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Integrating Personalized Care Planning into Primary Care: a Multiple-Case Study of Early Adopting Patient-Centered Medical Homes
Abstract
Background
Personalized care planning is a patient-centered, whole-person approach to treatment planning. Personalized care plans improve patient outcomes and are now mandated for chronic care management reimbursement. Yet guidance on how to best implement personalized care planning in practice is limited.
Objective
We examined the adoption of personalized care planning in patient-centered medical home (PCMH) clinics to identify processes and organizational characteristics that facilitated or hindered use in routine practice.
Design
Qualitative multiple-case study design. We conducted site visits at PCMH clinics in four US Veterans Health Administration (VHA) medical centers. Data included 10 general clinic observations, 34 direct observations of patient-provider clinical encounters, 60 key informant interviews, and a document review. Data were analyzed via qualitative content analysis using a priori and emergent coding.
Participants
Employees and patients participating in clinical encounters in PCMH clinics at four VHA medical centers.
Key Results
Each clinic used a distinct approach to personalized care planning: (1) distributed tasks approach; (2) two-tiered approach; (3) health coaching approach; and (4) leveraging a village approach. Each varied in workflow, healthcare team utilization, and degree of integration into clinical care. Across sites, critical components for implementation included expanding planning beyond initial assessment of patient priorities; framing the initiative for patients; using a team-based approach to care plan development and updates; using communication mechanisms beyond the electronic health record; and engaging stakeholders in implementation planning.
Conclusions
Personalized care planning is a novel patient-centered practice, but complicated to implement. We found variation in effective implementation and identified critical components to structuring this practice in a manner that engages patients in treatment aligned with personal priorities. Primary care practices seeking to implement personalized care planning must go beyond simply asking patients a series of questions to establish a plan. They must also engage team members in plan development, communication, and dissemination.
... In turn, the National Academy of Medicine of the United States, describes six standard components of quality in medical care, which should characterize all the outcomes of such care, namely; patient-centered, safe, effective, efficient, timely, and equitable (48). Thus, in dental patient-centered care, specific health needs and desired health outcomes drive all health care decisions (49), which highlights eight essential principles: access to care, respect for patient preference, coordination and integration of care, information and education, physical comfort, emotional support, continuation and transition of care, and involvement of family or friends (50,51). Due to the importance of the aforementioned antecedents, Figure 3 shows the elements that make up the attributes of quality in dental care, which are schematized in a dynamic cycle with applicability in the contexts of the global dental health subsystems. ...
... Hence, the implementation of network systems significantly optimizes processes in dental clinics, allowing better planning and use of human talent time in administrative procedures and dental services (69,70). By virtue of the above, the application of computer tools and technologies in health establishes a course to be followed at a global level, and makes visible the magnitude and impact of information and communication technologies on access and opportunity for dental health services (49). Strategies such as feedback contribute to optimizing quality and identifying the needs felt individually and as a group by the population (71). ...
Introduction: The quality of care in dental health is a concept inherent to insurance and refersto the capacity of services to improve the health outcomes of individuals and populations. This approach focuses not only on the optimal dental care provided, but also on the patient experience and the effectiveness of treatments. Objective:To analyze the dental care process from the context of quality. Materials and Methods:Integrative documentary review in the databases Scopus, ScienceDirect, ProQuest and Pubmed, using the descriptors “health quality”, “dental care”, “dental health services”, “health care quality”, and Boolean operators AND and OR, the search was limited to publications from the period 2017 to 2024, in English and Spanish with information about the quality of care and its relationship with dental health, were identified A total of 532 records were collected, of which 99 were selected. Conclusions:The quality of dental health care is an essential component to ensure optimized and effective care for people. The continuous implementation of evidence-based strategies, together with a patient-centered approach, are essential to achieve sustainable improvements for countries' health systems. Hence, the link between health quality and dental care processes.
... Specifically, the cleft side exhibited a higher prevalence of immature (stage A) and early maturation (stage B) stages compared to the control group. These findings are consistent with previous studies that have reported delayed craniofacial development in CLP patients, likely due to the congenital anomalies and subsequent surgical interventions affecting normal growth patterns [13][14][15][16][17][18]. The higher prevalence of immature sutures on the cleft side suggests that these patients may require prolonged or differently timed orthodontic interventions to achieve optimal outcomes [17,18]. ...
... These findings are consistent with previous studies that have reported delayed craniofacial development in CLP patients, likely due to the congenital anomalies and subsequent surgical interventions affecting normal growth patterns [13][14][15][16][17][18]. The higher prevalence of immature sutures on the cleft side suggests that these patients may require prolonged or differently timed orthodontic interventions to achieve optimal outcomes [17,18]. ...
Introduction
The zygomaticomaxillary suture (ZMS) is vital for craniofacial development and orthodontic treatment planning. Located at the junction of the zygomatic and maxillary bones, the ZMS undergoes significant changes during growth, affecting midfacial morphology and stability. Understanding ZMS maturation is essential for optimizing orthodontic interventions, especially in patients with cleft lip and palate (CLP), who often exhibit altered craniofacial growth patterns due to congenital deformities and surgical interventions.
Methodology
A retrospective analysis was conducted with 50 participants, including 25 patients with unilateral CLP and 25 age-matched controls. Clinical and radiographic data, including lateral cephalometric radiographs and cone-beam computed tomography (CBCT) scans, were collected to assess ZMS maturation stages. The stages, ranging from immature (stage 0) to fully mature (stage 4), were evaluated using established radiographic criteria. Statistical analyses, including Chi-square tests and logistic regression, were performed to compare the distribution of maturation stages between groups.
Results
Significant differences were observed in ZMS maturation stages between the cleft side, non-cleft side, and control group. The cleft side exhibited a higher prevalence of immature (stage 0) and early maturation (stage 1) stages compared to the control group, with mean values of 4 ± 1.2 and 5 ± 1.3, respectively. The control group showed a higher prevalence of fully mature (stage 4) sutures, with a mean value of 8 ± 1.4. The p-values for stages 0, 1, and 4 were 0.045, 0.034, and 0.039, respectively, indicating statistical significance. The findings highlight distinct maturation patterns in CLP patients, with delayed ZMS maturation on the cleft side. This suggests the need for tailored orthodontic interventions to accommodate prolonged growth phases in CLP patients. The study underscores the importance of detailed ZMS assessments for personalized treatment planning. Future research should focus on longitudinal studies to further understand CLP’s impact on craniofacial development.
Conclusion
Assessing ZMS maturation provides critical insights for optimizing orthodontic and surgical treatment outcomes in CLP patients. By identifying specific developmental delays and tailoring interventions accordingly, clinicians can improve the effectiveness and stability of treatments. This study contributes to the growing body of evidence supporting individualized treatment plans based on precise developmental assessments.
... By using a person-centered approach, health care workers learn about each person's values, goals, and preferences to support their individual definitions of well-being, promote resilience, and restore health. [6][7][8]11 Integrating a WH approach into care is predicated on health care workers reconceptualizing their roles beyond find-it-fix-it medicine. 1 WH is different from other health promotion approaches that prioritize biomedical definitions of health (e.g., diabetes management, smoking cessation) and require skills to carry out person-centered interactions that elicit patients' perspectives and goals. ...
... Early WH implementation efforts in all Flagship sites emphasized creating infrastructure and developing WH-aligned services. 8,14,31 Thus, it is not surprising that respondents' depictions of WH reflected a narrower programmatic focus rather than capturing the philosophical shift associated with cultural transformation. When respondents characterized WH as services delivered elsewhere in the organization, they missed personcentered communication as a key aspect of a WH approach, limiting the transformation of the culture of care to one in which aligning care with patients' personal goals is a top priority. ...
Objective: Whole person health care, like that being implemented in the U.S. Veterans Health Administration (VHA), involves person-centered approaches that address what matters most to patients to achieve well-being beyond the biomedical absence of disease. As whole health (WH) approaches expand, their integration into clinical practice is predicated on health care employees reconceptualizing practice beyond find-it-fix-it medicine and embracing WH as a new philosophy of care. This study examined employee perspectives of WH and their integration of this approach into care. Design: We conducted a survey with responses from 1073 clinical and 800 nonclinical employees at 5 VHA WH Flagship sites about their perceptions and use of a WH approach. We used descriptive statistics to examine employees' support for WH and conducted thematic analysis to qualitatively explore their perceptions about this approach from free-text comments supplied by 475 respondents. Results: On structured survey items, employees largely agreed that WH was a valuable approach but were relatively less likely to have incorporated it into practice or report support within their organization for WH. Qualitative comments revealed varying conceptualizations of WH. While some respondents understood that WH represented a philosophical shift in care, many characterized WH narrowly as services. These conceptualizations contributed to lower perceived relevance, skepticism, and misgivings that WH diverted needed resources away from existing clinical services. Organizational context including leadership messaging, siloed structures, and limited educational opportunities reinforced these perceptions. Conclusions: Successfully transforming the culture of care requires a shift in mindset among employees and leadership alike. Employees' depictions didn't always reflect WH as a person-centered approach designed to engage patients to enhance their health and well-being. Without consistent leadership messaging and accessible training, opportunities to expand understandings of WH are likely to be missed. To promote WH transformation, additional attention is needed for employees to embrace this approach to care.
... Integrated care models aim to address the high healthcare utilisation of older adults with complex needs [6,7]. One model of care is the integrated patient-centred medical home (PCMH), a relatively new care model recommended in primary care settings mainly in the United States (US) and Australia [8][9][10]. It is based on the concept of person-centred care, which aims to foster trust and relationships among patients, their families, and healthcare staff, involve patients in decision making about their health, and develop individualised care plans by multidisciplinary teams [11]. ...
... Most studies on the integrated PCMH care model were principally carried out in the US and Australia and, of note, there is a lack of studies in Asia [8][9][10]. It is challenging to generalise findings to Asia due to different healthcare system structures and cultures, and there is a need to grow the body of literature on the PCMH in Asian contexts [21]. ...
The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (β = −0.85; 95%CI = −1.55 to −0.14) and primary care visits (β = −1.70; 95%CI = −2.17 to −1.22) and a decrease in specialist outpatient visits (β = −0.29; 95%CI = −0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.
... Part of the United States' Department of Veterans' Affairs (VA), the Veterans Health Administration (VHA) is the largest integrated health care system in the United States and has invested in the implementation of evidence-based components of highquality chronic care through a Whole Health approach, which focuses on whole person care and includes non-clinical domains of health (e.g., social support, environment, spirituality, and personal development) [8,9]. This care paradigm differs from a reactive, diseaseoriented approach by promoting the patient's active role in healthcare planning and placing importance on the patient's social context and priorities [10][11][12][13]. ...
... 13 [5][6][7][8][9][10][11][12][13][14][15][16][17] "When in a group setting, conversations often turn to advice giving which is sometimes difficult to redirect. It is also difficult to make sure everyone's concerns are addressed while not allowing one person to dominate the conversation". ...
Evidence-based approaches promoting patient engagement and chronic illness self-management include peer support, shared decision-making, and education. Designed based on these components, Taking Charge of My Life and Health (TCMLH) is a group-based, ‘Whole Person’ care program promoting mental and physical self-care and patient empowerment. Despite evidence of effectiveness, little is known about implementation for TCMLH and similar programs. In this first-of-its-kind, multi-methods evaluation conducted between 2015–2020, we report on implementation strategies and intervention adaptations with a contextual analysis to describe TCMLH translational efforts in Veterans Health Administration (VHA) facilities across the United States. Quantitative and qualitative data were collected via listening sessions with TCMLH facilitators, open-ended survey responses from facilitators, and quarterly reports from clinical implementation sites. We used the Consolidated Framework for Implementation Research (CFIR) to analyze, interpret, and organize qualitative findings, and descriptive statistics to analyze quantitative data. Most TCMLH programs (58%) were adapted from the original format, including changes to the modality, duration, or frequency of sessions. Findings suggest these adaptations occurred in response to barriers including space, staffing constraints, and participant recruitment. Overall, findings highlight practical insights for improving the implementation of TCMLH, including recommendations for additional adaptations and tailored implementation strategies to promote its reach.
... 14 Known as the Whole Health System (WHS) of care, this approach transforms the organization and culture of health care from a disease-driven model to a patientcentered, partnership model that empowers and equips people to take charge of their health and wellbeing 15 (see Figure 1). Guided by personal health plans, 16 this approach focuses on patients' life mission, aspiration, and purpose (i.e., what matters most to the patient) as the foundation for health care delivery, putting patients' goals at the center of care, in addition to treatment of disease. Complementary and integrative health therapies (e.g., acupuncture, yoga, tai chi) and self-care skill building classes in core areas (e.g., personal development, healthy eating, spirituality, and physical movement) are integrated into existing primary and specialty care services to help patients achieve and maintain health, while peer specialists and health coaches support patients as they identify and work towards their goals. ...
... .) it was really, I felt, a struggle before." [Site 16,WH Clinical Director] This quick pivot to virtual platforms was not without challenges. Initial national VA guidance around the use of various platforms including Zoom, VA Video Connect (VVC), Facebook Live, WebEx, Microsoft Teams, and FaceTime shifted frequently. ...
Background:
The US Veterans Health Administration (VA) is transforming its healthcare system to create a Whole Health System (WHS) of care. Akin to such reorganization efforts as creating patient-centered medical homes and primary care behavioral health integration, the WHS goes beyond by transforming the entire system to one that takes a proactive approach to support patient and employee health and wellness. The SARS-CoV-2 pandemic disrupted the VA's healthcare system and added stress for staff and patients, creating an exogenous shock for this transformation towards a WHS.
Objective:
We examined the relationship between VA's WHS transformation and the pandemic to understand if transformation was sustained during crisis and contributed to VA's response.
Methods:
Qualitative interviews were conducted as part of a multi-year study of WHS transformation. A single multi-person interview was conducted with 61 WHS leaders at 18 VA Medical Centers, examining WH transformation and use during the pandemic. Data were analyzed using rapid directed content analysis.
Results:
While the pandemic initially slowed transformation efforts, sites intentionally embraced a WH approach to support patients and employees during this crisis. Efforts included conducting patient wellness calls, and, for patients and employees, promoting complementary and integrative health therapies, self-care, and WH concepts to combat stress and support wellbeing. A surge in virtual technology use facilitated innovative delivery of complementary and integrative therapies and promoted continued use of WH activities.
Conclusion:
The pandemic called attention to the need for healthcare systems to address the wellbeing of both patients and providers to sustain high quality care delivery. At a time of crisis, VA sites sustained WH transformation efforts, recognizing WH as one strategy to support patients and employees. This response indicates cultural transformation is taking hold, with WH serving as a promising approach for promoting wellbeing among patients and employees alike.
... In the shared decision-making systems theme, the absence of formal multiprofessional meetings and structured interprofessional communication restrict opportunities for information sharing, inclusive decision-making, leading to hierarchical dynamics where physicians often dominated care plans despite nurses' relevant input (38). The example of a nurse following the physician's directive without question, despite having pertinent information, suggests a hierarchical culture that may stifle open communication and hinder person-centeredness (39). ...
Introduction
An aging population and the increasing prevalence of chronic conditions challenge healthcare systems in developed countries. In response, there is a growing emphasis on person-centered care, as advocated by the World Health Organization and integrated into national health strategies in countries such as the UK and Sweden. However, transitioning to person-centered care is a complex, long-term process shaped by organizational culture and care environments. These contextual factors play crucial roles in the development and sustainability of person-centered practice, significantly transforming the experiences of both older adults and staff.
Objective
To describe how workplace culture within an inpatient hospital department shapes person-centered care practices for older adults with chronic illnesses.
Methods
A qualitative, descriptive, exploratory-observational study was performed. Data were collected through participant observation guided by the Workplace Culture Critical Analysis Tool®. In a deductive thematic content analysis, data patterns of meaning were identified. The themes were generated underpinned by the Person-Centered Practice Framework dimensions of prerequisites, the practice environment, and person-centered processes and their respective constructs.
Results
Themes related to all person-centered practice dimensions were identified. Task demands during shifts create tension between routine-oriented work and the holistic, individualized approach required for person-centeredness. The absence of systematic multiprofessional team meetings further exacerbates this issue, limiting collaborative decision-making and personalized care planning. The contrasts in some subthemes may be related to discrepancies in the care provided by different professionals.
Conclusion
This study highlights the tension between routine-driven care and individualized approaches. Addressing identified challenges, such as formalizing multiprofessional meetings and enhancing reflective practices, is crucial for advancing person-centered care in this setting.
... The pain IDT program produced by the LSS methodology is a unique approach to interdisciplinary pain care whose core elements, including a shared appointment with all interdisciplinary team members present, pain education, phone coaching, shared decision making, motivational interviewing, personalized health planning co-developed by patient and provider, all of which have been supported by the literature. [47][48][49][50][51][52] PREVAIL IDT Track's decreased time burden for the patient and health care system may lend itself to rapid scalability across the nation as an example of pain IDT infrastructure and a strong practice in the VHA 43 that warrants future study. ...
Background
Chronic pain is highly prevalent in US military Veterans, and pain interdisciplinary teams (IDTs) are the gold standard in pain care. There is no standard or guidance for how best to develop and implement pain interdisciplinary teams within complex health care systems.
Objectives
The purpose of this quality improvement project was to evaluate the effectiveness of the standard 9-step Lean 6 Sigma (LSS) methodology in redesigning a pre-existing VA outpatient pain clinic solely offering interventional pain services into an efficient, sustainable pain IDT program.
Methods
The initial evaluation process at a VA Medical Center that primarily serves rural Veterans was redesigned with the a priori goal of developing an efficient, sustainable IDT program that decreased driving days (ie, in-person appointments) required for a comprehensive initial pain evaluation, decreased number of consults required for initial pain evaluations, increased the number of consults to Whole Health services, and increased compliance with policies and standards. Feedback from administrators, clinicians, and Veterans was used to identify inefficiencies then iteratively design, test, and finalize a redesigned service called the PREVAIL Interdisciplinary Team Track (PREVAIL IDT Track). Baseline data was collected for 1 year followed by sustainment data for 14 months. Results were analyzed using descriptive statistics.
Results
PREVAIL IDT Track decreased the number of in-person appointments from 5 to 2, decreased consults required for evaluations from 5 to 1, increased the number of unique consults to Whole Health education classes, and made the VA fully compliant with policies and standards. To date, 486 Veterans have participated in the redesigned program, including 167 graduates and 212 current enrollees in this sustained clinical program.
Conclusion
The success of PREVAIL IDT Track suggests that LSS may be a promising method for redesigning sustainable pain IDTs in VA that improve efficiency.
... 29 Physicians who consider their patients' SEDH context can offer a patient- centered, whole-person care approach with targeted interventions instead of relying on generic treatment plans that may not be suitable for certain individuals. [30][31][32] This study has limitations. As age-adjusted stroke mortality was obtained from death certificates based on ICD-10 codes, inaccurate classification, and the lack of sufficient deaths in individual counties may lead to unreliable data. ...
We used machine learning methods to explore sociodemographic and environmental determinants of health (SEDH) associated with county-level stroke mortality in the USA. We conducted a cross-sectional analysis of individuals aged ≥15 years who died from all stroke subtypes between 2016 and 2020. We analyzed 54 county-level SEDH possibly associated with age-adjusted stroke mortality rates/100,000 people. Classification and Regression Tree (CART) was used to identify specific county-level clusters associated with stroke mortality. Variable importance was assessed using Random Forest analysis. A total of 501,391 decedents from 2397 counties were included. CART identified 10 clusters, with 77.5% relative increase in stroke mortality rates across the spectrum (28.5 vs 50.7 per 100,000 persons). CART identified 8 SEDH to guide the classification of the county clusters. Including, annual Median Household Income ($), live births with Low Birthweight (%), current adult Smokers (%), adults reporting Severe Housing Problems (%), adequate Access to Exercise (%), adults reporting Physical Inactivity (%), adults with diagnosed Diabetes (%), and adults reporting Excessive Drinking (%). In conclusion, SEDH exposures have a complex relationship with stroke. Machine learning approaches can help deconstruct this relationship and demonstrate associations that allow improved understanding of the socio-environmental drivers of stroke and development of targeted interventions.
... This means tailoring pain management strategies to each patient's specific characteristics and circumstances. Individualized care plans ensure that the chosen analgesic agents and techniques are the best fit for the patient, optimizing the effectiveness of pain relief [64]. ...
Orthopedic surgeries, ranging from joint replacements to fracture fixations, are integral procedures that enhance the quality of life for countless individuals. Effective postoperative pain management is crucial in ensuring optimal patient recovery and satisfaction. This comprehensive review analyzes the diverse array of analgesic modalities employed in orthopedic practice for postoperative pain relief. The review systematically explores the pharmacological landscape of analgesics commonly used in orthopedic settings, including opioids, non-steroidal anti-inflammatory drugs, acetaminophen, and adjuvant medications. Emphasis is placed on their mechanisms of action, efficacy profiles, and potential adverse effects. Special attention is given to the evolving role of multimodal analgesia, which combines various agents to achieve synergistic pain control while minimizing individual drug-related complications. Furthermore, the review addresses the emerging trends and advancements in postoperative analgesia within orthopedics, such as integrating regional anesthesia techniques, peripheral nerve blocks, and novel pharmacological agents. A critical evaluation of evidence-based practices and recent clinical trials is incorporated to guide practitioners in making informed decisions regarding postoperative pain management. Consideration is also given to the individualized nature of pain experiences and the importance of patient-centric approaches. The review underscores the significance of tailoring analgesic regimens based on patient characteristics, surgical procedures, and potential complications, fostering a personalized and effective pain management strategy. In conclusion, this comprehensive review is valuable for orthopedic practitioners, anesthetists, and healthcare professionals involved in postoperative care. By synthesizing current knowledge and highlighting evolving trends, the review contributes to the ongoing dialogue on optimizing pain management strategies in orthopedic practice, ultimately improving patient outcomes and satisfaction.
... Patient activation leads to the empowerment of patients to perform diabetes selfcare and maintain good health rather than simply complying with recommended care plans (Salisbury et al., 2018). Moreover, personalized care plans tailored to patient priorities and social contexts (Edwards et al., 2017) are now mandated for chronic care management reimbursement (Bolton et al., 2019). These care plans respect the preferences of patients, decrease challenges in disease management and decrease hospitalizations (Salisbury et al., 2018). ...
Aim:
To examine the relationship between patient-provider communication, psychosocial patient self-efficacy, resources and support for self-management and socio-demographics within individualized care of older adults with diabetes.
Design:
A quantitative study with a cross-sectional survey design.
Methods:
Data were collected from September 2019 to January 2021 using: Individualized Care Scale, The Communication Assessment Tool, The Diabetes Empowerment Scale and The Resources and Support for Self-Management Scale. Patients with either Type 1 or Type 2 diabetes mellitus that were 65 years old and over (N = 145) participated in the study.
Results:
The most positive aspects of patient-provider communication were respect and creating a comfortable environment for the patient. A significant relationship was observed between patients' perceptions and support of individualized care and diabetes-related measures. Effective communication was the main factor associated with support for individualizing care, and together with education level, empowerment and access to resources, explained 23% of the variance.
... In this study, the results of the prognostic score was better in patients receiving primary nursing over patients receiving routine nursing. Such results suggest that the patient-centered primary nursing can improve the prognosis of patients [26]. The improvement in the prognosis may be due to the all-round management by primary nursing to control the complexity of the disease. ...
Objective:
This study aimed to explore the role of primary nursing in patients with hypertensive intracerebral hemorrhage (HICH) undergoing minimally invasive surgery.
Methods:
We randomly assigned 106 patients with HICH treated in our hospital to receive routine nursing (54 cases, group A) or primary nursing in addition to routine nursing (52 cases, group B). The scores of negative emotions, incidence of complications, quality of life, and prognosis of all patients were recorded.
Results:
The score of negative emotions and the incidence of complications were lower in group B than in group A (P < 0.05). The scores of quality of life and prognosis were higher in group B than in group A (P < 0.05).
Conclusion:
Primary nursing intervention can improve the prognosis and postoperative quality of life of patients with HICH undergoing minimally invasive surgery.
... In the existing disease-centered model, all decisions on patient care are made based on the expertise of doctors and other medical personnel. However, in the patient-centered model, patients actively participate in their treatment process and their needs and preferences are reflected in care-related decision making [1,2]. These changes in the decision-making structure of medical services create competition among medical institutions, forcing them to take steps to survive financially. ...
Recent changes in the medical paradigm highlight the importance of patient-centered communication. However, because of the lack of awareness of dental clinics and competency of medical personnel, the quality of medical services in terms of the communication between doctors and patients has not improved. This study analyzed the impact of health communication and medical service quality, service value, and patient satisfaction on the intention to revisit dental clinics. The study participants were outpatients treated at 10 dental clinics in Seoul. The research data were collected using a questionnaire during visits to these dental clinics from December 1 to December 30, 2016. A total of 600 questionnaires were distributed (60 copies to each clinics) and 570 valid questionnaires were used for the analysis. The influence of the factors was determined using structural equation modeling. The factors influencing service value were reliability (β = 0.364, p < 0.001), expertise (β = 0.319, p < 0.001), communication by doctors (β = 0.224, p < 0.001), and tangibility (β = 0.136, p < 0.05). In addition, the factors influencing patient satisfaction were reliability (β = 0.258, p < 0.001), tangibility (β = 0.192, p < 0.001), communication by doctors (β = 0.163, p < 0.001), and expertise (β = 0.122, p < 0.01). Further, service value (β = 0.438, p < 0.001) raised patient satisfaction, which was found to influence the intention to revisit dental clinics (β = 0.383, p < 0.001). Providing accurate medical services to inpatients based on smooth communication between doctors and patients improves patient satisfaction. In addition, doctors can build long-term relations with patients by increasing patients’ intention to revisit through patient-oriented communication.
... Patientcentered care is inherently not formulaic, and implementing communication-based interventions in an inflexible manner risks losing the spirit of patient-centered care. 5 Instead, clinicians should strive to find the crucial, yet difficult, balance between authentic, fact-based, but flexible communication that is attentive to the idiosyncratic nature of the patientprovider relationship. ...
... ; https://doi.org/10.1101/2020.10.21.20216929 doi: medRxiv preprint is confirmed. In fact, RCTs and implementation efforts to successfully deliver such a care planning in PHC have recently been conducted (71)(72)(73) or are under development (74), including one RCT that used the INTERMED tool (35) Further investigations are also needed to establish how, integrated on centralized electronic health records (EHS) (75) and telemedicine (76,77), INTERMED could become a component of a computerized health decision support tool, profile-guided and action-oriented, to deliver personalized care planning in health services networks (78,79). In this way, INTERMED could to help direct health system networks towards the much-needed biopsychosocial, people-centered and integrated care, including in Brazil and other low-and-middle income countries (80)(81)(82)(83)(84). ...
Background
While considerable attention has been devoted to patients’ health complexity epidemiology, comparatively less attention has been paid to tools to identify and describe, in a personalized and comprehensive way, “complex patients” in primary health care (PHC).
Objective
To evaluate INTERMED tool’s validity and feasibility to assess health complexity in PHC.
Design
Cross-sectional psychometric study.
Setting
Three Brazilian PHC Units.
Participants
230 patients above 18 years of both sexes.
Measurements
Spearman’s rho assessed concurrent validity between the whole INTERMED and their four domains (biological, psychological, social, health system) with other well-validated instruments. Pearson’s X ² measured associations of the sum of INTERMED “current state” items with use of PHC, other health services and medications. Cronbach’s Alpha assessed internal consistency. INTERMED acceptability was measured through patients’ views on questions and answers’ understanding and application length as well as objective application length. Applicability was measured through patients’ views on its relevance to describe health aspects essential to care and INTERMED’s items-related information already existing in patients’ health records.
Results
18.3% of the patients were “complex” (INTERMED’s 20/21 cut-off). Spearman’s correlations located between 0.44 - 0.65. Pearson’s coefficients found were X ² = 26.812 and X ² = 26.883 (both p = 0.020) and X2 = 28.270 (p = 0.013). Cronbach’s Alpha was 0.802. All patients’ views were very favorable. Median application time was 7 minutes and 90% of the INTERMED’s interviews took up to 14 minutes. Only the biological domain had all its items described in more than 50% of the health records.
Limitations
We utilized the cutoff point used in all previous studies, found in research performed in specialized health services.
Conclusion
We found good feasibility (acceptability and applicability), and validity measures comparable to those found from specialized health services. Further investigations of INTERMED predictive validity and suitability for routine PHC use are worthwhile.
... 1, 2 Personalized care planning represents a systematic approach to patient-centered management of patients with chronic and comorbid conditions. 3,4 Bolton et al. 5 examine the operation of a US Veterans Health Administration (VHA)-initiated version of personalized care planning (personal health planning (PHP)). Personalized care planning, involving holistic care incorporating patient values, preferences, and expectations within a collaborative and iterative team-based process, is not straightforward. ...
Background
Health care systems are increasingly focused on assessing patient well-being and functioning. The objective of the current analysis was to evaluate a pragmatic question: to what extent and in what way can the PHQ-2, a routinely collected screening measure, be used to help clinicians and a learning health system understand the well-being and functioning of its beneficiaries?
Methods
The current analysis focused on 2872 Veterans who completed a large-scale longitudinal survey about health and wellness for whom we were able to link survey responses to PHQ-2 scores recorded in their electronic health records (EHR). Regression analyses examined the cross-sectional and longitudinal associations between PHQ-2 scores recorded in the EHR and measures of well-being (life satisfaction, purpose in life, and social health) and functioning (pain severity and interference, physical and mental health, and perceived stress).
Results
Veterans were aged 65 years on average (11% women). PHQ-2 scores were correlated cross-sectionally with all well-being and functioning measures; however, there was minimal variance accounted for. Changes in the PHQ-2 over time were associated with 3 measures: purpose in life ( b = −0.19; 95% CI: −0.34, −0.04), mental health functioning ( b = −0.29, 95% CI: −0.54, −0.04), and perceived stress ( b = 0.13; 95% CI: 0.02, 0.24).
Conclusions
The PHQ-2 was minimally associated with patient well-being and functioning, with more work needed on how the PHQ-2 may be used in large health care settings within the context of VA Whole Health. Assessment of well-being is critical as VA’s Whole Health transformation continues, and identifying strategies for well-being measurement is an integral next step.
Yaşlılık, Yaşlanma Fizyolojisi ve Teoriler Osman BAL Yaşlanmanın Biyolojik Temelleri ve Yaşlanma Mekanizmaları Çiğdem ÖKTEN Çok Yönlü Geriatrik Değerlendirme Sema ÜSTÜNDAĞ Geriatrik Sendromlar Latife UTAŞ AKHAN Yaşlılıkta Sık Görülen Sorunlar (Kronik Hastalıklar) ve Yönetimi Nurten TERKEŞ Geriatrik Aciller Ayşenur KAMALAK BAYRAM Yaşlılarda Evde Bakım Nurten TERKEŞ Yaşlı Bireylerde İletişim Esra KARABULUT Yaşlı Ayrımcılığı, İstismarı ve İhmali Havva GEZGİN YAZICI Yaşlılıkta Kriz ve Yas Fatma BOĞAN Yaşlılarda Etik ve Yasal Konular Büşra ARIK ŞEN Esra KARABULUT Geriatrik Rehabilitasyon Buşra ARIK ŞEN
Artificial intelligence (AI) is gradually being incorporated into various aspects of healthcare, including pre-diagnosis, diagnosis, patient care, and patient follow-up. Microbiology is one of the broad subjects that has importance in diagnosis, treatment, and post-treatment phases. Along with other subjects of healthcare, microbiology is also being adopting AI in various domains. As AI technologies are new and evolving, ethical application is of utmost importance in human healthcare. With this background, this chapter discusses various ethical issues related to the development and application of AI in healthcare.
https://www.sciencedirect.com/science/article/abs/pii/S0580951724000254
The passage of the PACT Act of 2022 expanded the services veterans receive through the U.S. Department of Veterans Affairs (VA), ensuring they now qualify for benefits if they've been exposed to certain toxins during their military service. This significant expansion of VA benefits also highlights the need for nurses and other health providers working outside the VA system—who care for millions of veterans—to be well-informed about their patients' military experiences and any potential environmental exposures and health impacts. In this article, the author raises awareness of military environmental exposures and offers guidance about exposure-informed care.
Chronic pain affects over 50 million Americans per year and costs society billions of dollars annually. It is widely accepted that the biomedical model is outdated and research on the biopsychosocial model of chronic pain has increased in recent years, concurrent with investigations into self-management of chronic pain. The Veterans Health Administration (VHA) has incorporated both of these approaches into their Whole Health System. This work describes the VHA Whole Health System, reviews the literature on alignment between the Whole Health System’s Circle of Health and chronic pain, and explains how the VHA Whole Health model may be used as a method for organizing self-management strategies within a personal health plan in the context of chronic pain. Given the infusion of nurses throughout the health- care system, nurses are in a unique position to champion this biopsychosocial-spiritual approach to care.
Background
The Veterans Health Administration (VA) is undergoing a transformation in how healthcare is organized and provided. This transformation to a Whole Health System of Care encompasses the integration of complementary and integrative health services, education, and Whole Health coaching to develop Veterans’ self-care skills. During the COVID-19 pandemic, these services were provided via telehealth (tele-WH).
Objective
We sought to understand Veteran and provider perspectives on how tele-WH impacts Veteran engagement in Whole Health-aligned services and the impact on their well-being.
Methods
Semi-structured interviews were conducted with 51 providers who delivered tele-WH at 10 VA Medical Centers (VAMCs) and 19 Veterans receiving tele-WH at 6 VAMCs. Participants were asked about their experiences with tele-WH, what they perceived to be the impact of tele-WH on Veterans, and their preferences moving forward. Interviews were transcribed, and a content analysis was performed using a rapid approach.
Results
We identified 3 major themes that describe the perceived impact of tele-WH on Veterans. These include: (1) increased use of Whole Health-aligned services; (2) deeper engagement with Whole-Health aligned services; and (3) improvements in social, psychological, and physical well-being.
Conclusion
Tele-WH is perceived to be a strong complement to in-person services and is a promising mechanism for improving engagement with Whole Health-aligned services and promoting Veteran well-being. Future research is needed to measure outcomes identified in this study and to support more equitable access to telehealth for all.
Objective:
To describe how a partnered evaluation of the Whole Health (WH) system of care-comprised of the WH pathway, clinical care, and well-being programs-produced patient outcomes findings, which informed Veterans Health Administration (VA) policy and system change.
Data sources:
Electronic health records (EHR)-based cohort of 1,368,413 patients and a longitudinal survey of Veterans receiving care at 18 WH pilot medical centers.
Study design:
In partnership with VA operations, we focused the evaluation on the impact of WH services utilization on Veterans' (1) use of opioids and (2) care experiences, care engagement, and well-being. Outcomes were compared between Veterans who did and did not use WH services identified from the EHR.
Data collection:
Pharmacy records and WH service data were obtained from the VA EHR, including WH coaching, peer-led groups, personal health planning, and complementary, integrative health therapies. We surveyed veterans at baseline and 6 months to measure patient-reported outcomes.
Principal findings:
Opioid use decreased 23% (31.5-6.5) to 38% (60.3-14.4) among WH users depending on level of WH use compared to a secular 11% (12.0-9.9) decrease among Veterans using Conventional Care. Compared to Conventional Care users, WH users reported greater improvements in perceptions of care (SMD = 0.138), engagement in health care (SMD = 0.118) and self-care (SMD = 0.1), life meaning and purpose (SMD = 0.152), pain (SMD = 0.025), and perceived stress (SMD = 0.191).
Conclusions:
Evidence developed through this partnership yielded key VA policy changes to increase Veteran access to WH services. Findings formed the foundation of a congressionally mandated report in response to the Comprehensive Addiction and Recovery Act, highlighting the value of WH and complementary, integrative health and well-being programs for Veterans with pain. Findings subsequently informed issuance of an Executive Decision Memo mandating the integration of WH into mental health and primary care across VA, now one lane of modernization for VA.
Background:
Liver transplant recipients (LTRs) are at high risk for cardiovascular disease (CVD). We sought to characterize LTR, informal caregiver, and healthcare provider perceptions about CVD care after liver transplantation (LT) to inform the design of solutions to improve care.
Methods:
Participants included adult LTRs, their caregivers, and multi-specialty healthcare providers, recruited from an urban tertiary care network, who participated in 90-minute focus groups and completed a brief survey. Focus group transcripts were analyzed using thematic analysis and survey data were analyzed using descriptive statistics.
Results:
Seventeen LTRs, 9 caregivers, and 22 providers participated in 7 separate focus groups. Most (93.3%) LTRs and caregivers were unaware of the risk of CVD after LT. While 54.5% of providers were confident discussing CVD risk factors with LTRs, only 36.3% were confident managing CVD risk factors in LTRs; and only 13.6% felt that CVD risk factors in their LTR patients were well-controlled. Barriers to CVD care for LTRs included: (1) lack of awareness of CVD risk after LT, (2) lack of confidence in ability to provide proper CVD care to LTRs, (3) reluctance to provide CVD care without transplant provider review, and (4) complexity of communication with the multidisciplinary LTR care team about CVD care. Participant recommendations included improved education for LTRs and caregivers about CVD risk factors, electronic health record alerts for providers, clearly defined CVD care provider roles, increased use of the transplant pharmacist, and multidisciplinary provider meetings to discuss LTRs' care plans.
Conclusion:
Multiple barriers to CVD care after LT were identified and targeted recommendations were proposed by participants. Transplant centers should integrate participants' recommendations when designing interventions to optimize CVD care for LTRs.
Personalized health planning can be operationalized as a health care delivery
model to support personalized, proactive, patient-driven care.
Background
Failure to address social determinants of health (SDH) may contribute to the problem of readmissions in high-risk individuals. Comprehensive shared care plans (CSCP) may improve care continuity and health outcomes by communicating SDH risk factors across settings.
Purpose
The purpose of this study to evaluate the state of knowledge for integrating SDH into a CSCP. Our scoping review of the literature considered 13,886 articles, of which seven met inclusion criteria.
Results
Identified themes were: integrate health and social sectors; interoperability; standardizing ontologies and interventions; process implementation; professional tribalism; and patient centeredness.
Discussion
There is an emerging interest in bridging the gap between health and social service sectors. Standardized ontologies and theoretical definitions need to be developed to facilitate communication, indexing, and data retrieval.
Conclusions
We identified a gap in the literature that indicates that foundational work will be required to guide the development of a CSCP that includes SDH that can be shared across settings. The lack of studies published in the United States suggests that this is a critical area for future research and funding.
BACKGROUND:
Daily clinical team meetings (i.e., "huddles") may be helpful in implementing new roles and responsibilities for patient care because they provide a regular opportunity for member learning and feedback.
PURPOSES:
We examined how huddles were implemented in the context of the VA patient-centered medical home (PCMH) transformation, including assessing barriers and facilitators to regular huddling among small teams ("teamlets"). We assessed the extent to which teamlet members that huddled had higher self-efficacy for PCMH changes, reported better teamwork experiences, and perceived more supportive practice environments.
METHODOLOGY/APPROACH:
We used a convergent mixed-methods approach to analyze 79 teamlet member interviews from six VA primary care practices and 418 clinician and staff PCMH survey responses from the six interviewed practices and 13 additional practices in the same region.
FINDINGS:
Most members reported participating in teamlet huddles when asked in surveys (85%). A minority of interview participants, however, described routine huddling focused on previsit planning that included all members. When members reported routine teamlet huddling, activities included (a) previsit planning, (b) strategizing treatment plans for patients with special or complex needs, (c) addressing daily workflow and communication issues through collective problem solving, and (d) ensuring awareness of what team members do and what actions are happening on the teamlet and in the practice. Primary care providers (PCPs) were least likely to report routine huddling. PCP huddlers reported greater self-efficacy for implementing PCMH changes. All huddlers, irrespective of role, reported better teamwork and more supportive practice climates. The most common barriers to teamlet huddling were limited time and operational constraints.
PRACTICE IMPLICATIONS:
In order to improve the impact of huddles on patient care, practice leaders should clearly communicate the goals, requirements, and benefits of huddling and provide adequate time and resources to ensure that frontline teams use huddle time to improve patient care.
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.
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.
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.
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.
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.
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.
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.
While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.
Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model-Patient Aligned Care Teams (PACT)-we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.
A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites).
PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region.
On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination.
Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.
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.
To examine the early experiences of primary care personnel as they assumed new roles through reorganization into teamlets.
Convergent mixed methods study design involving semi-structured interviews and a survey; data were collected in 2011 and 2012.
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.
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.
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.
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.
Review the operational definitions of health and wellness coaching as published in the peer-reviewed medical literature.
As global rates of preventable chronic diseases have reached epidemic proportions, there has been an increased focus on strategies to improve health behaviors and associated outcomes. One such strategy, health and wellness coaching, has been inconsistently defined and shown mixed results.
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review of the medical literature on health and wellness coaching allowed for compilation of data on specific features of the coaching interventions and background and training of coaches.
Eight hundred abstracts were initially identified through PubMed, with 284 full-text articles ultimately included. The majority (76%) were empirical articles. The literature operationalized health and wellness coaching as a process that is fully or partially patient-centered (86% of articles), included patient-determined goals (71%), incorporated self-discovery and active learning processes (63%) (vs more passive receipt of advice), encouraged accountability for behaviors (86%), and provided some type of education to patients along with using coaching processes (91%). Additionally, 78% of articles indicated that the coaching occurs in the context of a consistent, ongoing relationship with a human coach who is trained in specific behavior change, communication, and motivational skills.
Despite disparities in how health and wellness coaching have been operationalized previously, this systematic review observes an emerging consensus in what is referred to as health and wellness coaching; namely, a patient-centered process that is based upon behavior change theory and is delivered by health professionals with diverse backgrounds. The actual coaching process entails goal-setting determined by the patient, encourages self-discovery in addition to content education, and incorporates mechanisms for developing accountability in health behaviors. With a clear definition for health and wellness coaching, robust research can more accurately assess the effectiveness of the approach in bringing about changes in health behaviors, health outcomes and associated costs that are targeted to reduce the global burden of chronic disease.
Background
Patient-centered medicine is developing alongside the concepts of personalized medicine and tailored therapeutics. The main objective of patient-centered medicine is to improve health outcomes of individual patients in everyday clinical practice, taking into account the patient’s objectives, preferences, values as well as the available economic resources.
Discussion
Patient-centered medicine implies a paradigm shift in the relationship between doctors and patients, but also requires the development of patient-oriented research. Patient-oriented research should not be based on the evaluation of medical interventions in the average patient, but on the identification of the best intervention for every individual patient, the study of heterogeneity and the assignment of greater value to observations and exceptions. The development of information-based technologies can help to close the gap between clinical research and clinical practice, a fundamental step for any advance in this field.
Summary
Evidence-based medicine and patient centered medicine are not contradictory but complementary movements. It is not possible to practice patient-centered medicine that is not based on evidence, nor is it possible to practice evidence-based medicine at a distance from the individual patient.
Patient-centered care has become a central aim for the nation's health system, yet patient experience surveys indicate that the system is far from achieving it. Based on interviews with leaders of patient-centered organizations and initiatives, this report identifies seven key factors for achieving patient-centered care at the organization level: 1) top leadership engagement, 2) a strategic vision clearly and constantly communicated to every member of the organization, 3) involvement of patients and families at multiple levels, 4) a supportive work environment for all employees, 5) systematic measurement and feedback, 6) the quality of the built environment, and 7) supportive information technology. The report illustrates how these factors can be successfully implemented through case examples of two organizations, MCG Health System in Georgia and Bronson Methodist Hospital in Michigan. The report concludes with a discussion of strategies at the organization and system level that can help leverage widespread implementation of patient-centered care.
Residency programs face inevitable challenges as they redesign their practices for higher quality care and resident training. Identifying and addressing early barriers can help align priorities and thereby augment the capacity to change.
Evaluation of the Colorado Family Medicine Residency PCMH Project included iterative qualitative analysis of field notes, interviews, and documents to identify early barriers to change and strategies to overcome them.
Nine common but not universal barriers were identified: (1) a practice's history reflected some negative past experiences with quality improvement or routines incompatible with transformative change, (2) leadership gaps were evident in unprepared practice leaders or hierarchical leadership, (3) resistance and skepticism about change were expressed through cynicism aimed at change or ability to change, (4) unproductive team processes were reflected in patterns of canceled meetings, absentee leaders, or lack of accountability, (5) knowledge gaps about the Patient-centered Medical Home (PCMH) were apparent from incomplete dissemination about the project or planned changes, (6) EHR implementation distracted focus or stalled improvement activity, (7) sponsoring organizations' constraints emerged from staffing rules and differing priorities, (8) insufficient staff participation resulted from traditional role expectations and structures, and (9) communication was hampered by ineffective methods and part-time faculty and residents. Early barriers responded to varying degrees to specific interventions by practice coaches.
Some barriers that interfere with practices getting started with cultural and structural transformation can be addressed with persistent attention and reflection from on-site coaches and by realigning the talents, leaders, and priorities already in these residency programs.
To investigate organizational facilitators and barriers to patient-centered care in US health care institutions renowned for improving the patient care experience.
A qualitative study involving interviews of senior staff and patient representatives. Semi-structured interviews focused on organizational processes, senior leadership, work environment, measurement and feedback mechanisms, patient engagement and information technology and access.
Eight health care organizations across the USA with a reputation for successfully promoting patient-centered care.
Forty individuals, including chief executives, quality directors, chief medical officers, administrative directors and patient committee representatives.
Interviewees reported that several organizational attributes and processes are key facilitators for making care more patient-centered: (i) strong, committed senior leadership, (ii) clear communication of strategic vision, (iii) active engagement of patient and families throughout the institution, (iv) sustained focus on staff satisfaction, (v) active measurement and feedback reporting of patient experiences, (vi) adequate resourcing of care delivery redesign, (vii) staff capacity building, (viii) accountability and incentives and (ix) a culture strongly supportive of change and learning. Interviewees reported that changing the organizational culture from a 'provider-focus' to a 'patient-focus' and the length of time it took to transition toward such a focus were the principal barriers against transforming delivery for patient-centered care.
Organizations that have succeeded in fostering patient-centered care have gone beyond mainstream frameworks for quality improvement based on clinical measurement and audit and have adopted a strategic organizational approach to patient focus.
Objective
Chronic diseases account for 70% of U.S. deaths. Health coaching may help patients adopt healthy lifestyle behaviors that prevent and control diseases. This integrative review analyzed health coaching studies for evidence of effectiveness and to identify key program features.
Data Source
Multiple electronic databases were utilized, yielding a final sample of 15 documents.
Study Inclusion and Exclusion Criteria
The search was limited to peer-reviewed research articles published between 1999 and 2008. Studies were further analyzed if they (1) specifically cited coaching as a program intervention, and (2) applied the intervention to research.
Data Extraction
Articles describing various quantitative and qualitative methodologies were critically analyzed using a systematic method.
Data Synthesis
Data were synthesized using a matrix format according to purpose, method, intervention, findings, critique, and quality rating.
Results
All 15 studies utilized nonprobability sampling, 7 (47%) with randomized intervention and control groups. Significant improvements in one or more of the behaviors of nutrition, physical activity, weight management, or medication adherence were identified in six (40%) of the studies. Common features of effective programs were goal setting (73%), motivational interviewing (27%), and collaboration with health care providers (20%).
Conclusions
Health coaching studies with well-specified methodologies and more rigorous designs are needed to strengthen findings; however, this behavioral change intervention suggests promise.
The patient centered medical home has received considerable attention as a potential way to improve primary care quality and limit cost growth. Little information exists that systematically compares PCMH pilot projects across the country.
Cross-sectional key-informant interviews.
Leaders from existing PCMH demonstration projects with external payment reform.
We used a semi-structured interview tool with the following domains: project history, organization and participants, practice requirements and selection process, medical home recognition, payment structure, practice transformation, and evaluation design.
A total of 26 demonstrations in 18 states were interviewed. Current demonstrations include over 14,000 physicians caring for nearly 5 million patients. A majority of demonstrations are single payer, and most utilize a three component payment model (traditional fee for service, per person per month fixed payments, and bonus performance payments). The median incremental revenue per physician per year was 720 to $91,146). Two major practice transformation models were identified--consultative and implementation of the chronic care model. A majority of demonstrations did not have well-developed evaluation plans.
Current PCMH demonstration projects with external payment reform include large numbers of patients and physicians as well as a wide spectrum of implementation models. Key questions exist around the adequacy of current payment mechanisms and evaluation plans as public and policy interest in the PCMH model grows.
The patient-centered medical home (PCMH) is emerging as a potential catalyst for multiple health care reform efforts. Demonstration projects are beginning in nearly every state, with a broad base of support from employers, insurers, state and federal agencies, and professional organizations. A sense of urgency to show the feasibility of the PCMH, along with a 3-tiered recognition process of the National Committee on Quality Assurance, are influencing the design and implementation of many demonstrations. In June 2006, the American Academy of Family Physicians launched the first National Demonstration Project (NDP) to test a model of the PCMH in a diverse national sample of 36 family practices. The authors make up an independent evaluation team for the NDP that used a multimethod evaluation strategy, including direct observation, in-depth interviews, chart audit, and patient and practice surveys. Early lessons from the real-time qualitative analysis of the NDP raise some serious concerns about the current direction of many of the proposed PCMH demonstration projects and point to some positive opportunities. We describe 6 early lessons from the NDP that address these concerns and then offer 4 recommendations for those assisting the transformation of primary care practices and 4 recommendations for individual practices attempting transformation.
The problem-oriented model upon which much of modern medical care is based has resulted in tremendous advancements in the diagnosis and treatment of many illnesses. Unfortunately, it is less well suited to the management of a number of modern health care problems, including chronic incurable illnesses, health promotion and disease prevention, and normal life events such as pregnancy, well-child care, and death and dying. It is not particularly conducive to an interdisciplinary team approach and tends to shift control of health away from the patient and toward the physician. Since when using this approach the enemies are disease and death, defeat is inevitable. Proposed here is a goal-oriented approach that is well suited to a greater variety of health care issues, is more compatible with a team approach, and places a greater emphasis on physician-patient collaboration. Each individual is encouraged to achieve the highest possible level of health as defined by that individual. Characterized by a greater emphasis on individual strengths and resources, this approach represents a more positive approach to health care. The enemy, not disease or death but inhumanity, can almost always be averted.
Content analysis is a widely used qualitative research technique. Rather than being a single method, current applications of content analysis show three distinct approaches: conventional, directed, or summative. All three approaches are used to interpret meaning from the content of text data and, hence, adhere to the naturalistic paradigm. The major differences among the approaches are coding schemes, origins of codes, and threats to trustworthiness. In conventional content analysis, coding categories are derived directly from the text data. With a directed approach, analysis starts with a theory or relevant research findings as guidance for initial codes. A summative content analysis involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context. The authors delineate analytic procedures specific to each approach and techniques addressing trustworthiness with hypothetical examples drawn from the area of end-of-life care.
Community-based participatory research (CBPR) has emerged in the past decades as an alternative research paradigm, which integrates education and social action to improve health and reduce health disparities. More than a set of research methods, CBPR is an orientation to research that focuses on relationships between academic and community partners, with principles of colearning, mutual benefit, and long-term commitment and incorporates community theories, participation, and practices into the research efforts. As CBPR matures, tensions have become recognized that challenge the mutuality of the research relationship, including issues of power, privilege, participation, community consent, racial and/or ethnic discrimination, and the role of research in social change. This article focuses on these challenges as a dynamic and ever-changing context of the researcher-community relationship, provides examples of these paradoxes from work in tribal communities, discusses the evidence that CBPR reduces disparities, and recommends transforming the culture of academia to strengthen collaborative research relationships.
Submitted as Invited Editorial response to Singh Ospina et. al. Eliciting the Patient’s Agenda – Secondary Analysis of Recorded Clinical Encounters. In 1984, Elliot Mishler published a book called the Discourse of Medicine in which he argued that patients and providers bring different stories to a clinical encounter—the former reflecting the world in which the patient manages their health and illness and the latter reflecting the biomedical definitions of disease and treatment. He showed that providers far too often interrupt the patient stories in favor of a more biomedical version of the person in front of them. It was the beginning of reflections on the need to bridge these two stories in order to foster better communication and patient-centered care.
An inherently action-focused research orientation, community-based participatory research is particularly well suited to dissemination and implementation research. Prominent among the latter are enhanced dissemination and implementation of findings through the authentic engagement of community partners and other stakeholders throughout. In this discussion of community-based participatory research, and the use of the Chinatown Restaurant Worker Study to illustrate its principles in action, the authors have highlighted many of the benefits community-based participatory research can offer to research and its dissemination and implementation. Drawing on this and other community-based participatory research case studies and literature, the chapter also suggests a number of implications that community-based participatory research holds for dissemination and implementation research, and bridging the gap between research and practice.
To the Editor Dr Edwards and colleagues¹ asked if personalized care planning can improve primary care. Their discussion belies the complexity of implementing their 3 essential components without an underlying organizational transformation. Personalized care planning is predicated on patient-centered care, necessitating cultural transformation toward a biopsychosocial perspective, seeing the patient as a person and the physician as a person, each sharing power and responsibility, and a therapeutic alliance²—features often at odds with a disease-focused culture of medicine.
Personalized care planning, a formal process in which clinicians and patients collaborate in the creation of longitudinal treatment plans, is a frequently mentioned tool to improve the quality and patient-centeredness of primary care for medically complex, high-needs individuals.¹ A systematic review of personalized care planning interventions demonstrated small improvements in quality of care for persons with diabetes, hypertension, and asthma; improvements in self-efficacy and self-care; and some improvements in psychological and general health indicators; moreover, interventions were most effective when they were integrated into routine care.
This major final rule with comment period addresses changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. See the Table of Contents for a listing of the specific issues addressed in this rule.
Research evaluating the effectiveness, function, and implementation of patient-centered medical homes (PCMHs) has found major socioprofessional transformations and contributions of primary care physicians and, to a lesser degree, nurses. Our longitudinal ethnographic research with teams implementing PCMH in Veterans Health Administration (VHA) primary care identifies the important but largely underutilized contributions of clerks to PCMH outcomes. Although the relationship of high-performing clerical staff to patient satisfaction is widely acknowledged, PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships are engendered through the care-coordination activities clerks perform, which may be bolstered by organizational investment in clerks as skilled health care team members.
Technological advances, coupled with a shift toward patient-centered care and unprecedented consumer access to information, have created a new era of consumer engagement, empowerment, and activation. This transformation has striking implications and opportunities for clinical informaticians, including the emergence and evolution of the interdisciplinary field of Consumer Health Informatics. In this chapter, we explore the fundamentals based on a sociotechnical perspective, major drivers, factors which influence consumer adoption and use, and key elements and strategies associated with implementation. We provide an overview of evidence in the literature and methods for assessing impact, and conclude with a discussion of emerging trends.
In practice, patient goals–directed care begins with a skilled clinician eliciting patients’ health outcome goals and care preferences. Clinically feasible methods are available to help patients move from general values or unrealistic goals to specific, measurable, achievable, realistic, and time-bound (SMART) goals that integrate understanding of prognosis, clinical course, and realistic outcomes as essential for use in clinical decision making.⁶ Although many clinicians can do it, advanced practice registered nurses or nurses may be more likely than physicians to have the requisite time and communication training to elicit goals effectively.⁶ Regardless of which health team member does the elicitation, all clinicians should verify these outcome goals and care preferences when discussing care options. Although a concern for clinicians, patients are unlikely to identify unrealistic or unachievable goals or change their goals in the absence of change in health status or life circumstances when skilled individuals conduct the goals elicitation.⁶ Requests for low-value care are also minimized when diagnostic tests and treatments are offered within the context of likelihood of achieving the person’s own goals.
Background:
The term "medical neighborhood" refers to relationships that patient-centered medical homes (PCMHs) seek to establish with other providers to facilitate coordinated patient care. Yet, how PCMHs can accomplish this coordination is not well understood.
Purpose:
Drawing upon organizational theory (; ; ), we explored how PCMHs use coordination mechanisms to build and optimize their medical neighborhoods.
Methodology:
We used mixed methods, blending data collected via interviews and surveys with practice leaders and care coordinators at 30 months after a PCMH collaborative intervention in Colorado as well as surveys from all providers from 13 PCMHs before and 30 months after the intervention. We used thematic analysis to understand the role and use of coordination mechanisms by PCMHs and changes in the ability to coordinate and deliver care continuity.
Findings:
PCMHs drew on four coordination mechanisms to build relationships with their medical neighbors: interorganizational routines to improve reliability of information flow; information connectivity to facilitate continuity and safe care; boundary spanners to integrate care across silos; and communication, negotiation, and decision mechanisms to introduce shared accountability. When providers were fairly confident of the patient's diagnosis and management required sequential interactions (such as tests or procedures), PCMHs tended to coordinate care through interorganizational routines and information connectivity. When a diagnosis was less certain and required reciprocal interaction (i.e., consultation), PCMHs employed boundary spanners and communication, negotiation, and decision mechanisms.
Practice implications:
Use of coordination mechanisms by PCMHs can help to improve care coordination in medical neighborhoods. All four mechanisms appear to be useful. The optimal mix of coordination mechanisms requires attention to patient context. Successfully building medical neighborhoods also requires meta-leaders, collaboration competencies, and high-quality relationships between providers in primary care, specialty care, and hospitals.
This chapter seeks to demonstrate the value added from community participation to the research process itself. It shows how Community-Based Participatory Research (CBPR) methods are useful in the dissemination and implementation (D&I) of research findings and some of the lessons from CBPR for D&I research. It discusses challenges that can play out in participatory research, followed by a more detailed examination of the specific ways in which a CBPR approach can enhance the D&I of research findings through collaborative design, analysis, dissemination, and research translation. A case study of a community-university-health department CBPR project that endeavored to study and improve the health and working conditions of restaurant workers in San Francisco's Chinatown District is presented. Then, some of the methods used to involve all partners in study design, data analysis, and translation of findings into action, as well as some of the benefits of doing so, are discussed. Finally, key lessons learned, through this and other CBPR efforts, are shared, and their implications for improving the breadth and effectiveness of the critical dissemination and implementation phases of research are summarized.
The patient-centered medical home model relies on team-based care for meaningful practice transformation. This article adds to the literature on the importance of teams in primary care by exploring the barriers and facilitators to establishing high functioning teams during a patient-centered medical home transformation process.
Personalised care planning for adults with chronic or long-term health conditions
Angela Coulter1,*,
Vikki A Entwistle2,
Abi Eccles3,
Sara Ryan4,
Sasha Shepperd5,
Rafael Perera6
Editorial Group: Cochrane Consumers and Communication Group
Published Online: 3 MAR 2015
Assessed as up-to-date: 1 JAN 2014
DOI: 10.1002/14651858.CD010523.pub2
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010523. DOI: 10.1002/14651858.CD010523.pub2.
Author Information
1
University of Oxford, Health Services Research Unit, Nuffield Department of Population Health, Oxford, UK
2
University of Aberdeen, Health Services Research Unit, Aberdeen, UK
3
University of Oxford, Department of Primary Care Health Sciences, Oxford, Oxfordshire, UK
4
University of Oxford, Quality and Outcomes Research Unit and Health Experiences Research Group, Oxford, Oxfordshire, UK
5
University of Oxford, Nuffield Department of Population Health, Oxford, Oxfordshire, UK
6
University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, UK
*Angela Coulter, Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK. angela.coulter@dph.ox.ac.uk.
Abstract
Background
Personalised care planning is a collaborative process used in chronic condition management in which patients and clinicians identify and discuss problems caused by or related to the patient's condition, and develop a plan for tackling these. In essence it is a conversation, or series of conversations, in which they jointly agree goals and actions for managing the patient's condition.
Objectives
To assess the effects of personalised care planning for adults with long-term health conditions compared to usual care (i.e. forms of care in which active involvement of patients in treatment and management decisions is not explicitly attempted or achieved).
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, ProQuest, clinicaltrials.gov and WHO International Clinical Trials Registry Platform to July 2013.
Selection criteria
We included randomised controlled trials and cluster-randomised trials involving adults with long-term conditions where the intervention included collaborative (between individual patients and clinicians) goal setting and action planning. We excluded studies where there was little or no opportunity for the patient to have meaningful influence on goal selection, choice of treatment or support package, or both.
Data collection and analysis
Two of three review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes were effects on physical health, psychological health, subjective health status, and capabilities for self management. Secondary outcomes included effects on health-related behaviours, resource use and costs, and type of intervention. A patient advisory group of people with experience of living with long-term conditions advised on various aspects of the review, including the protocol, selection of outcome measures and emerging findings.
Main results
We included 19 studies involving a total of 10,856 participants. Twelve of these studies focused on diabetes, three on mental health, one on heart failure, one on end-stage renal disease, one on asthma, and one on various chronic conditions. All 19 studies included components that were intended to support behaviour change among patients, involving either face-to-face or telephone support. All but three of the personalised care planning interventions took place in primary care or community settings; the remaining three were located in hospital clinics. There was some concern about risk of bias for each of the included studies in respect of one or more criteria, usually due to inadequate or unclear descriptions of research methods.
Physical health
Nine studies measured glycated haemoglobin (HbA1c), giving a combined mean difference (MD) between intervention and control of -0.24% (95% confidence interval (CI) -0.35 to -0.14), a small positive effect in favour of personalised care planning compared to usual care (moderate quality evidence).
Six studies measured systolic blood pressure, a combined mean difference of -2.64 mm/Hg (95% CI -4.47 to -0.82) favouring personalised care (moderate quality evidence). The pooled results from four studies showed no significant effect on diastolic blood pressure, MD -0.71 mm/Hg (95% CI -2.26 to 0.84).
We found no evidence of an effect on cholesterol (LDL-C), standardised mean difference (SMD) 0.01 (95% CI -0.09 to 0.11) (five studies) or body mass index, MD -0.11 (95% CI -0.35 to 0.13) (four studies).
A single study of people with asthma reported that personalised care planning led to improvements in lung function and asthma control.
Psychological health
Six studies measured depression. We were able to pool results from five of these, giving an SMD of -0.36 (95% CI -0.52 to -0.20), a small effect in favour of personalised care (moderate quality evidence). The remaining study found greater improvement in the control group than the intervention group.
Four other studies used a variety of psychological measures that were conceptually different so could not be pooled. Of these, three found greater improvement for the personalised care group than the usual care group and one was too small to detect differences in outcomes.
Subjective health status
Ten studies used various patient-reported measures of health status (or health-related quality of life), including both generic health status measures and condition-specific ones. We were able to pool data from three studies that used the SF-36 or SF-12, but found no effect on the physical component summary score SMD 0.16 (95% CI -0.05 to 0.38) or the mental component summary score SMD 0.07 (95% CI -0.15 to 0.28) (moderate quality evidence). Of the three other studies that measured generic health status, two found improvements related to personalised care and one did not.
Four studies measured condition-specific health status. The combined results showed no difference between the intervention and control groups, SMD -0.01 (95% CI -0.11 to 0.10) (moderate quality evidence).
Self-management capabilities
Nine studies looked at the effect of personalised care on self-management capabilities using a variety of outcome measures, but they focused primarily on self efficacy. We were able to pool results from five studies that measured self efficacy, giving a small positive result in favour of personalised care planning: SMD 0.25 (95% CI 0.07 to 0.43) (moderate quality evidence).
A further five studies measured other attributes that contribute to self-management capabilities. The results from these were mixed: two studies found evidence of an effect on patient activation, one found an effect on empowerment, and one found improvements in perceived interpersonal support.
Other outcomes
Pooled data from five studies on exercise levels showed no effect due to personalised care planning, but there was a positive effect on people's self-reported ability to carry out self-care activities: SMD 0.35 (95% CI 0.17 to 0.52).
We found no evidence of adverse effects due to personalised care planning.
The effects of personalised care planning were greater when more stages of the care planning cycle were completed, when contacts between patients and health professionals were more frequent, and when the patient's usual clinician was involved in the process.
Authors' conclusions
Personalised care planning leads to improvements in certain indicators of physical and psychological health status, and people's capability to self-manage their condition when compared to usual care. The effects are not large, but they appear greater when the intervention is more comprehensive, more intensive, and better integrated into routine care.
Plain language summary
Effects of personalised care planning for people with long-term conditions
Background
People with long-term health conditions play an important part in managing their own health. But some of the tasks involved can be complicated, and require confidence and skill. Such tasks include taking medicines properly, monitoring symptoms, adopting or maintaining healthy lifestyles, managing their emotions, solving practical problems, knowing when and how to seek medical advice or community support, and coping with the impact of the condition(s) on their daily lives. Personalised care planning aims to provide support from health professionals that is tailored to the needs of individual patients. Such support recognises patients’ concerns, and helps them become more able to manage their own health. Personalised care planning is a conversation, or series of conversations, between a patient and a clinician when they jointly agree on goals and actions for managing the patient's health problems.
Review question
We carried out this systematic review to find out whether a personalised approach, in which patients are encouraged to participate in setting goals and action plans and determining their support needs, leads to better outcomes than when these decisions are taken by health professionals alone.
Results
We found 19 randomised trials published before July 2013 that addressed this issue, involving 10,856 participants with conditions such as diabetes, mental health problems, heart failure, kidney disease, and asthma. The studies looked at a range of different interventions designed to involve patients and support self management. We combined and summarised results from studies that measured similar outcomes and found that involvement in personalised care planning probably led to small improvements in some indicators of physical health (better blood glucose levels, lower blood pressure measurements among people with diabetes, and control of asthma). It also probably reduced symptoms of depression, and improved people's confidence and skills to manage their health. We observed no effect on cholesterol, body mass index or quality of life. We found no evidence of any harms arising from personalised care planning. We found that the process worked best when it included preparation, record-sharing, care co-ordination and review, involved more intensive support from health professionals, and was integrated into routine care. However, the quality of evidence was only moderate, meaning that further research might change these findings.
Conclusion
We concluded that personalised care planning is a promising approach that offers the potential to provide effective help to patients, leading to better health outcomes. More research is needed to work out which aspects are most effective for specific patient groups.
The patient-centered medical home (PCMH) describes mechanisms for organizing primary care to provide high-quality care across the full range of individuals' health care needs. It is being widely implemented by provider organizations and third-party payers.
To describe approaches for PCMH implementation and summarize evidence for effects on patient and staff experiences, process of care, and clinical and economic outcomes.
PubMed (through 6 December 2011), Cumulative Index to Nursing & Allied Health Literature, and the Cochrane Database of Systematic Reviews (through 29 June 2012).
English-language trials and longitudinal observational studies that met criteria for the PCMH, as defined by the Agency for Healthcare Research and Quality, and included populations with multiple conditions.
Information on study design, populations, interventions, comparators, financial models, implementation methods, outcomes, and risk of bias were abstracted by 1 investigator and verified by another.
In 19 comparative studies, PCMH interventions had a small positive effect on patient experiences and small to moderate positive effects on the delivery of preventive care services (moderate strength of evidence). Staff experiences were also improved by a small to moderate degree (low strength of evidence). Evidence suggested a reduction in emergency department visits (risk ratio [RR], 0.81 [95% CI, 0.67 to 0.98]) but not in hospital admissions (RR, 0.96 [CI, 0.84 to 1.10]) in older adults (low strength of evidence). There was no evidence for overall cost savings.
Systematic review is challenging because of a lack of consistent definitions and nomenclature for PCMH.
The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes.
Background:
The Veterans Health Administration (VHA) is the largest integrated US health system to implement the patient-centered medical home. The Patient Aligned Care Team (PACT) initiative (implemented 2010-2014) aims to achieve team based care, improved access, and care management for more than 5 million primary care patients nationwide.
Objectives:
To describe PACT and evaluate interim changes in PACT-related care processes.
Study design:
Data from the VHA Corporate Data Warehouse were obtained from April 2009 (pre- PACT) to September 2012. All patients assigned to a primary care provider (PCP) at all VHA facilities were included.
Methods:
Nonparametric tests of trend across time points.
Results:
VHA increased primary care staff levels from April 2010 to December 2011 (2.3 to 3.0 staff per PCP full-time equivalent). In-person PCP visit rates slightly decreased from April 2009 to April 2012 (53 to 43 per 100 patients per calendar quarter; P < .01), while in-person nurse encounter rates remained steady. Large increases were seen in phone encounters (2.7 to 28.8 per 100 patients per quarter; P < .01), enhanced personal health record use (3% to 13% of patients enrolled), and electronic messaging to providers (0.01% to 2.3% of patients per quarter). Post hospitalization follow-up improved (6.6% to 61% of VA hospital discharges), but home telemonitoring (0.8% to 1.4% of patients) and group visits (0.2 to 0.65 per 100 patients per quarter; P < .01) grew slowly.
Conclusions:
Thirty months into PACT, primary care staff levels and phone and electronic encounters have greatly increased; other changes have been positive but slower.
Abstract The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study. (Population Health Management 2013;00:1-7).
This volume explores the philosophical underpinnings, history, and key elements of five qualitative inquiry approaches: narrative research, phenomenology, grounded theory, ethnography, and case study. Using an accessible and engaging writing style, author John W. Creswell compares theoretical frameworks, methodologies in employing standards of quality, strategies for writing introductions to studies, the collection and analysis of data, narrative writing, and result verification. New to the Second Edition: (a) Brings the philosophical and theoretical orientations to the beginning of the book: This change helps ground students in the foundational thinking behind these methods much earlier. (b) Gives broader coverage of narrative research: Creswell expands one of the original five approaches from "Biography" to "Narrative," thus exploring a wider range of narrative opportunities--biography still being one of them. (c) Offers a much deeper discussion of interpretive approaches: This edition places much more emphasis on interpretive and postmodern perspectives such as feminism, ethnicity, and critical theory. (d) Provides more specific steps for doing research within each approach: Creswell discusses the actual procedure for each approach and includes the types of qualitative research within each of the five approaches. (e) Illustrates phenomenology and ethnography: The Second Edition contains two new, recent sample journal articles: one covering a phenomenological study, the other covering ethnographic study. (f) Includes additional examples: The author provides examples from the field of human services to enhance the already robust examples from education, sociology, and psychology. Intended Audience: This is a useful text for advanced undergraduate and graduate courses in introductory qualitative research methods across the social, behavioral, and health sciences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To examine the relationship between practices' reported use of patient-centered medical home (PCMH) processes and patients' perceptions of their care experience.
Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices.
This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients' care experience and the use of PCMH processes in the practices where they receive care.
We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.
We found that practices' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.
In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.
An alternative approach to improving the quality of care — especially for patients with multiple conditions, severe disability, or short life expectancy — is to determine whether patients' individual health goals (e.g., for symptoms and functional status) are being met.
A 'patient-centred' approach is increasingly regarded as crucial for the delivery of high quality care by doctors. However, there is considerable ambiguity concerning the exact meaning of the term and the optimum method of measuring the process and outcomes of patient-centred care. This paper reviews the conceptual and empirical literature in order to develop a model of the various aspects of the doctor-patient relationship encompassed by the concept of 'patient-centredness' and to assess the advantages and disadvantages of alternative methods of measurement. Five conceptual dimensions are identified: biopsychosocial perspective; 'patient-as-person'; sharing power and responsibility; therapeutic alliance; and 'doctor-as-person'. Two main approaches to measurement are evaluated: self-report instruments and external observation methods. A number of recommendations concerning the measurement of patient-centredness are made.
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