Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults.

OBJECTIVE: Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners. METHODS: Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups. RESULTS: The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs. CONCLUSIONS: Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.

Emergency department safety assessment and follow-up evaluation 2: An implementation trial to improve suicide prevention.

BACKGROUND: Emergency departments (EDs) are important for preventing suicide. Historically, many patients with suicide risk are not detected during routine clinical care, and those who are often do not receive suicide-specific intervention. The original Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE 1) study examined the implementation of universal suicide risk screening and a multi-component ED-initiated suicide prevention intervention. PURPOSE: The ED-SAFE 2 aims to study the impact of using a continuous quality improvement approach (CQI) to improve suicide related care, with a focus on improving universal suicide risk screening in adult ED patients and evaluating implementation of a new brief intervention called the Safety Planning Intervention (SPI) into routine clinical practice. CQI is a quality management process that uses data and collaboration to drive incremental, iterative improvements. The SPI is a personalized approach that focuses on early identification of warning signs and execution of systematic steps to manage suicidal thoughts. ED-SAFE 2 will provide data on the effectiveness of CQI procedures in improving suicide-related care processes, as well as the impact of these improvements on reducing suicide-related outcomes. METHODS: Using a stepped wedge design, eight EDs collected data cross three study phases: Baseline (retrospective), Implementation (12 months), and Maintenance (12 months). Lean methods, a specific approach to pursuing CQI which focuses on increasing value and eliminating waste, were used to evaluate and improve suicide-related care. CONCLUSIONS: The results will build upon the success of the ED-SAFE 1 and will have a broad public health impact through promoting better suicide-related care processes and improved suicide prevention.

An analysis of patient-provider secure messaging at two Veterans Health Administration medical centers: message content and resolution through secure messaging.

OBJECTIVE: We sought to understand how patients and primary care teams use secure messaging (SM) to communicate with one another by analyzing secure message threads from 2 Department of Veterans Affairs facilities. METHODS: We coded 1000 threads of SM communication sampled from 40 primary care teams. RESULTS: Most threads (94.5%) were initiated by patients (90.4%) or caregivers (4.1%); only 5.5% were initiated by primary care team members proactively reaching out to patients. Medication renewals and refills (47.2%), scheduling requests (17.6%), medication issues (12.9%), and health issues (12.7%) were the most common patient-initiated requests, followed by referrals (7.0%), administrative issues (6.5%), test results (5.4%), test issues (5.2%), informing messages (4.9%), comments about the patient portal or SM (4.1%), appreciation (3.9%), self-reported data (2.8%), life issues (1.5%), and complaints (1.5%). Very few messages were clinically urgent (0.7%) or contained other potentially challenging content. Message threads were mostly short (2.7 messages), comprising an average of 1.35 discrete content types. A substantial proportion of issues (24.2%) did not show any evidence of being resolved through SM. Time to response and extent of resolution via SM varied by message content. Proactive SM use by teams varied, but was most often for test results (32.7%), medication-related issues (21.8%), medication renewals (16.4%), or scheduling issues (18.2%). CONCLUSIONS: The majority of messages were transactional and initiated by patients or caregivers. Not all content categories were fully addressed over SM. Further education and training for both patients and clinical teams could improve the quality and efficiency of SM communication.

Patient Portals: An Underused Resource for Improving Patient Engagement.

The potential of patient portals to improve patient engagement and health outcomes has been discussed for more than a decade. The slow growth in patient portal adoption rates among patients and providers in the United States, despite external incentives, indicates that this is a complex issue. We examined evidence of patient portal use and effects with a focus on the pulmonary domain. We found a paucity of studies of patient portal use in pulmonary practice, and highlight gaps for future research. We also report on the experience of a pulmonary department using a patient portal to highlight the potential of these systems.

Exploring the effect of complex patients on care delivery tasks.

PURPOSE: The needs of complex patients with chronic conditions can be unpredictable and can strain resources. Exploring how tasks vary for different patients, particularly those with complex needs, can yield insights about designing better processes in healthcare. The purpose of this paper is to explore the tasks required to manage complex patients in an anticoagulation therapy context. DESIGN/METHODOLOGY/APPROACH: The authors analyzed interviews with 55 staff in six anticoagulation clinics using the Systems Engineering Initiative for Patient Safety (SEIPS) work system framework. The authors qualitatively described complex patients and their effects on care delivery. FINDINGS: Data analysis highlighted how identifying complex patients and their effect on tasks and organization, and the interactions between them was important. Managing complex patients required similar tasks as non-complex patients, but with greater frequency or more intensity and several additional tasks. After complex patients and associated patient interaction and care tasks were identified, a work system perspective was applied to explore how such tasks are integrated within clinics and the resulting implications for resource allocation. PRACTICAL IMPLICATIONS: The authors present a complex patient management framework to guide workflow design in specialty clinics, to better support high quality, effective, efficient and safe healthcare. ORIGINALITY/VALUE: The complex patient framework presented here, based on the SEIPS framework, suggests a more formal and integrated analysis be completed to provide better support for appropriate resource allocation and care coordination.

Composite model for profiling physicians across domains of care.

Physician profiling methods are envisioned as a means of promoting healthcare quality by recognizing the contributions of individual physicians. Developing methods that can reliably distinguish among physicians' performance is challenging because of small sample sizes, incomplete data, and physician panel differences. In this study, we developed a hierarchical, weighted composite model to reliably compare primary care physicians across domains of care, and we demonstrated its use within a clinical system. We evaluated 199 primary care physicians from a large integrated healthcare delivery system using 19 quality and two efficiency measures taken from the Healthcare Effectiveness Data and Information Set and existing pay-for-performance programs. Individual measures were calculated, compared to benchmarks, and grouped into two composites: one focused on quality and one on efficiency. Each composite was fitted to the model, assessed for reliability (signal-to-noise ratio), and weighted to create a single summary score for each primary care physician. The quality-of-care composite had a median reliability of .98, with 99.5% of all physician reliability estimates exceeding threshold. The efficiency composite had a median reliability of .97, with 94.9% of all physician reliability estimates exceeding threshold. Our results demonstrate that reliable physician profiling is possible across care domains using a hierarchical composite model based on multiple data. The model was used to distribute incentive payouts among primary care physicians but is adaptable to many settings.