Delegating Responsibility from Clinicians to Nonprofessional Personnel: The Example of Hypertension Control
ABSTRACT Involving nonclinician personnel in the treatment of hypertension may provide a solution to improve blood pressure control; however, this team-based approach cannot be implemented without first determining clinicians' willingness to delegate patient care to nonclinician team members. This study explores clinicians' perspectives on working with nonclinicians trained as "health coaches" to address medication adherence and lack of medication intensification among low-income patients with uncontrolled hypertension.
We used a qualitative research approach to determine clinicians' opinions on the Treat-to-Target study, an intervention to improve blood pressure control. We conducted focus groups with clinicians who practice family medicine in a safety net clinic. Transcripts were analyzed using thematic content analysis.
Seven overarching themes emerged: (1) Clinicians support the delegation of functions to health coaches; (2) clinicians like the high frequency of coach-patient interactions; (3) clinicians feel that health coaching assists medication adherence; (4) clinicians have varying views on home titration; (5) coach-clinician communication is necessary for successful delegation; (6) coaching helps clinicians understand their patients' barriers to hypertension control; and (7) clinicians would like health coaching to continue on a permanent basis.
Clinicians appreciate the presence of nonclinicians on the primary care team. In the coming era of primary care clinician shortage, clinicians can be supportive of nonprofessional team members assisting with the care of patients with hypertension.
SourceAvailable from: Katrina Donahue[Show abstract] [Hide abstract]
ABSTRACT: Patient and practice perspectives can inform development of team-based approaches to improving blood pressure control in primary care. We used a community-based participatory research approach to assess patient and practice perceptions regarding the value of team-based strategies for controlling blood pressure in a rural North Carolina population from 2010 through 2012. In-depth interviews were conducted with 41 adults with hypertension, purposely sampled to include diversity of sex, race, literacy, and blood pressure control, and with key office staff at 5 rural primary care practices in the southeastern US "stroke belt." Interviews explored barriers to controlling blood pressure, the practice's role in controlling blood pressure, and opinions on the use of team care delivery. Patients reported that provider strategies to optimize blood pressure control should include regular visits, medication adjustment, side-effect discussion, and behavioral counseling. When discussing team-based approaches to hypertension care, patients valued verbal encouragement, calls from the doctor's office, and the opportunity to ask questions. However, they voiced concerns about the effect of having too many people involved in their care. Practice staff focused on multiple, broad methods to control blood pressure including counseling, regular office visits, media to improve awareness, and support groups. An explicit focus of delivering care as teams was a newer concept. When developing a team approach to hypertension treatment, patients value high-quality communication and not losing their primary relationship with their provider. Practice staff members were open to a team-based approach but had limited knowledge of what such an approach would entail.Preventing chronic disease 04/2014; 11:E69. DOI:10.5888/pcd11.130157 · 1.96 Impact Factor
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ABSTRACT: Background & aim: Six Oregon primary care clinics integrated a team-based, systematized alcohol and drug Screening, Brief Intervention, Referral to Treatment (SBIRT) process into their standard clinic workflow. Clinic staff administered screening forms and brief assessments, and clinicians were trained to perform brief interventions and treatment referrals when needed. Methods: Patient-level data from the electronic health record (EHR) were used to calculate implementation rates in each clinic – specifically, how often each step of a 3-step SBIRT process was performed when indicated. Rates were tracked on a quarterly basis over 2 years. Results: Implementation rates increased over time for screening and assessment tasks performed by clinic staff, but not for brief interventions performed by clinicians. Averaged over time, annual screens were given to approximately 44% of eligible patients, brief assessments to around 66% of eligible patients, and brief interventions to about 40% of those eligible. Considerable variability existed across individual clinics, some of which demonstrated notably high rates. Conclusion: A team-based approach to SBIRT in primary care settings capitalizes on the medical home model but also creates unique challenges. Facilitative EHR tools are necessary.Journal of Substance Use 12/2013; DOI:10.3109/14659891.2013.866176 · 0.48 Impact Factor
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ABSTRACT: Graduate nursing education in the United States has undergone significant changes over the last decade with institution of the doctorate in nursing practice (2006) and the revised Essentials of Master's Education in Nursing (2011). An overview of the status of community/public health nursing (C/PHN) education and practice during the past 100 years provides a historic context for understanding the current situation of the specialty. An analysis of U.S. graduate nursing programs in C/PHN is used to foreground a discussion of the factors that may significantly affect community/public health nurses' interest in graduate education and the ability to sustain a master's-prepared C/PHN workforce. Questions are raised about how the potential loss of this particular specialty may influence the practice of C/PHN and the role of nursing in general in ensuring the public's health. Recommendations are offered for strengthening the specialty long-term, with a particular focus on C/PHN education and practice.Nursing Outlook 11/2014; 62(6). DOI:10.1016/j.outlook.2014.06.007 · 1.83 Impact Factor