First Things First: Foundational Requirements for a Medical Home in an Academic Medical Center

BACKGROUND

In 2010, the Veterans Health Administration (VHA) began implementation of its medical home, Patient Aligned Care Teams (PACT), in 900 primary care clinics nationwide, with 120 located in academically affiliated medical centers. The literature on Patient-Centered Medical Home (PCMH) implementation has focused mainly on small, nonacademic practices.

OBJECTIVE

To understand the experiences of primary care leadership, physicians and staff during early PACT implementation in a VHA academically affiliated primary care clinic and provide insights to guide future PCMH implementation.

DESIGN

We conducted a qualitative case study during early PACT implementation.

PARTICIPANTS

Primary care clinical leadership, primary care providers, residents, and staff.

APPROACH

Between February 2011 and March 2012, we conducted 22 semi-structured interviews, purposively sampling participants by clinic role, and convenience sampling within role. We also conducted observations of 30 nurse case manager staff meetings, and collected data on growth in the number of patients, staff, and physicians. We used a template organizing approach to data analysis, using select constructs from the Consolidated Framework for Implementation Research (CFIR).

KEY RESULTS

Establishing foundational requirements was an essential first step in implementing the PACT model, with teamlets able to do practice redesign work. Short-staffing undermined development of teamlet working relationships. Lack of co-location of teamlet members in clinic and difficulty communicating with residents when they were off-site hampered communication. Opportunities to educate and reinforce PACT principles were constrained by the limited clinic hours of part-time primary care providers and residents, and delays in teamlet formation.

CONCLUSIONS

Large academic medical centers face special challenges in implementing the medical home model. In an era of increasing emphasis on patient-centered care, our findings will inform efforts to both improve patient care and train clinicians to move from physician-centric to multidisciplinary care delivery.

     

VA Experience in Implementing Patient-Centered Medical Home Using a Breakthrough Series Collaborative

BACKGROUND

Veterans Health Administration (VHA) seeks to improve the delivery of patient-centered care. A Patient-Centered Medical Home (PCMH) Model, named Patient Aligned Care Team (PACT), was implemented to transform the VHA primary care delivery process. VHA used a collaborative learning model as a key approach to disseminate PACT concepts and changes.

OBJECTIVE

To describe and examine VHA’s experience disseminating PACT transformation using a Breakthrough Series Collaborative method.

DESIGN

Observational study.

PARTICIPANTS

Approximately 250–350 individuals from 141 teams participated in six face-to-face learning sessions across 21 months.

MAIN MEASURES

1) PACT Collaborative participant surveys; 2) Coach Assessment Scores and Plan-Do-Study-Act (PDSA) data; and 3) PACT Compass (national measures to assess PACT implementation within VA healthcare system).

KEY RESULTS

A majority of the participants indicated that the PACT Collaborative was necessary to implement PACT. The number of PDSAs increased steadily during the Collaborative period; 93 % (n?=?1,547) of PDSAs were successfully implemented. Teams successfully achieved over 80 % of their aims, which were highly correlated with PDSAs implemented (R²?=?0.88). The most successful aims achieved were offering same-day appointments, increasing non-face-to-face care, and improving team communication. PACT Compass indicated an improvement after the Collaborative (p-value?<?.000), and providers observed differences in their care practice (p-value?<?0.002). This positive impact may be due to the spread of the PACT Model through the PACT Collaborative, among other learning initiatives.

CONCLUSIONS

For complex collaborative models such as PACT, more than three learning sessions may be required. As VHA continues to disseminate the PACT Model through primary care, into specialty/surgical care and beyond, the Collaborative Learning Model may continue to be an effective way to leverage a small number of faculty, coaches, and industrial engineers across an extremely large population.

     

Teamlet Structure and Early Experiences of Medical Home Implementation for Veterans

BACKGROUND

High functioning interdisciplinary primary care teams are a critical component of the patient-centered medical home. In 2010, the Veterans Administration (VA) implemented a medical home model termed the Patient Aligned Care Teams (PACT), with reorganization of staff into small teams (“teamlets”) as a core feature.

OBJECTIVE

To examine the early experiences of primary care personnel as they assumed new roles through reorganization into teamlets.

DESIGN

Convergent mixed methods study design involving semi-structured interviews and a survey; data were collected in 2011 and 2012.

PARTICIPANTS

We interviewed 41 frontline teamlet members (i.e., primary care physicians and staff) from three practices that were part of a PACT demonstration laboratory and examined clinician and staff survey data from 22 practices.

MAIN MEASURES

Semi-structured interview guide and clinician and staff survey questions covering the following domains: teamlet formation and structure, within-teamlet communication, cross-coverage, role changes, teamlet training, impact on Veterans, and leadership facilitation and support.

KEY RESULTS

Respondents had limited input into teamlet structure and indicated limited training on the PACT initiative. Guidelines delineating each teamlet member’s roles and responsibilities were emphasized as important needs. Chronic understaffing also contributed to implementation challenges and territorial attitudes surfaced when cross-coverage was not clear. In addition, several core features of VA’s medical home transformation were not fully implemented by teamlet members. Most also reported limited guidance and feedback from leadership. Despite these challenges, teamlet-based care was perceived to have a positive impact on Veterans’ experiences of primary care and also resulted in improved communication among staff.

CONCLUSIONS

The PACT teamlet model holds much promise for improving primary care at the VA. However, more comprehensive training, improving the stability of teamlets, developing clear cross-coverage policies, and better defined teamlet member responsibilities are important areas in need of attention by VA leadership.

     

Multimethod Evaluation of the VA’s Peer-to-Peer Toolkit for Patient-Centered Medical Home Implementation

BACKGROUND

Effective implementation of the patient-centered medical home (PCMH) in primary care practices requires training and other resources, such as online toolkits, to share strategies and materials. The Veterans Health Administration (VA) developed an online Toolkit of user-sourced tools to support teams implementing its Patient Aligned Care Team (PACT) medical home model.

OBJECTIVE

To present findings from an evaluation of the PACT Toolkit, including use, variation across facilities, effect of social marketing, and factors influencing use.

INNOVATION

The Toolkit is an online repository of ready-to-use tools created by VA clinic staff that physicians, nurses, and other team members may share, download, and adopt in order to more effectively implement PCMH principles and improve local performance on VA metrics.

DESIGN

Multimethod evaluation using: (1) website usage analytics, (2) an online survey of the PACT community of practice’s use of the Toolkit, and (3) key informant interviews.

PARTICIPANTS

Survey respondents were PACT team members and coaches (n?=?544) at 136 VA facilities. Interview respondents were Toolkit users and non-users (n?=?32).

MEASURES

For survey data, multivariable logistic models were used to predict Toolkit awareness and use. Interviews and open-text survey comments were coded using a “common themes” framework. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analyses.

KEY RESULTS

The Toolkit was used by 6,745 staff in the first 19 months of availability. Among members of the target audience, 80 % had heard of the Toolkit, and of those, 70 % had visited the website. Tools had been implemented at 65 % of facilities. Qualitative findings revealed a range of user perspectives from enthusiastic support to lack of sufficient time to browse the Toolkit.

CONCLUSIONS

An online Toolkit to support PCMH implementation was used at VA facilities nationwide. Other complex health care organizations may benefit from adopting similar online peer-to-peer resource libraries.

     

“We’ve Not Gotten Even Close to What We Want to Do”: a Qualitative Study of Early Patient-Centered Medical Home Implementation

BACKGROUND

The Veterans Health Administration (VA) Patient Aligned Care Teams (PACT) initiative is designed to deliver a medical home model of care associated with better patient outcomes, but success will depend in part on the model’s acceptability and sustainability among clinic employees.

OBJECTIVE

We sought to identify key themes in the experience of primary care providers, nurse care managers, clerical and clinical associates, and clinic administrators implementing PACT, with the aim of informing recommendations for continued development of the model and its components.

DESIGN

Observational qualitative study; data collection from 2010 to 2013, using role-stratified and team focus groups and semi-structured interviews.

PARTICIPANTS

241 of 337 (72 %) identified primary care clinic employees in PACT team or administrative roles, from 15 VA clinics in Oregon and Washington.

APPROACH

Data coded and analyzed using conventional content analysis techniques.

KEY RESULTS

Overall, participants were enthusiastic about the PACT concept, but felt necessary resources for success were not yet in place. Well-functioning teams were perceived as key to successful implementation. Development of such teams depended on adequate staffing, training, and dedicated time for team development. Changes within the broader VA system were also seen as necessary, including devolving greater control to the clinic level and improving system alignment with the PACT model. PACT advocates from among clinic and institutional level leadership were identified as a final key ingredient for success. These themes were consistent despite differences in clinic settings and characteristics.

CONCLUSIONS

PACT implementation faced significant challenges in its early years. Realizing PACT’s transformative potential will require acting on the needs identified by clinic workers in this study: ensuring adequate staffing in all team roles, devoting resources to in-depth training for all employees in communication and other skills needed to maximize team success, and aligning the broader VA hospital system with PACT’s decentralized, team-based approach.

     

Teamwork and Delegation in Medical Homes: Primary Care Staff Perspectives in the Veterans Health Administration

BACKGROUND

The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential.

OBJECTIVE

To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation.

DESIGN

Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States.

PARTICIPANTS

A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates.

APPROACH

Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation.

KEY RESULTS

We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation.

CONCLUSIONS

Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

     

Exploring End-of-Residency Transitions in a VA Patient Aligned Care Team

BACKGROUND

End-of-residency transitions create disruptions in primary care continuity. The national implementation of Patient Aligned Care Teams (PACT) in Veterans Health Administration (VA) primary care clinics creates an opportunity to mitigate this discontinuity through the provision of team-based care.

OBJECTIVES

To identify team-based solutions to end-of-residency transitions in a resident PACT continuity clinic by assessing the knowledge, attitudes, and perceptions of non-physician PACT members and resident PACT physicians.

DESIGN AND PARTICIPANTS

Cross-sectional survey of 27 resident physicians and 24 non-physician PACT members in the Internal Medicine Clinic at the Audie L. Murphy VA Hospital in the South Texas Veterans Health Care System.

RESULTS

Twenty-seven residents and 24 non-physician PACT members completed the survey, with response rates of 90 % and 100 %, respectively. All residents and 96 % of non-physician PACT members agreed or strongly agreed that the residents were responsible for informing patients about end-of-residency transitions. Only 38 % of non-physician PACT members versus 52 % of residents indicated that non-physician PACT members should be responsible for this transition. Approximately 80 % of resident physicians and non-physician PACT members agreed there should be a formalized approach to these transitions; 67 % of non-physician PACT members were willing to support this transition. Potential barriers to team-based care transitions were identified. Major themes of write-in suggestions for improving the transition focused on communication and relationships between the patient and PACT and among the PACT members.

CONCLUSIONS

PACT implementation changes the roles and relationship structures among all team members. While end-of-residency transitions create a disruption in the relationship system, the remainder of the PACT may bridge this transition. Our results demonstrate the importance of a team-based solution that engages all PACT members by improving communication and fostering effective team relationships.

     

Prevalence of Intimate Partner Violence among Women Veterans who Utilize Veterans Health Administration Primary Care

OBJECTIVES

The objectives of this study were to identify the prevalence of past-year intimate partner violence (IPV) among women Veterans utilizing Veterans Health Administration (VHA) primary care, and to document associated demographic, military, and primary care characteristics.

DESIGN

This was a retrospective cohort design, where participants completed a telephone survey in 2012 (84% participation rate); responses were linked to VHA administrative data for utilization in the year prior to the survey.

PARTICIPANTS

A national stratified random sample of 6,287 women Veteran VHA primary care users participated in the study.

MAIN MEASURES

Past-year IPV was assessed using the HARK screening tool. Self-report items and scales assessed demographic and military characteristics. Primary care characteristics were assessed via self-report and VHA administrative data.

KEY RESULTS

The prevalence of past-year IPV among women Veterans was 18.5% (se?=?0.5%), with higher rates (22.2% - 25.5%) among women up to age 55. Other demographic correlates included indicators of economic hardship, lesbian or bisexual orientation, and being a parent/guardian of a child less than 18 years old. Military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of Military Sexual Trauma (MST). Most (77.3%, se?=?1.2%) women who experienced IPV identified a VHA provider as their usual provider. Compared with women who did not report past-year IPV, women who reported IPV had more primary care visits, yet experienced lower continuity of care across providers.

CONCLUSIONS

The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VHA as a source of health care, reinforces the importance of screening all women for IPV in VHA primary care settings. Key considerations for service implementation include sensitivity with respect to sexual orientation, race/ethnicity, and other aspects of diversity, as well as care coordination and linkages with social services and MST-related care.

     

Elements of Team-Based Care in a Patient-Centered Medical Home Are Associated with Lower Burnout Among VA Primary Care Employees

BACKGROUND

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.

OBJECTIVE

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).

DESIGN

Web-based, cross-sectional survey and administrative data from May 2012.

PARTICIPANTS

A total of 4,539 VA primary care personnel from 588 VA primary care clinics.

MAIN MEASURES

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.

KEY RESULTS

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.

CONCLUSIONS

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.

     

Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare

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.

     

An Inventory of VHA Emergency Departments’ Resources and Processes for Caring for Women

BACKGROUND

More women are using Veterans’ Health Administration (VHA) Emergency Departments (EDs), yet VHA ED capacities to meet the needs of women are unknown.

OBJECTIVE

We assessed VHA ED resources and processes for conditions specific to, or more common in, women Veterans.

DESIGN/SUBJECTS

Cross-sectional questionnaire of the census of VHA ED directors

MAIN MEASURES

Resources and processes in place for gynecologic, obstetric, sexual assault and mental health care, as well as patient privacy features, stratified by ED characteristics.

KEY RESULTS

All 120 VHA EDs completed the questionnaire. Approximately nine out of ten EDs reported having gynecologic examination tables within their EDs, 24/7 access to specula, and Gonorrhea/Chlamydia DNA probes. All EDs reported 24/7 access to pregnancy testing. Fewer than two-fifths of EDs reported having radiologist review of pelvic ultrasound images available 24/7; one-third reported having emergent consultations from gynecologists available 24/7. Written transfer policies specific to gynecologic and obstetric emergencies were reported as available in fewer than half of EDs. Most EDs reported having emergency contraception 24/7; however, only approximately half reported having Rho(D) Immunoglobulin available 24/7. Templated triage notes and standing orders relevant to gynecologic conditions were reported as uncommon. Consistent with VHA policy, most EDs reported obtaining care for victims of sexual assault by transferring them to another institution. Most EDs reported having some access to private medical and mental health rooms. Resources and processes were found to be more available in EDs with more encounters by women, more ED staffed beds, and that were located in more complex facilities in metropolitan areas.

CONCLUSIONS

Although most VHA EDs have resources and processes needed for delivering emergency care to women Veterans, some gaps exist. Studies in non-VA EDs are required for comparison. Creative solutions are needed to ensure that women presenting to VHA EDs receive efficient, timely, and consistently high-quality care.

     

Dual Medicare and Veteran Health Administration Use and Ambulatory Care Sensitive Hospitalizations

OBJECTIVE

The objective of the study is to examine the association between ambulatory care sensitive hospitalizations (ACSH) and dual Medicare/Veteran Health Administration use.

PARTICIPANTS

A nationally representative sample of Medicare beneficiaries, who participated in the Medicare Current Beneficiary Survey (MCBS).

DESIGN/MEASUREMENTS

Cross-sectional analyses (

RESULTS

Among inpatient users, 10.1% had ACSH events for acute conditions and 15.8% for chronic conditions. Among all survey respondents, 5% had any ACSH event. Among predominant-VHA users the rate was 4.9% and among veterans with some VHA use it was 3.7%. In bivariate and multivariate analyses, dual Medicare/VHA use was not significantly associated with any ACSH.

CONCLUSION

In a representative sample of Medicare beneficiaries, despite low income and health status, veterans with dual Medicare/VHA use were as likely as veterans without dual use to have any ACSH, perhaps due to expanded healthcare access and emphasis on primary care in the VHA system.

     

Military Sexual Trauma Among Homeless Veterans

BACKGROUND

Military sexual trauma (MST) is the Veteran Health Administration’s (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans.

OBJECTIVE

To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men.

DESIGN AND PARTICIPANTS

National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010.

MAIN MEASURES

All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization.

KEY RESULTS

Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST.

CONCLUSIONS

A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless programs in providing mental health care to homeless Veterans.

     

Does Improved Continuity of Primary Care Affect Clinician–Patient Communication in VA?

BACKGROUND

Recent changes in health care delivery may reduce continuity with the patient’s primary care provider (PCP). Little is known about the association between continuity and quality of communication during ongoing efforts to redesign primary care in the Veterans Administration (VA).

OBJECTIVE

To evaluate the association between longitudinal continuity of care (COC) with the same PCP and ratings of patient–provider communication during the Patient Aligned Care Team (PACT) initiative.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Four thousand three hundred ninety-three VA outpatients who were assigned to a PCP, had at least three primary care visits to physicians or physician extenders during Fiscal Years 2009 and 2010 (combined), and who completed the Survey of Healthcare Experiences of Patients (SHEP) following a primary care visit in Fiscal Year (FY)2011.

MAIN MEASURES

Usual Provider of Continuity (UPC), Modified Modified Continuity Index (MMCI), and duration of PCP care were calculated for each primary care patient. UPC and MMCI values were categorized as follows: 1.0 (perfect), 0.75–0.99 (high), 0.50–0.74 (intermediate), and < 0.50 (low). Quality of communication was measured using the four-item Consumer Assessment of Healthcare Providers and Systems-Health Plan program (CAHPS-HP) communication subscale and a two-item measure of shared decision-making (SDM). Excellent care was defined using an “all-or-none” scoring strategy (i.e., when all items within a scale were rated “always”).

KEY RESULTS

UPC and MMCI continuity remained high (0.81) during the early phase of PACT implementation. In multivariable models, low MMCI continuity was associated with decreased odds of excellent communication (OR?=?0.74, 95 % CI?=?0.58–0.95) and SDM (OR?=?0.70, 95 % CI?=?0.49, 0.99). Abbreviated duration of PCP care (< 1 year) was also associated with decreased odds of excellent communication (OR?=?0.35, 95 % CI?=?0.18, 0.71).

CONCLUSIONS

Reduced PCP continuity may significantly decrease the quality of patient–provider communication in VA primary care. By improving longitudinal continuity with the assigned PCP, while redesigning team-based roles, the PACT initiative has the potential to improve patient–provider communication.

     

National Implementation of Acute Stroke Care Centers in the Veterans Health Administration (VHA): Formative Evaluation of the Field Response

Background

In 2011, the Veterans Health Administration (VHA) released the Acute Ischemic Stroke (AIS) Directive, which mandated reorganization of acute stroke care, including self-designation of stroke centers as Primary (P), Limited Hours (LH), or Supporting (S).

Objectives

In partnership with the VHA Offices of Emergency Medicine and Specialty Care Services, the VA Stroke QUERI conducted a formative evaluation in a national sample of three levels of stroke centers in order to understand barriers and facilitators.

Design and Approach

The evaluation consisted of a mixed-methods assessment that included a qualitative assessment of data from semi-structured interviews with key informants and a quantitative assessment of stroke quality-of-care data reporting practices by facility characteristics.

Participants

The final sample included 38 facilities (84 % participation rate): nine P, 24 LH, and five S facilities. In total, we interviewed 107 clinicians and 16 regional Veterans Integrated Service Network (VISN) leaders.

Results

Across all three levels of stroke centers, stroke teams identified the specific need for systematic nurse training to triage and initiate stroke protocols. The most frequently reported barriers centered around quality-of-care data collection. A low number of eligible veterans arriving at the VAMC in a timely manner was another major impediment. The LH and S facilities reported some unique barriers: access to radiology and neurology services; EMS diverting stroke patients to nearby stroke centers, maintaining staff competency, and a lack of stroke clinical champions. Solutions that were applied included developing stroke order sets and templates to provide systematic decision support, implementing a stroke code in the facility for a coordinated response to stroke, and staff resource allocation and training. Data reporting by facility evaluation demonstrated that categorizing site volume did indicate a lower likelihood of reporting among VAMCs with 25–49 acute stroke admissions per year.

Conclusions

The AIS Directive brought focused attention to reorganizing stroke care across a wide range of facility types. Larger VA facilities tended to follow established practices for organizing stroke care, but the unique addition of the LH designation presented some challenges. S facilities tended to report a lack of a coordinated stroke team and champion to drive process changes.

     

Cost of Transformation among Primary Care Practices Participating in a Medical Home Pilot

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 Quality

     

Highly Effective Cystic Fibrosis Clinical Research Teams: Critical Success Factors

BACKGROUND

Bringing new therapies to patients with rare diseases depends in part on optimizing clinical trial conduct through efficient study start-up processes and rapid enrollment. Suboptimal execution of clinical trials in academic medical centers not only results in high cost to institutions and sponsors, but also delays the availability of new therapies. Addressing the factors that contribute to poor outcomes requires novel, systematic approaches tailored to the institution and disease under study.

OBJECTIVE

To use clinical trial performance metrics data analysis to select high-performing cystic fibrosis (CF) clinical research teams and then identify factors contributing to their success.

DESIGN

Mixed-methods research, including semi-structured qualitative interviews of high-performing research teams.

PARTICIPANTS

CF research teams at nine clinical centers from the CF Foundation Therapeutics Development Network.

APPROACH

Survey of site characteristics, direct observation of team meetings and facilities, and semi-structured interviews with clinical research team members and institutional program managers and leaders in clinical research.

KEY RESULTS

Critical success factors noted at all nine high-performing centers were: 1) strong leadership, 2) established and effective communication within the research team and with the clinical care team, and 3) adequate staff. Other frequent characteristics included a mature culture of research, customer service orientation in interactions with study participants, shared efficient processes, continuous process improvement activities, and a businesslike approach to clinical research.

CONCLUSIONS

Clinical research metrics allowed identification of high-performing clinical research teams. Site visits identified several critical factors leading to highly successful teams that may help other clinical research teams improve clinical trial performance.