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1.
Donna L. Washington Bevanne Bean-Mayberry Alison B. Hamilton Kristina M. Cordasco Elizabeth M. Yano 《Journal of general internal medicine》2013,28(2):571-576
BACKGROUND
The number of women Veterans (WVs) utilizing the Veterans Health Administration (VA) has doubled over the past decade, heightening the importance of understanding their healthcare delivery preferences and utilization patterns. Other studies have identified healthcare issues and behaviors of WVs in specific military service eras (e.g., Vietnam), but delivery preferences and utilization have not been examined within and across eras on a population basis.OBJECTIVE
To identify healthcare delivery preferences and healthcare use of WVs by military service era to inform program design and patient-centeredness.DESIGN AND PARTICIPANTS
Cross-sectional 2008–2009 survey of a nationally representative sample of 3,611 WVs, weighted to the population.MAIN MEASURES
Healthcare delivery preferences measured as importance of selected healthcare features; types of healthcare services and number of visits used; use of VA or non-VA; all by military service era.KEY RESULTS
Military service era differences were present in types of healthcare used, with World War II and Korea era WVs using more specialty care, and Vietnam era-to-present WVs using more women’s health and mental health care. Operations Enduring Freedom, Iraqi Freedom, New Dawn (OEF/OIF/OND) WVs made more healthcare visits than WVs of earlier military eras. The greatest healthcare delivery concerns were location convenience for Vietnam and earlier WVs, and cost for Gulf War 1 and OEF/OIF/OND WVs. Co-located gynecology with general healthcare was also rated important by a sizable proportion of WVs from all military service eras.CONCLUSIONS
Our findings point to the importance of ensuring access to specialty services closer to home for WVs, which may require technology-supported care. Younger WVs’ higher mental health care use reinforces the need for integration and coordination of primary care, reproductive health and mental health care.2.
Grant R. Martsolf Ryan Kandrack Robert A. Gabbay Mark W. Friedberg 《Journal of general internal medicine》2016,31(7):723-731
Background
Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments.Objectives
To estimate costs of transformation incurred by primary care practices participating in a medical home pilot.Design
We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes.Setting
The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot.Participants
Twelve practices that participated in the PACCI.Measurements
One-time and ongoing yearly costs attributed to medical home transformation.Results
Practices incurred median one-time transformation-associated costs of $30,991 per practice (range, $7694 to $117,810), equivalent to $9814 per clinician ($1497 to $57,476) and $8 per patient ($1 to $30). Median ongoing yearly costs associated with transformation were $147,573 per practice (range, $83,829 to $346,603), equivalent to $64,768 per clinician ($18,585 to $93,856) and $30 per patient ($8 to $136). Care management activities accounted for over 60% of practices’ transformation-associated costs. Per-clinician and per-patient transformation costs were greater for small and independent practices than for large and system-affiliated practices.Limitations
Error in interviewee recall could affect estimates. Transformation costs in other medical home interventions may be different.Conclusions
The costs of medical home transformation vary widely, creating potential financial challenges for primary care practices—especially those that are small and independent. Tailored subsidies from payers may help practices make these investments.Primary Funding Source
Agency for Healthcare Research and Quality3.
Background
Identifying patient-level and disease-specific predictors of healthcare utilization in inflammatory bowel disease (IBD) may allow targeted interventions to reduce costs and improve outcomes.Aim
To identify demographic and clinical predictors of healthcare utilization among veterans with IBD.Methods
We conducted a single-center cross-sectional study of veterans with IBD from 1998 to 2010. Demographics and disease characteristics were abstracted by manual chart review. Annual number of IBD-related visits was estimated by dividing total number of IBD-related inpatient and outpatient encounters by duration of IBD care. Associations between predictors of utilization were determined using stepwise multivariable linear regression.Results
Overall, 676 patients (56% ulcerative colitis (UC), 42% Crohn’s disease (CD), and 2% IBD unclassified (IBDU)) had mean 3.08 IBD-related encounters annually. CD patients had 3.59 encounters compared to 2.73 in UC (p < 0.01). In the multivariable model, Hispanics had less visits compared to Caucasians and African-Americans (2.09 vs. 3.09 vs. 3.42), current smokers had more visits than never smokers (3.54 vs. 2.43, p = 0.05), and first IBD visit at age <40 had more visits than age >65 (3.84 vs. 1.75, p = 0.04). UC pancolitis was associated with more visits than proctitis (3.47 vs. 2.15, p = 0.04). CD penetrating phenotype was associated with more encounters than inflammatory type (4.68 vs. 4.15, p = 0.04).Conclusions
We found that current tobacco use, age <40 at first IBD visit, UC pancolitis, and CD fistuilizing phenotype in addition to Caucasian and African-American race were independent predictors of increased healthcare utilization. Interventions should be targeted at these groups to decrease healthcare utilization and costs.4.
5.
Colin Buzza Sarah S. Ono Carolyn Turvey Stacy Wittrock Matt Noble Gautam Reddy Peter J. Kaboli Heather Schacht Reisinger 《Journal of general internal medicine》2011,26(2):648
Background
Distance to healthcare services is a known barrier to access. However, the degree to which distance is a barrier is not well described. Distance may impact different patients in different ways and be mediated by the context of medical need.Objective
Identify factors related to distance that impede access to care for rural veterans.Approach
Mixed-methods approach including surveys, in-depth interviews, and focus groups at 15 Veterans Health Administration (VHA) primary care clinics in 8 Midwestern states. Survey data were compiled and interviews transcribed and coded for thematic content.Participants
Surveys were completed by 96 patients and 88 providers/staff. In-depth interviews were completed by 42 patients and 64 providers/staff. A total of 7 focus groups were convened consisting of providers and staff.Key results
Distance was identified by patients, providers, and staff as the most important barrier for rural veterans seeking healthcare. In-depth interviews revealed specific examples of barriers to care such as long travel for common diagnostic services, routine specialty care, and emergency services. Patient factors compounding the impact of these barriers were health status, functional impairment, travel cost, and work or family obligations. Providers and staff reported challenges to healthcare delivery due to distance.Conclusions
Distance as a barrier to healthcare was not uniformly defined. Rather, its importance was relative to the health status and resources of patients, complexity of service provided, and urgency of service needed. Improved transportation, flexible fee-based services, more structured communication mechanisms, and integration with community resources will improve access to care and overall health status for rural veterans.6.
Joseph J. Gallo Seungyoung Hwang Jin Hui Joo Hillary R. Bogner Knashawn H. Morales Martha L. Bruce Charles F. ReynoldsIII 《Journal of general internal medicine》2016,31(4):380-386
Background
Two-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care.Objective
We evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity.Design
Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care.Patients
The sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline.Intervention
For 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence.Main Measures
Depression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index).Key Results
In the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95 % CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95 % CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk.Conclusions
Depression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.7.
Stefan G. Kertesz Erika Laine Austin Sally K. Holmes David E. Pollio Joseph E. Schumacher Bert White Carol VanDeusen Lukas 《Journal of general internal medicine》2014,29(4):835-844
BACKGROUND
While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)’s national effort to end Veteran homelessness represents an externally focused organizational endeavor.OBJECTIVE
Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals.DESIGN
This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs).PARTICIPANTS
Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012.APPROACH
Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM).KEY RESULTS
Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation.CONCLUSION
Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.8.
Background
Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. “Virtual visits” are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit.Objective
To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care.Design
Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences.Participants
Primary care patients with hypertension.Exposure
Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension.Main measures
Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit.Key results
Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140–160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, ??2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, ??0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]).Conclusions
Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.9.
Polly Hitchcock Noël Michael L. Parchman John W. WilliamsJr. John E. Cornell Lee Shuko John E. Zeber Lewis E. Kazis Austin F. S. Lee Jacqueline A. Pugh 《Journal of general internal medicine》2007,22(3):419-424
Background
Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.Objective
The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.Design
This research is designed as a cross-sectional survey.Participants
Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.Measurements
Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.Results
Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were “definitely” willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were “definitely” willing to see 6 of 11 non-physician healthcare providers.Conclusions
Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.10.
David Michael Levine Jeffrey A. Linder Bruce E. Landon 《Journal of general internal medicine》2018,33(4):481-486
Background
Despite new incentives for US primary care, concerns abound that patient-centered practice capabilities are lagging.Objective
Describe the practice structure, patient-centered capabilities, and payment relationships of US primary care practices; identify disparities in practice capabilities.Design
Analysis of the 2015 Medical Organizations Survey (MOS), part of the nationally representative Medical Expenditure Panel Survey (MEPS).Setting
Practice-reported information from primary care practices of MEPS respondents who reported receiving primary care and made at least one visit in 2015 to that practice.Participants
Surveyed primary care practices (n?=?4318; 77% response rate) providing primary care to 7161 individuals, representing 101,159,263 Americans.Main Measures
Practice structure (ownership and personnel); practice capabilities (certification as a patient-centered medical home [PCMH], electronic health record [EHR] use, and x-ray capability); and payment orientation (accountable care organization [ACO] and capitation).Key Results
Independently owned practices served 55% of patients, hospital-owned practices served 19%, and nonprofit/government/academic-owned served 20%. Solo practices served 25% of patients and practices with 2–10 physicians served 53% of patients. Forty-one percent of patients were served by practices certified as PCMHs. Practices with EHRs cared for 90% of patients and could exchange secure messages with 78% of patients. Practices with in-office x-ray capability cared for 34% of patients. Practices participating in ACOs and capitation served 44% and 46% of patients, respectively. Primary care patients in the South, compared to the rest of the country, had less access to nearly all practice capabilities, including patient care coordination (adjusted difference, 13% [95% CI, 8–18]) and secure EHR messaging (adjusted difference, 6% [95% CI, 1–10]). Uninsured patients were less likely to be served at a practice that used an EHR (adjusted difference, 9% [95% CI, 2–16]).Conclusions
Participants’ primary care practices were mostly independently owned, nearly always used EHRs (albeit of varying capability), and frequently participated in innovative payment arrangements for a portion of their patients. Patient practices in the South had fewer capabilities than the rest of the country.11.
Jason A. Nieuwsma George L. Jackson Mark B. DeKraai Denise J. Bulling William C. Cantrell Jeffrey E. Rhodes Mark J. Bates Keith Ethridge Marian E. Lane Wendy N. Tenhula Sonja V. Batten Keith G. Meador 《Journal of general internal medicine》2014,29(4):885-894
BACKGROUND
Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains’ current and potential roles in caring for veterans and service members with mental health needs.OBJECTIVE
Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings.DESIGN
A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains.PARTICIPANTS
Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n?=?2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities.MAIN MEASURES
Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete.KEY RESULTS
When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8–100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved.CONCLUSIONS
Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.12.
Mark Fleisher Jan Marsal Scott D. Lee Laura E. Frado Alyssa Parian Burton I. Korelitz Brian G. Feagan 《Digestive diseases and sciences》2018,63(4):825-833
Background
Approximately 15–20% of ulcerative colitis patients and 20–40% of those with Crohn’s disease experience extraintestinal manifestations (EIMs) of their inflammatory bowel disease (IBD). Clinicians who treat IBD must manage EIMs affecting multiple organs that variably correlate with intestinal disease activity. Vedolizumab is a monoclonal antibody for the treatment of IBD with a gut-selective mechanism of action.Aims
This report evaluates whether vedolizumab is an effective treatment of EIMs, given its gut-specific mechanism of action.Methods
We report 8 case studies of patients with various EIMs, including pyoderma gangrenosum, peripheral arthralgia/arthritis, axial arthropathies, erythema nodosum, and uveitis, who received vedolizumab therapy.Results
Vedolizumab therapy was effective for pyoderma gangrenosum in ulcerative colitis, uveitis, erythema nodosum, polyarticular arthropathy, and ankylosing spondylitis/sacroiliitis but did not provide sustained benefit for the treatment of pyoderma gangrenosum in a patient with Crohn’s disease.Conclusions
These cases demonstrate the potential of vedolizumab as a treatment of EIMs in patients with IBD.13.
14.
Aisha James Seth A. Berkowitz Jeffrey M. Ashburner Yuchiao Chang Daniel M. Horn Sandra M. O’Keefe Steven J. Atlas 《Journal of general internal medicine》2018,33(4):463-470
Background
Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care.Objective
To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control.Design
Retrospective difference-in-difference analysis.Participants
Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis).Intervention
From July 1, 2014–December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation.Main Measures
Meeting guideline concordant LDL and BP goals.Key Results
At baseline, there were racial/ethnic disparities in meeting LDL (p?=?0.007) and BP (p?=?0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09–1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80–1.65) and Hispanic (OR 1.29 95% CI 0.66–2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05–1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94–1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59–1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p?=?0.73 for LDL and p?=?0.69 for BP).Conclusions
The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality.Clinical Trials #: NCT02812303 (ClinicalTrials.gov).15.
Background
Adherence to treatment is a key therapeutic goal in chronic disorders including diabetes, inflammatory bowel disease (IBD), and hypertension. Non-adherence has been associated with increased health care costs. Previous studies have evaluated adherence to treatment in inflammatory bowel disease, as well as predictors of non-adherence. Higher belief of necessity for medications and membership of IBD patient organizations have been associated with higher medication adherence.Aim
This study aimed to identify patient reported factors that influence understanding of IBD in college age patients with IBD.Methods
We conducted questionnaire based survey among a group of college age patients with IBD who attended a structured program. The program consisted of a clinical appointment with an IBD physician, lecture by an IBD physician, followed by interactive segment between patients. Educational material was available for patients to review. In addition, opportunity was given to patients to share their story and ask questions in a safe environment.Results
A total of 26 patients participated in the two C-IBD sessions over a 2-year period. Twenty-three were enrolled in college, 1 was a recent graduate, and 2 were of college age but not enrolled. All patients thought the program was beneficial, 96% rated the overall experience as “awesome” or “very good.” Seventy-six percent of patients reported sharing their story as the most beneficial. Only 19% found the physician lecture beneficial.Conclusion
A targeted approach to a vulnerable population with IBD is an additional useful tool in improving understanding of IBD. This may lead to improved compliance with management plans.16.
Joseph E. Glass Kipling M. Bohnert Richard L. Brown 《Journal of general internal medicine》2016,31(7):739-745
BACKGROUND
There is limited data on the extent to which indicated alcohol interventions are delivered in U.S. ambulatory care settings.OBJECTIVE
To assess the receipt of alcohol-related services, including assessment of use, advice to reduce drinking, and information about alcohol treatment, during ambulatory care visits.DESIGN
Secondary data analysis of the 2013 National Survey on Drug Use and Health, a cross-sectional, nationally representative survey of civilians in the non-institutionalized U.S. general population (response rate 71.7 %).PARTICIPANTS
Adult ambulatory care users in the public use data file who did not obtain emergency or inpatient services (n?=?17,266).MAIN MEASURES
Measurements included respondents’ alcohol consumption, heavy episodic drinking, alcohol use disorder, healthcare use, and receipt of alcohol-related interventions.KEY RESULTS
Approximately 71.1 % of ambulatory care users received an alcohol assessment. Among past-month heavy episodic drinkers without an alcohol use disorder who reported receiving an alcohol assessment, 4.4 % were advised to cut back. Among individuals with alcohol abuse and alcohol dependence who reported receiving an alcohol assessment, 2.9 % and 7.0 %, respectively, were offered information about treatment.CONCLUSIONS
Rates of alcohol screening and assessment were relatively high among adults who attended healthcare visits, but rates of intervention were low, even when individuals were assessed for use. Efforts are needed to expand delivery of interventions when patients are identified as positive for risky drinking, hazardous alcohol use, and alcohol use disorders during ambulatory care visits.17.
Timothy P. Hogan Bonnie Wakefield Kim M. Nazi Thomas K. Houston Frances M. Weaver 《Journal of general internal medicine》2011,26(2):628
BACKGROUND
Many healthcare organizations have embraced eHealth technologies in their efforts to promote patient-centered care, increase access to services, and improve outcomes.OBJECTIVE
Using the Department of Veterans Affairs (VA) as a case study, this paper presents two specific eHealth technologies, the Care Coordination Home Telehealth (CCHT) Program and the My HealtheVet (MHV) personal health record (PHR) portal with integrated secure messaging, and articulates a vision of how they might be implemented as part of a patient-centric healthcare model and used in a complementary manner to enhance access to care and to support patient-centered care.METHODS
Based on our experience and ongoing work with both programs, we offer a series of recommendations for pursuing and ultimately achieving this vision.CONCLUSION
VA’s CCHT and MHV programs are examples of an expanding repertoire of eHealth applications available to patients and healthcare teams. VA’s new patient-centric healthcare model represents a significant shift in the way that services are delivered and a profound opportunity to incorporate eHealth technologies like the CCHT and MHV programs into clinical practice to increase access to care, and to ensure the responsiveness of such technologies to the preferences and circumstances of patients.18.
Devan Kansagara Anaïs Tuepker Sandy Joos Christina Nicolaidis Eleni Skaperdas David Hickam 《Journal of general internal medicine》2014,29(2):607-613
BACKGROUND
Quality improvement is a central goal of the patient-centered medical home (PCMH) model, and requires the use of relevant performance measures that can effectively guide comprehensive care improvements. Existing literature suggests performance measurement can lead to improvements in care quality, but may also promote practices that are detrimental to patient care. Staff perceptions of performance metric implementation have not been well-researched in medical home settings.OBJECTIVE
To describe primary care staff (clinicians and other staff) experiences with the use of performance metrics during the implementation of the Veterans Health Administration’s (VHA) Patient Aligned Care Team (PACT) model of care.DESIGN
Observational qualitative study; data collection using role-stratified focus groups and semi-structured interviews.PARTICIPANTS
Two hundred and forty-one of 337 (72 %) identified primary care clinic staff in PACT team and clinic administrative/other roles, from 15 VHA clinics in Oregon and Washington.APPROACH
Data coded and analyzed using conventional content analysis techniques.KEY RESULTS
Primary care staff perceived that performance metrics: 1) led to delivery changes that were not always aligned with PACT principles, 2) did not accurately reflect patient-priorities, 3) represented an opportunity cost, 4) were imposed with little communication or transparency, and 5) were not well-adapted to team-based care.CONCLUSIONS
Primary care staff perceived responding to performance metrics as time-consuming and not consistently aligned with PACT principles of care. The gaps between the theory and reality of performance metric implementation highlighted by PACT team members are important to consider as the medical home model is more widely implemented.19.
David P. Stevens Judith L. Bowen Julie K. Johnson Donna M. Woods Lloyd P. Provost Halsted R. Holman Constance S. Sixta Ed H. Wagner 《Journal of general internal medicine》2010,25(4):574-580