Shared Language for Shared Work in Population Health.

People working on behalf of population health, community health, or public health often experience confusion or ambiguity in the meaning of these and other common terms-the similarities and differences and how they bear on the tasks and division of labor for care delivery and public health. Shared language must be clear enough to help, not hinder people working together as they ultimately come to mutual understanding of roles, responsibilities, and actions in their joint work. Based on an iterative lexicon development process, the authors developed and propose a definitional framework as an aid to navigating among related population and community health terms. These terms are defined, similarities and differences clarified, and then organized into 3 categories that reflect goals, realities, and ways to get the job done. Goals include (a) health as well-being for persons, (b) population health as that goal expressed in measurable terms for groups, and (c) community health as population health for particular communities of interest, geography, or other defining characteristic-groups with shared identity and particular systemic influences on health. Realities are social determinants as influences, health disparities as effects, and health equity as both a goal and a design principle. Ways to get the job done include health care delivery systems for enrollees and public health in population-based civic activities-with a broad zone of collaboration where streams of effort converge in partnership with served communities. This map of terms can enable people to move forward together in a broad zone of collaboration for health with less confusion, ambiguity, and conflict.

Financial Impact of Universal Precepting in Family Medicine Residency Clinics.

BACKGROUND AND OBJECTIVES: Precepting methods have significant impact on the financial viability of family medicine residency programs. Following an adverse event, four University of Minnesota Family Medicine residency clinics moved from using Medicare's Primary Care Exception (PCE) and licensure precepting (LP) to a "universal precepting" method in which preceptors see every patient face to face. Variation in the implementation of universal precepting created a natural experiment of its financial impact. METHODS: Universal precepting was implemented in October 2013 across four residency programs. Billing codes were measured 1 year before and 2.5 years after implementation by clinic and residency year. RESULTS: There were significant financial differences between clinics based on original precepting method and implementation quality of universal precepting. The clinic moving from PCE to universal precepting with excellent implementation increased higher-level billing (99214) by 8%-10%. Clinics moving from LP demonstrated wide variation ranging from an 18% increase to a 13% decrease, consistent with the implementation quality. CONCLUSIONS: Clinics transitioning from PCE to universal precepting can see a significant increase in 99214 billing. Clinics transitioning from LP to universal precepting are at significant financial risk if poorly implemented, but may see increased 99214 billing with effective implementation. This suggests that both implementation quality and original precepting method impact 99214 billing rates when transitioning to universal precepting.

Transforming medical care: case study of an exemplary, small medical group.

PURPOSE: Most published descriptions of organizations providing or improving quality of care concern large medical groups or systems; however, 90% of the medical care in the United States is provided by groups of no more than 20 physicians. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality. METHODS: A 15-family physician medical group was identified from comparative public performance scores of 27 medical groups providing most of the primary care in our metropolitan area. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents were reviewed. Four primary care physician researchers and a consultant then reviewed transcriptions, field notes, and materials during semistructured sessions to identify the main attributes of this group and their probable origins. RESULTS: This medical group ranked first in a composite measure of preventive services and fourth and sixth, respectively, in composite scores for coronary artery disease and diabetes care. Our analysis identified 12 attributes of this group that seemed to be associated with its good care quality, with patient-centeredness being the foundational attribute for most of the others. Historical factors important to most of these attributes included small size, physician ownership, and a high value on practice consistency among the clinicians in the group. CONCLUSIONS: The identified 12 attributes of this medical group seem to be associated with its superior care quality, and most of them might be replicable by other small groups if they choose to work toward that end.

Use of clinical indicators to evaluate COPC projects.

BACKGROUND: In 1989, Ramsey Family and Community Medicine Residency adopted a population-based focus for teaching and clinical activities based on the principles of community-oriented primary care (COPC). Evaluation and outcomes measurement proved problematic for each of the five COPC projects we implemented. METHODS: Surrogate measures, or key clinical indicators, were used to monitor the following COPC projects at Ramsey Family Physicians clinic: preschool immunization, family-centered birth, intimate interpersonal violence, teenage pregnancy-sexually transmitted disease prevention, and human immunodeficiency virus (HIV) screening. RESULTS: Between 1995 and 1998, we documented a decline in preschool immunization rates, an increase in preterm births and low-birth-weight infants, improved intimate interpersonal violence screening, a high but stable teenage pregnancy rate, a decrease in teenage chlamydia rate, and improved HIV prenatal screening. Our data collection and analysis were complicated by a lack of relevant indicators related to target goals, a shifting denominator, incomplete data and an unstable numerator, disconnected data sources, and missing comparison data. CONCLUSIONS: COPC project evaluation is an evolving process, and measurement deficiencies become recognized with time. Even so, outcomes measurement legitimizes COPC interventions and provides a value-added component to resident education and clinical activities.