Provider Perspectives on Implementing Shared Decision Making for PTSD Treatment in VA Primary Care.

Shared decision making is an important implementation "pull" strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.

Moral Economy and Moral Capital in the Community of Clinical Practice.

This New Zealand study used focused ethnography to explore the activities of communities of clinical practice (CoCP) in a community-based long-term conditions management program within a large primary health care clinic. CoCP are the informal vehicles by which patient care was delivered within the program. Here, we describe the CoCP as a micro-level moral economy within which values such as trust, respect, authenticity, reciprocity, and obligation circulate as a kind of moral capital. As taxpayers, citizens who become patients are credited with moral capital because the public health system is funded by taxes. This moral capital can be paid forward, accrued, banked, redeemed, exchanged, and forfeited by patients and their health care professionals during the course of a patient's journey. The concept of moral capital offers another route into the "black box" of clinical work by providing an alternative theoretic for explaining the relational aspects of patient care.

Shared care requires a shared vision: communities of clinical practice in a primary care setting.

AIMS AND OBJECTIVES: To understand how a vision of care is formed and shared by patients and the primary care professionals involved in their care. BACKGROUND: To achieve the best health outcomes, it is important for patients and those who care for them to have a mutual understanding about what is important to the patient in their everyday life and why, and what care is necessary to realise this vision. Shared or team care does not necessarily translate to a consistent and integrated approach to a patient's care. An individual patient's care network of clinical and lay participants can be conceptualised as the patient's own 'Community of Clinical Practice' of which they are the central member. DESIGN: Working alongside a long-term conditions nursing team, we conducted a focused ethnography of nine 'Communities of Clinical Practice' in one general practice setting. METHOD: Participant observation, in-depth qualitative interviews with 24 participants including nine patients, and the patients' medical records. Data were analysed using a template organising style. FINDINGS: Primary care professionals' insight into a patient's vision of care evolves through a deep knowing of the patient over time; this is shared between 'Community of Clinical Practice' members, frequently through informal communication and realised through respectful dialogue. These common values - respect, authenticity, autonomy, compassion, trust, care ethics, holism - underpin the development of a shared vision of care. CONCLUSIONS: A patient's vision of care, if shared, provides a focus around which 'Community of Clinical Practice' members cohere. Nurses play an important role in sharing the patient's vision of care with other participants. RELEVANCE TO CLINICAL PRACTICE: A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a 'Community of Clinical Practice'.

Review of state legislative approaches to eliminating racial and ethnic health disparities, 2002-2011.

We conducted a legal mapping study of state bills related to racial/ethnic health disparities in all 50 states between 2002 and 2011. Forty-five states introduced at least 1 bill that specifically targeted racial/ethnic health disparities; we analyzed 607 total bills. Of these 607 bills, 330 were passed into law (54.4%). These bills approached eliminating racial/ethnic health disparities by developing governmental infrastructure, providing appropriations, and focusing on specific diseases and data collection. In addition, states tackled emerging topics that were previously lacking laws, particularly Hispanic health. Legislation is an important policy tool for states to advance the elimination of racial/ethnic health disparities.

Candidate metrics for evaluating the impact of prescriber education on the safe use of extended-release/long-acting (ER/LA) opioid analgesics.

OBJECTIVE: The objective of this study was to develop metrics to assess opioid prescribing behavior as part of the evaluation of the Extended-Release/Long-Acting (ER/LA) Opioid Analgesic Risk Evaluation and Mitigation Strategies (REMS). DESIGN: Candidate metrics were selected using published guidelines, examined using sensitivity analyses, and applied to cross-sectional rolling cohorts of Medicare patients prescribed with extended-release oxycodone (ERO) between July 2, 2006 and July 1, 2011. Potential metrics included prescribing opioid-tolerant-only ER/LA opioid analgesics to non-opioid-tolerant patients, prescribing early fills to patients, and ordering drug screens. RESULTS: Proposed definitions for opioid tolerance were seven continuous days of opioid usage of at least 30 mg oxycodone equivalents, within the 7 days (primary) or 30 days (secondary) prior to first opioid-tolerant-only ERO prescription. Forty-four percent of opioid-tolerant-only ERO episodes met the primary opioid tolerance definition; 56% met the secondary definition. Fills were deemed "early" if a prescription was filled before 70% (primary) or 50% (secondary) of the prior prescription's days' supply was to be consumed. Five percent (primary) and 2% (secondary) of episodes had more than or equal to two early fills during treatment. At least one drug screen was billed in 14% of episodes. Stratified analyses indicated that older patients were less likely to be opioid tolerant at the time of the first opioid-tolerant-only ERO prescription. CONCLUSIONS: Investigators propose three metrics to monitor changes in prescribing behaviors for opioid analgesics that might be used to evaluate the ER/LA Opioid Analgesics REMS. Low frequencies of patients, particularly those >85 years, were likely to be opioid tolerant prior to receiving prescriptions for opioid-tolerant-only ERO.

Physical therapy in the Emergency Department: A prospective cohort study from an Alternatives to Opioids program.

Objective: Musculoskeletal pain complaints are common in the emergency department (ED). The objective of this study was to determine the impact of physical therapy (PT) in the ED on pain and ED return. Methods: A prospective cohort study was performed with those presenting to the ED or Urgent Care at a single academic center for musculoskeletal pain between November 2020 and December 2022. All patients were referred to outpatient PT. During business hours, PT was available to begin treatment in the ED. Long-term follow-up was performed using the electronic health records. Statistical analyses included descriptive and non-parametric pairwise comparisons, Fisher's exact test, and multiple logistic regression. Results: A total of 974 patients were included in the study with 553 completing optional surveys. Back pain was most common. Pain was reduced at ED discharge for all patients, but pain was significantly improved if patients saw PT in the ED. Patients in the ED were less likely to keep their outpatient PT appointments than others, but importantly, patients who saw PT in the ED were less likely to return to the ED for the same complaint up to 1 year later. Those who kept PT appointments were likely to establish or maintain healthcare outside emergency services later. Conclusions: Initiating PT in this ED reduces pain at ED discharge. However, patients who utilized PT were more likely to later utilize health care resources outside of emergency services. Those who saw PT in this ED were less likely to return to the ED for the same complaint up to 1 year later.

Competing Demands: Scheduling Challenges in Being Veteran-centric in the Setting of Health System Initiatives to Improve Access.

INTRODUCTION: The Veterans Health Administration's (VHA) history of enhancing Veterans' healthcare access continued in 2016 with the launch of ChooseVA (née: MyVA Access). This initiative was designed to transform the VHA and rapidly increase Veteran's access to care across all the VHA facilities. Relevant to this article include mandates to improve patient-centered scheduling. In prioritizing patient-centered scheduling, the VHA and other large healthcare systems have the paradoxical task of providing health care that meets not only the needs of individual patients but also the collective needs of the population served. To our knowledge, meeting these competing needs has not been explored through the perspectives and experiences of providers and staff implementing patient-centered scheduling practices. MATERIALS AND METHODS: This was a qualitative exploratory study and was sanctioned as quality improvement (and thus exempt from Institutional Review Board review). We conducted visits at 25 VHA facilities. Sites were selected based on rurality, region, and facility access performance ratings. Data collection included semi-structured interviews and focus groups. Key informant participants included local leadership, administrators, providers, and support staff across primary care, specialty care, and mental health service lines. We analyzed transcribed audio recordings using inductive content analysis to identify barriers, facilitators, and contextual factors affecting the implementation of patient-centered scheduling. RESULTS: We conducted 208 individual interviews and focus groups between July and November 2017. Participants expressed dedication to patient-centered approaches to improve access to care for Veterans, stating efforts and challenges to meeting Veterans' needs and preferences. Being Veteran-centric meant accommodating Veterans, with a tension between meeting the needs of one Veteran versus all Veterans, managing expectations of same-day access, and potential hits to performance metrics. Strategies focused on engaging Veterans through education and establishing new expectations while recognizing the differing needs among subgroups receiving VHA care. CONCLUSIONS: Veterans Health Administration staff employed a mission-driven, culturally sensitive approach to meeting the diverse scheduling needs of the Veteran population. While potentially unique to the VHA, it may inform patient-centered scheduling practices for other culturally specific populations in other healthcare systems. Continued efforts to put Veterans at the center of VHA healthcare delivery by engaging them in meaningful ways while honoring their distinct needs are essential. Data are forthcoming on Veterans' perspectives of access, which we hope will further contribute to unfolding understandings of access within the VHA.

Exploring the value of social network 'care maps' in the provision of long-term conditions care.

OBJECTIVES: There is renewed attention to the role of social networks as part of person-centred long-term conditions care. We sought to explore the benefits of 'care maps' - a patient-identified social network map of their care community - for health professionals in providing person-centred care. METHODS: We piloted care maps with 39 patients with long-term conditions in three urban and one rural general practice and two hospital wards. We interviewed the health professionals (n = 39) of these patients about what value, if any, care maps added to patient care. We analysed health professional interview data using thematic analysis to identify common themes. RESULTS: Health professionals all said they learned about their patients as a person-in-context. There was an increased understanding of patients' support networks, synthesising what is known and unknown. Health professionals understood patients' perceptions of health professionals and what really mattered to patients. There was discussion about the therapeutic value of care maps. The maps prompted reflection on practice. DISCUSSION: Care maps facilitated a broader focus than the clinical presentation. Using care maps may enable health professionals to support self-management rather than feeling responsible for many aspects of care. Care maps had 'social function' for health professionals. They may be a valuable tool for patients and clinicians to bridge the gap between medical treatment and patients' lifeworlds.

General practice and patients' views of the social networks of patients with multimorbidity.

INTRODUCTION For patients with multimorbidity to live well, they need the support of not only health professionals but family, friends and organisations. These social networks provide support, potentially enabling the formation of a Community of Clinical Practice approach to multimorbidity care. AIM This study aimed to explore general practice knowledge of the social networks of patients with multimorbidity. METHODS Social network maps were completed by both patients and general practice. The social network maps of 22 patients with multimorbidity were compared with corresponding social network maps completed by general practice staff. RESULTS In 60% (13/22) of the patients, general practice staff held a high or moderate knowledge of individual patients' social networks. Information on social networks was recalled from staff memory and not systematically recorded in patients' electronic health records. DISCUSSION Social network information is not routinely collected, recorded or used by general practice to understand the support available to patients with multimorbidity. General practice could take an active role in coordinating social network supporters for certain patient groups with complex multimorbidity. For these groups, there is value in systematically recording and regularly updating their social network information for general practice to use as part of a coordinated Community of Clinical Practice.

Communities of clinical practice in action: Doing whatever it takes.

Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient's well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients' medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice's repertoires are characterised by care and are driven by the moral imperative to care. They do 'whatever it takes', although there is a cost to this form of care. Well-functioning communities of clinical practice use patient's well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the 'messiness' of community-based care.

Cracking open death: death conversations in primary care.

INTRODUCTION Research supports talking about death outside the end-of-life context. Benefits include allaying death anxiety to increased engagement in health promotion interventions. Nonetheless, the focus on death conversations remains centred on the imminently dying. This qualitative study investigated New Zealanders' perspectives on the value of, opportunities for, and barriers to death conversations in primary healthcare. METHODS Twenty-one participants were interviewed. Participants were young older adults (54-65 years) not receiving palliative care or diagnosed with a terminal illness. Most were women who identified ethnically as New Zealand European. An immersion-crystallisation approach to thematic development was used to accommodate the multidisciplinary research framework. RESULTS Four core themes were identified: 'a need to talk about death'; 'the role of the GP'; 'broaching the topic'; and 'media'. CONCLUSION A cultural silence on death has rendered both the medical and lay community insufficiently prepared for frank and meaningful engagement with the topic, exacerbated by restricted consultation timeframes. The ease of death conversations may be facilitated by taking a family-centred approach, using community organisations and settings, and harnessing conversation entry points provided by the media. Future research should aim to develop tailored resources and frameworks to support general practitioners' meaningful engagement with the topic of death both within and outside of the end-of-life context.

Treatment of opioid dependence in the setting of pregnancy.

Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. Treatment is best offered through a comprehensive treatment program designed to effectively deliver opioid agonist maintenance treatment along with psychosocial and obstetric care. As misuse of prescription analgesics increases in the United States, identification of the problem in pregnancy will become more important because this misuse is expected to lead to an increased prevalence of opioid dependence in pregnancy. Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.

Behavioral health referrals and treatment initiation rates in integrated primary care: a Collaborative Care Research Network study.

Although the benefits of integrating behavioral health (BH) services into primary care are well established (World Health Organization and World Organization of Family Doctors, 2012; Chiles et al. in Clin Psychol-Sci Pr 6:204-220, 1999; Cummings 1997; O'Donohue et al. 2003; Olfson et al. in Health Aff 18:79-93, 1999; Katon et al. in Ann Intern Med 124:917-925, 2001; Simon et al. in Arch Gen Psychiatry 52:850-856, 1995; Anderson et al. in Diabetes Care 24:1069-1078, 2001; Ciechanowski et al. in Arch Intern Med 160:3278-3285, 2000; Egede et al. in Diabetes Care 25:464-470, 2002), research has focused primarily on describing the types of interventions behavioral health providers (BHPs) employ rather than on reasons for referral, treatment initiation rates, or the patient characteristics that may impact them. This study presents the results of a multisite card study organized by The Collaborative Care Research Network, a subnetwork of the American Academy of Family Physicians' National Research Network devoted to conducting practice-based research focused on the provision of BH and health behavior services within primary care practices. The goals of the study included: (1) identifying the characteristics of patients referred for BH services; (2) codifying reasons for referral and whether patients were treated for the referral; (3) exploring any differences between patients who initiated BH contact and those who did not; and (4) assessing the types and frequency of BH services provided to patients who attended at least one appointment. Of the 200 patients referred to a BHP, 81 % had an initial contact, 71 % of which occurred on the same day. Men and women were equally likely to engage with a BHP although the time between appointments varied by gender. Depression and anxiety were the primary reasons for referral. Practice-based research is a viable strategy for advancing the knowledge about integrated primary care.

Mental health, substance abuse, and health behavior intervention as part of the patient-centered medical home: a case study.

Currently integrating mental health, substance abuse, and health behavior into Patient-Centered Medical Homes (PCMH) is being advocated with increasing frequency. There are no current reports describing efforts to accomplish this. A theory-based project was developed to integrate mental health, substance abuse, and health behavior services into the fabric and culture of an NCQA-certified level-three PCMH using funding from the Vermont legislature. A mixed methods case report of data from the first 34 months reviews planning, development, implementation, care model, information technology (IT), and data collection, and reports results using the elements of a RE-AIM framework. Early accomplishment of most RE-AIM dimensions is observed. Implementation remains a struggle, specifically the questions of role responsibilities, form, and financing. This effort is a successful pilot implementation of the Primary Care Behavioral Health (PCBH) model in the PCMH with the potential for dissemination toward additional implementation and a model for a comparative effectiveness trial.

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU.

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.

Abandonment at the end of life from patient, caregiver, nurse, and physician perspectives: loss of continuity and lack of closure.

BACKGROUND: Surveys and anecdotes suggest that patients and family members sometimes feel abandoned by their physicians at the transition to end-of-life care. To our knowledge, no prior studies describe abandonment prospectively. METHODS: We conducted a longitudinal, qualitative study of patients, family caregivers, physicians, and nurses using a community-based sample. Using a purposive strategy, we recruited 31 physicians who identified 55 patients with incurable cancer or advanced chronic obstructive pulmonary disease, 36 family caregivers, and 25 nurses. Eligible patients met the prognostic criterion that their physician "would not be surprised" if death occurred within a year. Qualitative, semistructured interviews were performed at enrollment, 4 to 6 months, and 12 months and were audiotaped, transcribed, and coded by an interdisciplinary team. When asked to talk about hope and prognostic information, participants spontaneously raised concerns about abandonment, and we incorporated this topic into our interview guide. RESULTS: Two themes were identified: before death, abandonment worries related to loss of continuity between patient and physician; at the time of death or after, feelings of abandonment resulted from lack of closure for patients and families. Physicians reported lack of closure but did not discuss this as abandonment. CONCLUSIONS: The professional value of nonabandonment at the end of life consists of 2 different elements: (1) providing continuity, of both expertise and the patient-physician relationship; and (2) facilitating closure of an important therapeutic relationship. Framing this professional value as continuity and closure could promote the development of interventions to improve this aspect of end-of-life care.