Evidence-based practice and patient-centered care: Doing both well.

BACKGROUND: Health care organizations increasingly strive to deliver care that is both evidence based and patient centered. Although often complementary, fundamental contradictions may exist between these goals, and the organizational culture and infrastructure necessary to be successful in one domain may inherently diminish performance in the other. PURPOSE: We assessed the relationship between evidence-based practice (EBP) and patient-centered care (PCC) by seeking to identify specific behavioral and process mechanisms, along with organizational characteristics that distinguish medical centers that are able to provide inpatient care that is both evidence based and patient centered from those where performance is either mixed or low in both domains. METHODOLOGY/APPROACH: We analyzed interview data from 142 employees at 12 Veterans Affairs Medical Centers selected based on EBP and PCC performance (high, low, or mixed) using a priori constructs consistent with organizational literature, as well as emergent themes. RESULTS: We confirmed that tensions may arise when attempting to deliver both EBP and PCC and found unique characteristics of organizations that do both well. High-performing sites exhibited organizational cultures of empowerment where both EBP and PCC expectations were emphasized; provided formal and informal institutional supports and structures with regard to PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that facilitated delivery of both EBP and PCC. CONCLUSIONS AND PRACTICE IMPLICATIONS: Organizations that excel in providing both EBP and PCC exhibit unique characteristics and processes. Recognizing that some characteristics such as culture are difficult to change, these findings nonetheless highlight areas that could be enhanced by medical centers striving to deliver care that is both evidence based and patient centered.

Understanding collaborative care implementation in the Department of Veterans Affairs: core functions and implementation challenges.

BACKGROUND: The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time. This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager? METHODS: This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same- both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes. RESULTS: Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders' agendas amidst competing priorities and logistics (staffing and space). CONCLUSIONS: Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.

Patient navigation: development of a protocol for describing what navigators do.

OBJECTIVE: To develop a structured protocol for observing patient navigators at work, describing and characterizing specific activities related to their goals. DATA SOURCES/SETTING: Fourteen extended observations of navigators at three programs within a national trial of patient navigation. STUDY DESIGN: Preliminary observations were guided by a conceptual model derived from the literature and expert consensus, then coded to develop and refine observation categories. These findings were then used to develop the protocol. METHODS: Observation fieldnotes were coded, using both a priori codes and new codes based on emergent themes. Using these codes, the team refined the model and constructed an observation tool that enables consistent categorization of the observed range of navigator actions. FINDINGS: Navigator actions across a wide variety of settings can be categorized in a matrix with two dimensions. One dimension categorizes the individuals and organizational entities with whom the navigator interacts; the other characterizes the types of tasks carried out by the navigators in support of their patients. CONCLUSIONS: Use of this protocol will enable researchers to systematically characterize and compare navigator activities within and across programs.

Crafting a melanoma educational campaign to reach middle-aged and older men.

BACKGROUND: From 1973 through 2002, melanoma mortality rates have risen steeply in middle-aged and older men. Men's higher mortality rate from melanoma is hardly an isolated example of the ways in which men's health lags behind women's health. Given the significantly higher melanoma mortality rates of men compared with women, there is now a need for a melanoma education program targeted to middle-aged and older men and their closest contacts, including spouses, significant others, and health care professionals. OBJECTIVES: In this article, we discuss the theoretical and practical foundations for such a program. Then, taking into account factors such as socioeconomic status, health literacy, and residence, we present suggestions for creating such a campaign. CONCLUSIONS: Planners for a new educational campaign must understand the target audience's motivations for and perceived barriers to behavioral change. Future studies should examine what motivates certain men to conduct skin self-examinations, ask their physicians about melanoma, and attend melanoma screenings, whereas other men with similar risk factors are less prevention conscious. Issues of health literacy and understandability of our messages must be further explored.