-
[show abstract]
[hide abstract]
ABSTRACT: Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model. We found that small practices were extremely physician-centric, lacked meaningful communication among physicians, were dominated by authoritarian leadership behavior, and were underserved by midlevel clinicians who had been cast into unimaginative roles. Our analysis suggests that in addition to payment reform, a shift in the mind-set of primary care physicians is needed. Unless primary care physicians can adopt new mental models and think in new ways about themselves and their practices, it will be very difficult for them and their practices to create innovative care teams, become learning organizations, and act as good citizens within the health care neighborhood.
Health Affairs 11/2012; 31(11):2417-22. · 4.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer (CRC) screening. Little is known regarding characteristics associated with patient adherence to physician recommendations in community and academic based primary care settings.
Data were analyzed from 975 patients, aged ≥50 years, recruited from 25 primary care practices in New Jersey. Chi-square and generalized estimate equation analyses determined independent correlates of receipt of and adherence to physician recommendation for CRC.
Patients reported high screening rates for CRC (59%). More than three fourths of patients reported either screening or having received a screening recommendation (82%). Men (P = .0425), nonsmokers (P = .0029), and patients who were highly educated (P = .0311) were more likely to receive a CRC screening recommendation. Patients more adhere to CRC screening recommendations were older adults (P < .0001), nonsmokers (P = .0005), those who were more highly educated (P = .0365), Hispanics (P = .0325), and those who were married (P < .0001).
Community and academic primary care clinicians appropriately recommended screening to high-risk patients with familial risk factors. However, they less frequently recommended screening to others (ie, women and smokers) also likely to benefit. To further increase CRC screening, clinicians must systematically recommend screening to all patients who may benefit.
The Journal of the American Board of Family Medicine 11/2012; 25(6):782-91. · 2.05 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Change champions are important for moving new innovations through the phases of initiation, development, and implementation. Although research attributes positive health care changes to the help of champions, little work provides details about the champion role.
Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data, which included field notes of team meetings, interviews, and transcripts of facilitator meetings, from a sample of 8 practices.
Our analysis yielded insights into the value of having 2 discrete types of change champions: (1) those associated with a specific project (project champions) and (2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes care processes. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing.
Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions-both project and organizational change champions-are critical players in supporting both innovation-specific and transformative change efforts.
The Journal of the American Board of Family Medicine 09/2012; 25(5):676-85. · 2.05 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Survivor care plans have been described as useful tools for enhancing the quality of follow-up care that cancer survivors receive after their active treatment has been completed. The relative success of current survivor care plan models is strongly dependent on the actions of individual patients. In this qualitative study of 33 cancer survivors, we explored patients' understanding of follow-up care and their motivations and resources for seeking care. Three types of survivor experiences were identified from narratives of patients treated in community oncology and NCI designated comprehensive cancer centers, ranging from non-activated patients who need enhanced health care communication and decision support to navigate their care to highly activated patients adept at navigating complex health care settings. Using the Patient-Centered Medical Home as a conceptual framework, we propose a research, policy and practice agenda that advocates for multi-faceted decision support to enhance cancer survivorship and follow-up care.
Translational behavioral medicine. 09/2012; 2(3):322-331.
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices. OBJECTIVE: To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices. DESIGN: We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach. PARTICIPANTS: All practice members and selected patients in seven community-based primary care practices in the Northeastern US. KEY RESULTS: The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care. CONCLUSIONS: The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.
Journal of General Internal Medicine 08/2012; · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The patient-centered medical home model of primary care requires increased collaboration in care delivery. Recent studies suggest that such a collaborative model of care is aided by physician leaders who practice an inclusive approach to leadership; however, they do not empirically demonstrate what such strategies look like in primary care settings, nor do they provide insights to help physician leaders capitalize on the benefits of such an approach. Our analysis offers extended case illustrations of 3 physician leadership behaviors that exemplify leadership inclusiveness (explicitly soliciting team input; engaging in participatory decision making; and facilitating the inclusion of non-team members) as well as 3 behaviors that are counter to inclusiveness. These 6 cases emerged from our analysis of 8 primary care practices that participated in a 3-month facilitated, team-based quality improvement intervention that encouraged leadership inclusiveness. Qualitative data include observational field notes, interviews, and audio-recorded quality improvement meetings. Through these exemplar and nonexemplar cases, we highlight successes and challenges physicians experienced in their collaborative attempts. Such insights may prove important to physicians, researchers, and policy makers alike as they determine how best to aid physician leaders who are being challenged to recreate themselves as facilitators of collaboration.
Quality management in health care 07/2012; 21(3):135-45.
-
[show abstract]
[hide abstract]
ABSTRACT: Recent efforts to encourage meaningful use of electronic health records (EHRs) assume that widespread adoption will improve the quality of ambulatory care, especially for complex clinical conditions such as diabetes. Cross-sectional studies of typical uses of commercially available ambulatory EHRs provide conflicting evidence for an association between EHR use and improved care, and effects of longer-term EHR use in community-based primary care settings on the quality of care are not well understood.
We analyzed data from 16 EHR-using and 26 non-EHR-using practices in 2 northeastern states participating in a group-randomized quality improvement trial. Measures of care were assessed for 798 patients with diabetes. We used hierarchical linear models to examine the relationship between EHR use and adherence to evidence-based diabetes care guidelines, and hierarchical logistic models to compare rates of improvement over 3 years.
EHR use was not associated with better adherence to care guidelines or a more rapid improvement in adherence. In fact, patients in practices that did not use an EHR were more likely than those in practices that used an EHR to meet all of 3 intermediate outcomes targets for hemoglobin A(1c), low-density lipoprotein cholesterol, and blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI, 1.12-2.51). Although the quality of care improved across all practices, rates of improvement did not differ between the 2 groups.
Consistent use of an EHR over 3 years does not ensure successful use for improving the quality of diabetes care. Ongoing efforts to encourage adoption and meaningful use of EHRs in primary care should focus on ensuring that use succeeds in improving care. These efforts will need to include provision of assistance to longer-term EHR users.
The Annals of Family Medicine 05/2012; 10(3):221-7. · 5.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Quality improvement (QI) interventions in health care organizations have produced mixed results with significant questions remaining about how QI interventions are implemented. Team-based reflection may be an important element for understanding QI implementation. Extensive research has focused on individual benefits of reflection including links between reflection, learning, and change. There are currently no published studies that explore how team-based reflection impact QI interventions. We selected 4 primary care practices participating in a QI trial that used a facilitated, team-based approach to improve colorectal cancer screening rates. Trained facilitators met with a team of practice members for up to eleven 1-hour meetings. Data include audio-recorded team meetings and associated fieldnotes. We used a template approach to code transcribed data and an immersion/crystallization technique to identify patterns and themes. Three types of team-based reflection and how each mattered for QI implementation were identified: organizational reflection promoted buy-in, motivation, and feelings of inspiration; process reflection enhanced team problem solving and change management; and relational reflection enhanced discussions of relational dynamics necessary to implement desired QI changes. If QI interventions seek to make changes where collaboration and coordination of care is required, then deliberately integrating team-based reflection into interventions can provide opportunities to facilitate change processes.
Quality management in health care 04/2012; 21(2):104-13.
-
[show abstract]
[hide abstract]
ABSTRACT: Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to "open up the black box" to better understand how and why such collaboratives work.
We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data that included audio recordings and field notes of QICs and practice-based team meetings.
Three themes emerged from our analysis: (1) practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance; (2) a mix of content and media in the QIC program was important for reaching all participants; (3) resources offered at the QIC did little to spur practice change efforts.
QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most.
The Journal of the American Board of Family Medicine 03/2012; 25(2):149-57. · 2.05 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Delays in treatment initiation may contribute to the poorer breast cancer survival among Black women compared with Whites. Lower socioeconomic status and lack of access to care are other reasons for the observed disparities. We, therefore, examined racial differences in treatment delays for early breast cancer in a similarly insured population of Medicaid beneficiaries.
A retrospective cohort study using linked New Jersey Cancer Registry and Medicaid Research files using logistic regression models.
237 Black and 485 White women aged 20-64 years diagnosed with early breast cancer between 1997 and 2001.
Delays in treatment initiation.
Blacks experience adjuvant chemotherapy delays more often than Whites. Black women had two-fold odds (95% confidence interval, 1.04, 4.38) of > or = 3 months delay in adjuvant chemotherapy than Whites. Blacks were also more likely to experience radiation treatment delays but this finding was not statistically significant (odds ratio 1.72, 95% CI .79, 3.77). No racial differences were observed for surgical and hormonal treatment delays.
Blacks experienced delays in initiating adjuvant chemotherapy more frequently than Whites. These differences were observed even in a population with similar socioeconomic status and insurance access, suggesting that cultural and psychosocial factors may contribute to the observed differences.
Ethnicity & disease 01/2012; 22(3):288-94. · 0.90 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Incorporating quality improvement (QI) into resident education and clinical care is challenging. This report explores key characteristics shaping the relative success or failure of QI efforts in seven primary care practices serving as family medicine residency training sites.
The authors used data from the 2002-2008 Using Learning Teams for Reflective Adaptation study to conduct a comparative case analysis. This secondary data analysis focused on seven residency training practices' experiences with the reflective adaptive process (RAP), a 12-week intensive QI process. Field notes, meeting notes, and audiotapes of RAP meetings were used to construct case summaries. A matrix comparing key themes across practices was used to rate practices' QI progress during RAP on a scale of 0 to 3.
Three practices emerged as unsuccessful (scores of 0-1) and four as successful (scores of 2-3). Larger practices with previous QI experience, faculty with extensive exposure to QI literature, and an office manager, residency director, or medical director who advocated the process made substantial progress during RAP, succeeding at QI. Smaller practices without these characteristics were unable to do so. Successful practices also engaged residents in the QI process and identified serious problems as potential crises; unsuccessful practices did not.
Larger residency training practices are more likely to have the resources and characteristics that permit them to create a QI-supportive culture leading to QI success. The authors suggest, however, that smaller practices may increase their chances of success by adopting a developmental approach to QI.
Academic medicine: journal of the Association of American Medical Colleges 12/2011; 86(12):1583-9. · 2.34 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches.
Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change.
A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice.
It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.
Medical care 12/2011; 49 Suppl:S28-35. · 3.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country's first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance. Additionally, transforming primary care requires synchronizing practice redesign with development of the health care "neighborhood," which is made up of a broad range of health and health care resources available to patients. It also requires payment reform that supports practice development and a policy environment that sets reasonable expectations and time frames for the adoption of appropriate innovations.
Health Affairs 03/2011; 30(3):439-45. · 4.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The adoption of electronic medical records (EMRs) in ambulatory settings has been widely recommended. It is hoped that EMRs will improve care; however, little is known about the effect of EMR use on care quality in this setting. This study compares EMR versus paper medical record documentation of basic health history and preventive service indicators in 47 community-based practices. Differences in practice-level documentation rates between practices that did and did not use an EMR were examined using the Kruskal-Wallis nonparametric test and robust regression, adjusting for practice-level covariates. Frequency of documentation of health history and preventive service indicator items were similar in the 2 groups of practices. Although EMRs provide the capacity for more robust record keeping, the community-based practices here do not use EMRs to their full capacity. EMR usage does not guarantee more systematic record keeping and thus may not lead to improved quality in the community practice setting.
American Journal of Medical Quality 01/2011; 26(4):272-7. · 1.64 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Lifestyle factors including smoking, obesity, and diabetes can increase colorectal cancer (CRC) risk. Controversy exists regarding screening rates in individuals at increased CRC risk. To examine the effect of risk on CRC screening in primary care, cross-sectional data collected during January 2006-July 2007 from 720 participants in 24 New Jersey primary care practices were analyzed. Participants were stratified by risk: high (personal/family history of CRC, history of polyps, inflammatory bowel disease), increased (obesity, Type II diabetes, current/former smokers), and average. Outcomes were up-to-date with CRC screening, receiving a physician recommendation for screening, and recommendation adherence. Chi-square and generalized linear modeling were used to determine the effect of independent variables on risk group and risk group on outcomes. Thirty-seven percent of participants were high-risk, 46% increased-risk, and 17% average-risk. Age, race, insurance, education, and health status were related to risk. High-risk participants had increased odds of being up-to-date with screening (OR 3.14 95% CI 1.85-5.32) and adhering to physician recommendation (OR 7.18 95% CI 3.58-14.4) compared to average-risk. Increased-risk participants had 32% decreased odds of screening (OR 0.68, 95% CI 0.42-1.08). Low screening rates among increased-risk individuals highlight the need for screening interventions targeting these patients.
Journal of Community Health 01/2011; 36(4):605-11. · 1.28 Impact Factor
-
Benjamin F Crabtree,
Sabrina M Chase,
Christopher G Wise,
Gordon D Schiff,
Laura A Schmidt,
Jeanette R Goyzueta,
Rebecca A Malouin,
Susan M C Payne,
Michael T Quinn,
Paul A Nutting,
William L Miller,
Carlos Roberto Jaén
[show abstract]
[hide abstract]
ABSTRACT: The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices.
Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign.
A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations.
Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.
Medical care 11/2010; 49(1):10-6. · 3.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.
Journal of General Internal Medicine 06/2010; 25(6):601-12. · 2.83 Impact Factor
-
Family practice management 03/2010; 17(2):31-4.
-
PhD Bijal A. Balasubramanian MBBS,
PhD Kitaw Demissie MD,
Benjamin F. Crabtree PhD,
Pamela A. Ohman Strickland PhD,
CTR Betsy Kohler MPH,
MPH George G. Rhoads MD,
Bijal A. Balasubramanian,
Kitaw Demissie, Benjamin F. Crabtree,
Pamela A. Ohman Strickland,
Betsy Kohler,
George G. Rhoads
[show abstract]
[hide abstract]
ABSTRACT: Black breast cancer patients have shorter survival compared to whites. Lack of optimal treatment may be a potential explanation for this difference. Although racial disparities in surgical and radiation therapy have been studied extensively, there is little information on racial disparities in use of adjuvant systemic therapy. Medicaid enrolled patients provide an opportunity to examine racial disparity in breast cancer treatment by minimizing the roles of access to health care and socioeconomic status. This study, therefore, compared breast cancer treatment, particularly adjuvant systemic therapy and survival in black and white women enrolled in Medicaid. Linked New Jersey Cancer Registry and Medicaid Research files provided diagnostic, prognostic, and treatment information on 237 black and 485 white women aged 20–64 years diagnosed with early stage breast cancer between January 1997 and December 2001. Racial differences in treatment and survival were examined using logistic regression and Cox proportional hazards models respectively. There were no differences in surgical, radiation, or adjuvant systemic treatment between blacks and whites. Breast cancer specific mortality (Hazard ratio (HR) = 1.37; 95% confidence interval (CI) = 0.94–1.98) and all-cause mortality (HR = 1.43; 95% CI = 1.08–1.89) were higher among blacks than whites. In this study of Medicaid-enrolled women with similar socioeconomic status and health care access, blacks and whites received similar breast cancer treatment. In spite of this, blacks had higher mortality than whites. Our findings suggest that factors other than treatment differences may contribute to the racial disparity in mortality.
The Breast Journal 02/2010; 16(2):162 - 168. · 1.64 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Numerous primary care practice development efforts, many related to the patient-centered medical home (PCMH), are emerging across the United States with few guides available to inform them. This article presents a relationship-centered practice development approach to understand practice and to aid in fostering practice development to advance key attributes of primary care that include access to first-contact care, comprehensive care, coordination of care, and a personal relationship over time.
Informed by complexity theory and relational theories of organizational learning, we built on discoveries from the American Academy of Family Physicians' National Demonstration Project (NDP) and 15 years of research to understand and improve primary care practice.
Primary care practices can fruitfully be understood as complex adaptive systems consisting of a core (a practice's key resources, organizational structure, and functional processes), adaptive reserve (practice features that enhance resilience, such as relationships), and attentiveness to the local environment. The effectiveness of these attributes represents the practice's internal capability. With adequate motivation, healthy, thriving practices advance along a pathway of slow, continuous developmental change with occasional rapid periods of transformation as they evolve better fits with their environment. Practice development is enhanced through systematically using strategies that involve setting direction and boundaries, implementing sensing systems, focusing on creative tensions, and fostering learning conversations.
Successful practice development begins with changes that strengthen practices' core, build adaptive reserve, and expand attentiveness to the local environment. Development progresses toward transformation through enhancing primary care attributes.
The Annals of Family Medicine 01/2010; 8 Suppl 1:S68-79; S92. · 5.36 Impact Factor
