information technology. PATIENT FOCUS, PROCESS IMPROVEMENT, AND PERFORMANCE PATTERNS: An exemplary microsystem will (1) have as its primary purpose a focus on the patient-a commitment to meet all patient needs; (2) make fundamental to its work the study, measurement, and improvement ofcare-a commitment to process improvement; and (3) routinely measure its patterns of performance, "feed back" the data, and make changes based on the data. LESSONS FROM MICRO PRACTICES: The literature and experience with micro practices suggest that they (1) constitute an important group in which to demonstrate the value of microsystem thinking; (2) can become very effective clinical microsystems; (3) can reduce their overhead costs to half that of larger freestanding practices, enabling them to spend more time working with their patients; (4) can develop new tools and approaches without going through layers of clearance; and (5) need not reinvent the wheel. CONCLUSIONS: Patient-reported data demonstrate how micro practices are using patient focus, process improvement, performance patterns, and information technology to improve performance. Pati ents should be able to report that they receive "exactly the care they want and need exactly when and how they want and need it."     

An appreciative inquiry approach to practice improvement and transformative change in health care settings

Amid tremendous changes and widespread dissatisfaction with the current health care system, many approaches to improve practice have emerged; however, their effects on quality of care have been disappointing. This article describes the application of a new approach to promote organizational improvement and transformation that is built upon collective goals and personal motivations, invites participation at all levels of the organization and connected community, and taps into latent creativity and energy. The essential elements of the appreciative inquiry (AI) process include identification of an appreciative topic and acting on this theme through 4 steps: Discovery, Dream, Design, and Destiny. We describe each step in detail and provide a case study example, drawn from a composite of practices, to highlight opportunities and challenges that may be encountered in applying AI. AI is a unique process that offers practice members an opportunity to reflect on the existing strengths within the practice, leads them to discover what is important, and builds a collective vision of the preferred future. New approaches such as AI have the potential to transform practices, improve patient care, and enhance individual and group motivation by changing the way participants think about, approach, and envision the future.     

Using primary-school children to improve child-rearing practices in rural Jamaica

Many children in Jamaica suffer from poor development, inadequate dental care and low immunization status. There is a need for low-cost innovative programmes to reach these children. We piloted an approach to teaching primary-school children basic child health and development concepts with the aim of improving their knowledge and practices and those of their guardians. The programme was conducted with 89 children from three grade levels in a remote rural school. The topic was taught throughout the school year with an action-oriented curriculum. Evaluation showed improvement in school children's knowledge and practices and guardians' knowledge. This approach is seen to be a feasible, low cost way of improving the quality of future child care.     

Quality improvement initiative in school-based health centers across new Mexico

BACKGROUND: Quality improvement principles have been applied extensively to health care organizations, but implementation of quality improvement methods in school‐based health centers (SBHCs) remains in a developmental stage with demonstration projects under way in individual states and nationally. Rural areas, such as New Mexico, benefit from the use of distance education techniques to reach providers throughout the state. METHODS: The Envision New Mexico (ENM) Quality Improvement Initiative involves training in quality improvement concepts and methods, identification of best practices for selected clinical services, and repeated use of data to measure changes leading to improvement. The ENM employs the Model for Improvement and the “Plan‐Do‐Study‐Act” tool, which enables providers to self‐evaluate, set goals, and assess results with their own data. RESULTS: Providers tend to overestimate their use of best practices. Contrasting these perceptions with findings from medical record reviews can provide impetus and focus for quality improvement through changes in specific clinical practices and management systems. Preliminary findings from New Mexico suggest that quality improvement interventions can be effective, with initial improvements over baseline reviews typically in the 20–40% range. CONCLUSION: Systematic efforts to enhance the quality of care can help improve both the effectiveness and efficiency of SBHCs, and provide evidence of the value of the care provided. Simple, efficient quality improvement techniques, with the use of distance learning technologies, can help achieve the full promise of expanded school‐based health care.     

Framing Reflexivity in Quality Improvement Devices in the Care for Older People

Health care organizations are constantly seeking ways to improve quality of care and one of the often-posed solutions to deliver ‘good care’ is reflexivity. Several authors stress that enhancing the organizations’ and caregivers’ reflexivity allows for more situated, and therefore better care. Within quality improvement initiatives, devices that guarantee quality are also seen as key to the delivery of good care. These devices do not solely aim at standardizing work practices, but are also of importance in facilitating reflexivity. In this article, we study how quality improvement devices position the relationship between situated reflection and standardization of work processes. By exploring the work of Michel Callon, Michael Lynch, and Lucy Suchman on reflexivity in work practices, we study the development and introduction of the Care Living Plan. This device aimed to transform care organizations of older people from their orientation towards the system of care into organizations that take a client-centred approach. Our analysis of the construction of specific forms of reflexivity in quality devices indicates that the question of reflexivity does not need to be opposed to standardization and needs to be addressed not only at the level of where reflexivity is organizationally situated and who gets to do the reflecting, but also on the content of reflexivity, such as what are the issues that care workers can and cannot reflect upon. In this paper we point out the theoretical importance of a more detailed empirical study of the framing of reflexivity in care practices.