Paul A Nutting

University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States

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Publications (113)473.93 Total impact

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    ABSTRACT: Objective: To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). Data sources/study setting: Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. Study design: We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. Data collection/extraction methods: We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. Principal findings: Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection. Conclusions: Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.
    No preview · Article · Nov 2015 · Health Services Research
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    ABSTRACT: Background Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes. Objective To examine practice contextual features that moderate intervention effectiveness. Design Secondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care. Participants Forty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment. Main Measures The primary outcome was a composite measure of diabetes process of care, ascertained by chart audit, regarding nine quality measures from the American Diabetes Association Physician Recognition Program: HgA1c, foot exam, blood pressure, dilated eye exam, cholesterol, nephropathy screen, flu shot, nutrition counseling, and self-management support. Data from practices included structural and demographic characteristics and Practice Culture Assessment survey subscales (Change Culture, Work Culture, Chaos). Key Results Across the three implementation approaches, demographic/structural characteristics (rural vs. urban + .70(p = .006), +2.44(p variability in practice Change Culture (high vs. low: −.24(p = .006), −.20(p = .0771), −.44(p = .0019) and Work Culture (high vs. low: +.56(p = .3160), −1.0(p = .008), −.25 (p = .0216) were associated with trajectories of change in diabetes process of care, either directly or differentially by study arm. Conclusions This study supports the need for broader use of methodological approaches to better examine contextual effects on implementation and effectiveness of quality improvement interventions in primary care settings.
    Full-text · Article · Dec 2014 · Journal of General Internal Medicine
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    ABSTRACT: The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory. We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results.Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease. We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion). Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations.
    Full-text · Article · Dec 2014 · Implementation Science
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    ABSTRACT: Background: Current research on primary care practice redesign suggests that outside facilitation can be an important source of support for achieving substantial change. Objectives: To analyse the specific sequence of strategies used by a successful practice facilitator during the American Academy of Family Physicians' (AAFP) National Demonstration Project (NDP). Methods: This secondary analysis describes a sequence of strategies used to produce change in family medicine practices attempting to adopt a new model of care. The authors analysed qualitative data generated by one facilitator and six practices by coding facilitator field notes, site visit reports, qualitative summaries, depth interviews and email strings. Results: The facilitator utilized practice member coaching in addition to consulting, negotiating and connecting approaches. Coaching strategies encouraged: (i) expansive, multi-directional, attentive styles of communication; (ii) solving practical problems together; (iii) modelling facilitative leadership and (iv) encouraging an expanded vision of care. Practice members who received consistent coaching reported internal shifts and new ways of conceptualizing work, not just success at implementing model components. They indicated that their facilitator had helped them think and behave in new ways while helping them achieve benchmarks. Conclusions: It was once believed that the transition from traditional models of family medicine practice to new models of care meant implementing new technological components, suggesting that outside facilitators should act as technological and care delivery consultants. However, coaches may be especially useful in helpful in practices undertake substantial changes.
    Full-text · Article · Oct 2014 · Family Practice
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    ABSTRACT: Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include long-term, meaning- and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.
    No preview · Article · Mar 2014 · Annual Review of Public Health
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    ABSTRACT: Purpose: We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation. Methods: We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. Results: Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices. Conclusions: Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.
    No preview · Article · Jan 2014 · The Annals of Family Medicine
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    Robert D Keeley · David R West · Brandon Tutt · Paul A Nutting
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    ABSTRACT: Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into "Patient-centered Medical Homes" (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient's perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians' and their patients' perceptions of the patients' experiences, expectations and preferences as they try to achieve care for depression. We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings. Three processes on the way to satisfactory depression care emerged: 1. a journey, often from fractured to connected care; 2. a search for a personal understanding of their depression; 3. creation of unique therapeutic spaces for treating current depression and preventing future episodes. Relative to patients' observations regarding stigma's effects on accepting a depression diagnosis and seeking treatment, clinicians tended to underestimate the presence and effects of stigma. Patients preferred clinicians who were empathetic listeners, while clinicians worried that discussing depression could open "Pandora's box" of lengthy discussions and set them irrecoverably behind in their clinic schedules. Clinicians and patients agreed that somatic manifestations of mental distress impeded the patients' ability to understand their suffering as depression. Clinicians reported supporting several treatment modalities beyond guideline-based approaches for depression, yet also displayed surface-level understanding of the often multifaceted support webs their patient described. Improving processes and outcomes in primary care may demand heightened ability to understand and measure the patients' experiences, expectations and preferences as they receive primary care. Future research would investigate a potential mismatch between clinicians' and patients' perceptions of the effects of stigma on achieving care for depression, and on whether time spent discussing depression during the clinical visit improves outcomes. Improving care and outcomes for chronic disorders such as depression may require primary care clinicians to understand and support their patients' unique 'therapeutic spaces.'
    Full-text · Article · Jan 2014 · BMC Family Practice
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    ABSTRACT: Innovative workforce models are being developed and implemented to meet the changing demands of primary care. A literature review was conducted to construct a typology of workforce models used by primary care practices. Ovid Medline, CINAHL, and PsycInfo were used to identify published descriptions of the primary care workforce that deviated from what would be expected in the typical practice in the year 2000. Expert consultants identified additional articles that would not show up in a regular computerized search. Full texts of relevant articles were read and matrices for sorting articles were developed. Each article was reviewed and assigned to one of 18 cells in the matrices. Articles within each cell were then read again to identify patterns and develop an understanding of the full spectrum of workforce innovation within each category. This synthesis led to the development of a typology of workforce innovations represented in the literature. Many workforce innovations added personnel to existing practices, whereas others sought to retrain existing personnel or even develop roles outside the traditional practice. Most of these sought to minimize the impact on the existing practice roles and functions, particularly that of physicians. The synthesis also identified recent innovations which attempted to fundamentally transform the existing practice, with transformation being defined as a change in practice members' governing variables or values in regard to their workforce role. Most conceptualizations of the primary care workforce described in the literature do not reflect the level of innovation needed to meet the needs of the burgeoning numbers of patients with complex health issues, the necessity for roles and identities of physicians to change, and the call for fundamentally redesigned practices. However, we identified 5 key workforce innovation concepts that emerged from the literature: team care, population focus, additional resource support, creating workforce connections, and role change.
    Full-text · Article · Dec 2013 · Medical care
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    ABSTRACT: Purpose: The purpose of this study was to evaluate a primary care practice-based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates. Methods: The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up. Results: Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients' colorectal cancer screening rates. Qualitative analyses provide insights into practices' QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates. Conclusions: Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.
    Full-text · Article · May 2013 · The Annals of Family Medicine
  • Paul A Nutting · Benjamin F Crabtree · Reuben R McDaniel
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    ABSTRACT: Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model. We found that small practices were extremely physician-centric, lacked meaningful communication among physicians, were dominated by authoritarian leadership behavior, and were underserved by midlevel clinicians who had been cast into unimaginative roles. Our analysis suggests that in addition to payment reform, a shift in the mind-set of primary care physicians is needed. Unless primary care physicians can adopt new mental models and think in new ways about themselves and their practices, it will be very difficult for them and their practices to create innovative care teams, become learning organizations, and act as good citizens within the health care neighborhood.
    No preview · Article · Nov 2012 · Health Affairs
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    ABSTRACT: The authors describe the implementation of a depression care management (DCM) program at Colorado Access, a public sector health plan, and describe the program's clinical and system outcomes for members with chronic medical conditions. High medical risk, high cost Medicaid health plan members were identified and systematically screened for depression. A total of 370 members enrolled in the DCM program. Longitudinal analyses revealed significantly reduced depression severity scores at 3, 6, and 12 months after intervention as compared to baseline depression scores. At 12 months, 56% of enrollees in the DCM program had either a 50% reduction in PHQ-9 scores or a PHQ-9 score < 10. Longitudinal economic analyses comparing 12 months before and after intervention revealed a significant but modest increase in ER visits, outpatient office visits, and overall medical and pharmacy costs when adjusted for months enrolled in DCM. Limitations and recommendations for the integrated depression care management are discussed.
    Full-text · Article · Oct 2012 · Depression research and treatment
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    ABSTRACT: Change champions are important for moving new innovations through the phases of initiation, development, and implementation. Although research attributes positive health care changes to the help of champions, little work provides details about the champion role. Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data, which included field notes of team meetings, interviews, and transcripts of facilitator meetings, from a sample of 8 practices. Our analysis yielded insights into the value of having 2 discrete types of change champions: (1) those associated with a specific project (project champions) and (2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes care processes. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing. Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions-both project and organizational change champions-are critical players in supporting both innovation-specific and transformative change efforts.
    Full-text · Article · Sep 2012 · The Journal of the American Board of Family Medicine
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    ABSTRACT: Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to "open up the black box" to better understand how and why such collaboratives work. We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data that included audio recordings and field notes of QICs and practice-based team meetings. Three themes emerged from our analysis: (1) practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance; (2) a mix of content and media in the QIC program was important for reaching all participants; (3) resources offered at the QIC did little to spur practice change efforts. QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most.
    Full-text · Article · Mar 2012 · The Journal of the American Board of Family Medicine
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    ABSTRACT: Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.
    Full-text · Article · Dec 2011 · Medical care
  • Paul A. Nutting · Carlos R. Jaen

    No preview · Article · Jun 2011 · Health Affairs
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    ABSTRACT: Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country's first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance. Additionally, transforming primary care requires synchronizing practice redesign with development of the health care "neighborhood," which is made up of a broad range of health and health care resources available to patients. It also requires payment reform that supports practice development and a policy environment that sets reasonable expectations and time frames for the adoption of appropriate innovations.
    Full-text · Article · Mar 2011 · Health Affairs
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    ABSTRACT: The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.
    Full-text · Article · Nov 2010 · Medical care
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    ABSTRACT: The Using Learning Teams for Reflective Adaptation (ULTRA) study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show significant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed. We analyzed field notes and interviews from a multimethod practice assessment, as well as field notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach. Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practice-wide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines. Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.
    Full-text · Article · Sep 2010 · The Annals of Family Medicine
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    ABSTRACT: Making the kind of improvement changes necessary to move toward a patient-centered medical home will continue to challenge small, independent primary care practices. Here we describe further analysis of a successful program to understand the roles of coleaders of a change management process. Through an improvement collaborative we trained 2 coleaders (a physician and a non-physician) from 16 small primary care practices to institute depression care improvements. These coleaders participated in 3 learning sessions that provided depression care content as well as skills to implement a change management strategy. Qualitative data were collected by observation during the learning sessions and through in-depth interviews conducted at baseline, between each learning session, at the end of the project, 6 months after the project ended, and, finally, 26 months after the project's end. Interview results with the coleaders affirmed that a team approach is a viable strategy for practice improvement. The 2 coleaders used their complementary skills, relationships, and credibility among the practice staff to implement and sustain practice improvements. In their differing roles, they varied in how they perceived barriers to change and how they assessed their team's progress. Involving both a physician and a non-physician as coleaders enables improvement teams in small primary care practices to make progress both in the clinical content of their work and in the critical change management activities involved with creating a team, managing meetings, and coordinating work between meetings. Using a coleader structure enriches the improvement process, broadens participation in the change process, and helps to sustain these efforts over time.
    Full-text · Article · Sep 2010 · The Journal of the American Board of Family Medicine
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    ABSTRACT: Long-term sustainment of improvements in care continues to challenge primary care practices. During the 2 years after of our Improving Depression Care collaborative, we examined how well practices were sustaining their depression care improvements. Our study design used a qualitative interview follow-up of a modified learning collaborative intervention. We conducted telephone interviews with practice champions from 15 of the original 16 practices. Interviews were conducted during a 3-month period in 2008, and were recorded and professionally transcribed. Data on each of the depression care improvements and the change management strategy emphasized during the learning collaborative were summarized after review of the primary data and a consensus process to resolve differing interpretations. During the period from 15 months to 3 years since our project began, depression screening or case finding was sustained in 14 of 15 practices. Thirteen practices sustained use of the 9-item Patient Health Questionnaire for depression monitoring, and one additional practice initiated it. Seven practices initiated self-management support and 2 of 3 practices sustained it. In contrast, tracking and case management proved difficult to sustain, with only 4 of 8 practices continuing this activity. Diffusion of use of the 9-item Patient Health Questionnaire to other clinicians in the practice was maintained in all but 3 practices and expanded in one practice. Six of the practices continued to use the change management strategy, including all 4 of the practices that sustained tracking. Practices demonstrated long-term sustained improvement in depression care with the exception of tracking and care management, which may be a more challenging innovation to sustain. We hypothesize that sustaining complex depression care innovations may require active management by the practice.
    No preview · Article · Sep 2010 · The Journal of the American Board of Family Medicine

Publication Stats

6k Citations
473.93 Total Impact Points

Institutions

  • 2010-2014
    • University of Texas Health Science Center at San Antonio
      • Department of Family & Community Medicine
      San Antonio, Texas, United States
  • 2005-2014
    • University of Colorado
      • Department of Family Medicine
      Denver, Colorado, United States
  • 2002-2014
    • National Research Center (CO, USA)
      Boulder, Colorado, United States
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2007-2010
    • Robert Wood Johnson University Hospital
      New Brunswick, New Jersey, United States
  • 1999
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 1996
    • Zoo Atlanta
      Atlanta, Georgia, United States
    • University of Oklahoma
      Norman, Oklahoma, United States
  • 1994
    • University at Buffalo, The State University of New York
      • Department of Family Medicine
      Buffalo, New York, United States