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ABSTRACT: BACKGROUND:: Much attention has been paid to improving the care of patients with cardiovascular disease by focusing attention on delivery system redesign and payment reforms that encompass the healthcare spectrum, from an acute episode to maintenance of care. However, 1 area of cardiovascular disease care that has received little attention in the advancement of quality is cardiac rehabilitation (CR), a comprehensive secondary prevention program that is significantly underused despite evidence-based guidelines that recommending its use. PURPOSE:: The purpose of this article was to analyze the applicability of 2 payment and reimbursement models-pay-for-performance and bundled payments for episodes of care - that can promote the use of CR. CONCLUSIONS:: We conclude that a payment model combining elements of both pay-for-performance and episodes of care would increase the use of CR, which would both improve quality and increase efficiency in cardiac care. Specific elements would need to be clearly defined, however, including: (a) how an episode is defined, (b) how to hold providers accountable for the care they provider, (c) how to encourage participation among CR providers, and (d) how to determine an equitable distribution of payment. CLINICAL IMPLICATIONS:: Demonstrations testing new payment models must be implemented to generate empirical evidence that a melded pay-for-performance and episode-based care payment model will improve quality and efficiency.
The Journal of cardiovascular nursing 02/2013; · 1.43 Impact Factor
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ABSTRACT: Over 24 million individuals in the United States speak English "less than very well" and are considered limited English proficient (LEP). Due to challenges inherent in patient-provider interactions with LEP patients, LEP individuals are at risk for a wide array of negative health consequences. Evidence suggests that having an interpreter present to facilitate interactions between LEP patients and health professionals can mitigate many of these disparities. This article presents the results and lessons learned from Speaking Together: National Language Services Network, a quality improvement (QI) collaborative of the Robert Wood Johnson Foundation to improve the quality of language services (LS) in hospitals. Using five LS performance metrics, hospitals were able to demonstrate that meaningful improvement was possible through targeted QI efforts. By the end of the collaborative, each of the hospitals demonstrated improvement by more than five percentage points on at least one of the five recorded quality metrics. Lessons learned from this work, such as the helpful use of quality metrics to track performance, and the engagement of physician champions and executive leadership to promote improvement can be utilized in hospitals across the country because they seek to improve care for LEP patients.
Journal for Healthcare Quality 03/2012; 34(2):53-63.
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ABSTRACT: Multiple studies have shown that racial and ethnic minorities often experience lower quality of health care when compared
with white patients (Institute of Medicine [IOM], 2002). Even after taking into account various factors like differences in
access to care and disease severity, racial and ethnic disparities in care remain, and are often associated with worse health
outcomes (IOM; Mead et al., 2008).
12/2010: pages 271-282;
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ABSTRACT: This paper examines the psychosocial challenges that interfere with low-income, underserved patients' ability to manage cardiovascular disease (CVD) and seeks to explore the differences in how men and women manifest these issues.
We convened 33 focus group discussions with low-income, underserved heart patients in 10 U.S. communities. Using content analysis, we identified key psychosocial issues that illustrate the psychosocial barriers patients experience as they manage their illness and analyzed these issues by gender to uncover differences in coping and self-management.
We identified eight factors that represent the most frequently cited psychosocial issues by participants: 1) depression; 2) fear; 3) anger; 4) disease stress; 5) financial stress; 6) social isolation; 7) burden to family and friends; and 8) social supports. For the most part, men and women characterized psychosocial problems very differently. Among the eight themes identified, four emerged as dominant themes among women participants and three emerged among male participants. One factor, depression, was a prevalent theme for both men and women.
This study suggests that low-income, underserved women and men experience gender-specific psychosocial problems that interfere with their ability to manage their disease. Programs and interventions to improve the psychosocial issues related to CVD, particularly for low-income underserved populations, may be more effective if they are designed to address the unique ways in which women and men experience their illnesses.
Women s Health Issues 09/2010; 20(5):308-15. · 1.61 Impact Factor
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ABSTRACT: This paper identifies common obstacles impeding effective self-management among patients with heart disease and explores how for disadvantaged patients access barriers interfere with typical management challenges to undermine patients' efforts to care for their illnesses.
We convened 33 focus group discussions with heart patients in 10 U.S. communities. Using content analysis, we identified and grouped the most common barriers that emerged in focus group discussions.
We identified nine major themes reflecting issues related to patients' ability to care for and manage their heart conditions. We grouped the themes into three domains of interest: (1) barriers that interfere with getting necessary services, (2) barriers that impede the monitoring and management of a heart condition on a daily basis, and (3) supports that enable self-management and improve care.
For disadvantaged populations, typical problems associated with self-management of a heart condition are aggravated by substantial obstacles to accessing care.
Ensuring disadvantaged patients with chronic heart conditions are linked to formal systems of care, such as cardiac rehabilitation programs, could better develop patients' self-management skills, reduce barriers to receiving care and improve the overall health outcomes of these patients.
Patient Education and Counseling 09/2009; 79(1):69-76. · 2.31 Impact Factor
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ABSTRACT: Minority populations bear a disproportionate burden of chronic disease, due to higher disease prevalence and greater morbidity and mortality. Recent research has shown that several factors, including confidence to self-manage care, are associated with better health behaviors and outcomes among those with chronic disease.
To examine the association between minority status and confidence to self-manage cardiovascular disease (CVD).
Survey respondents admitted to 10 hospitals participating in the "Expecting Success" program, with a diagnosis of CVD, during January-September 2006 (n = 1107).
Minority race/ethnicity was substantially associated with lower confidence to self-manage CVD, with 36.5% of Hispanic patients, 30.7% of Black patients, and 16.0% of white patients reporting low confidence (P < 0.001). However, in multivariate analysis controlling for socioeconomic status and clinical severity, minority status was not predictive of low confidence.
Although there is an association between race/ethnicity and confidence to self-manage care, that relationship is explained by the association of race/ethnicity with socioeconomic status and clinical severity.
Medical care 10/2008; 46(9):924-9. · 3.24 Impact Factor
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ABSTRACT: Identify characteristics of hospital-based language services (LS), and describe practices of identifying patients with limited English proficiency (LEP) and interpreter training. Participants Seventy-one hospitals applied to participate in a national initiative. Applicants were non-federal, acute care hospitals with substantial LEP populations, at least 10,000 discharges, and in-person interpreters.
Descriptive statistics were generated on language, collection of language data, LEP volume and service utilization, staffing and training requirements and organizational structure. The relationship between admissions and encounters was analyzed.
Ninety percent of hospitals collect primary language data. Spanish is the most common language (93% of hospitals). We found no statistically significant correlation between admissions and encounters. Eighty-four percent require training. Eighty-nine percent have a designated LS department but no clear organizational home.
Hospital-based LS programs are facing challenges identifying patients with language needs, staffing and training a workforce, and creating an organizational identity. Need is not associated with utilization, suggesting that LS are not reaching patients.
Journal of Immigrant and Minority Health 07/2008; 11(6):476-81. · 1.16 Impact Factor
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ABSTRACT: Health care spending comprises about 16% of the total United States gross domestic product and continues to rise. This article examines patterns of health care spending and the factors underlying their proportional growth. We examine the "usual suspects" most frequently cited as drivers of health care costs and explain why these may not be as important as they seem. We suggest that the drive for technological advancement, coupled with the entrepreneurial nature of the health care industry, has produced inherently inequitable and unsustainable health care expenditure and growth patterns. Successful health reform will need to address these factors and their consequences.
The Journal of Law Medicine & Ethics 02/2008; 36(4):644-51, 607. · 1.22 Impact Factor
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ABSTRACT: For a growing segment of the U.S. population, language barriers affect patients’ ability to communicate effectively with health care providers. “Speaking Together” is the first national quality improvement (QI) collaborative focusing on improving operations of hospital-based language services. We employed a multistage process to develop quality performance measures for Speaking Together participants to use throughout the collaborative. The measures, which are grounded in the Institute of Medicine’s six domains of quality, underwent multiple levels of review prior to pilot testing. Early experiences with the measures highlight challenges with collecting information on patient care that has not previously been collected and the importance of engaging staff, including registration staff and senior management. Speaking Together hospitals have shown that QI efforts to measure and advance the delivery of high-quality language services represent challenging but important tasks for improving delivery of care for patients with limited English proficiency.
01/2008;
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ABSTRACT: Racial and ethnic disparities in cardiovascular care are greatly influenced by market factors and how the health care system is organized. This study examines key health system factors that contribute to disparities in cardiac care among racial and ethnic minorities in the United States. A market assessment, consisting of site visits, interviews, and data collection from key health care providers in 10 communities, was undertaken to identify common characteristics in the health care markets and to explore how these factors may drive disparities in cardiac care.
Managed care interface 09/2007; 20(8):22-8.
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ABSTRACT: To create an index that would serve as a simple tool to measure the quality of hospital care by race and ethnicity.
Following extensive review of existing disparities indices, we created a disparities quality index (DQI) designed to easily measure differences in the quality of care hospitals deliver to different populations. The DQI uses performance data already collected by virtually all hospitals. It highlights areas where there are large numbers of patients in a specific population receiving potentially lower-quality care.
Data were collected from 2 acute care hospitals that participated in a multihospital collaborative.
We applied the DQI to 2 hospitals' quality data, specifically to their performance on the Hospital Quality Alliance measure for patients with heart failure who were receiving angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.
The DQI was simple to apply and was able to measure differences in the care of different ethnic groups. It also detected changes in disparities over time.
The DQI can help hospitals and other providers focus on the domain of equity in their quality-improvement efforts. Further testing is required to determine its applicability for community-wide equity projects.
Quality management in health care 18(2):84-90.
