Practice Expenses Associated with Comprehensive Primary Care Capabilities.

Through the Comprehensive Primary Care (CPC) and Comprehensive Primary Care Plus (CPC+) programs, the Centers for Medicare & Medicaid Services (CMS) has encouraged primary care practices to invest in "comprehensive primary care" capabilities. Empirical evidence suggests these capabilities are under-reimbursed or not reimbursed under prevailing fee-for-service payment models. To help CMS design alternative payment models (APMs) that reimburse the costs of these capabilities, the authors developed a method for estimating related practice expenses. Fifty practices, sampled for diversity across CPC+ participation status, geographic region, rural status, size, and parent-organization affiliation, completed the study. Researchers developed a mixed-methods strategy, beginning with interviews of practice leaders to identify their capabilities and the types of costs incurred. This was followed by researcher-assisted completion of a workbook tailored to each practice, which gathered related labor and nonlabor costs. In a final interview, practice leaders reviewed cost estimates and made any needed corrections before approval. A main goal was to address a persistent question faced by CMS: When practices reported widely divergent costs for a given capability, was that divergence due to practices having different prices for the same capability or from their having substantially different capabilities? The cost estimation method developed in this project collected detailed data on practice capabilities and their costs. However, the small sample did not allow quantitative estimation of the contributions of service level and pricing to the variation in overall costs. This cost estimation method, deployed on a larger scale, could generate robust data to inform new payment models aimed at incentivizing and sustaining comprehensive primary care.

A scoping review of strategies for financing the implementation of evidence-based practices in behavioral health systems: State of the literature and future directions.

Background: Increased availability of evidence-based practices (EBPs) is essential to alleviating the negative public health and societal effects of behavioral health problems. A major challenge to implementing and sustaining EBPs broadly is the limited and fragmented nature of available funding. Method: We conducted a scoping review that assessed the current state of evidence on EBP financing strategies for behavioral health based on recent literature (i.e., post-Affordable Care Act). We defined financing strategies as techniques that secure and direct financial resources to support EBP implementation. This article introduces a conceptualization of financing strategies and then presents a compilation of identified strategies, following established reporting guidelines for the implementation strategies. We also describe the reported level of use for each financing strategy in the research literature. Results: Of 23 financing strategies, 13 were reported as being used within behavioral health services, 4 had potential for use, 5 had conceptual use only, and 1 was potentially contraindicated. Examples of strategies reported being used include increased fee-for-service reimbursement, grants, cost sharing, and pay-for-success contracts. No strategies had been evaluated in ways that allowed for strong conclusions about their impact on EBP implementation outcomes. Conclusion: The existing literature on EBP financing strategies in behavioral health raises far more questions than answers. Therefore, we propose a research agenda that will help better understand these financing strategies. We also discuss the implications of our findings for behavioral health professionals, system leaders, and policymakers who want to develop robust, sustainable financing for EBP implementation in behavioral health systems. Plain language abstract: Organizations that treat behavioral health problems (mental health and substance use) often seek to adopt and use evidence-based practices (EBPs). A challenge to adopting EBPs broadly is the limited funding available, often from various sources that are poorly coordinated with one another. To help organizations plan effectively to adopt EBPs, we conducted a review of recent evidence (i.e., since the passage of the 2010 Affordable Care Act) on strategies for financing EBP adoption in behavioral health systems. We present definitions of 23 identified strategies and describe each strategy's reported (in the research literature) level of use to fund EBP adoption in behavioral health services. Of the 23 financing strategies, 13 strategies had evidence of use, 4 had potential for use, 5 had conceptual use only, and 1 was potentially contraindicated. Examples of strategies with evidence of use include increased fee-for-service reimbursement, grants, cost sharing, and pay-for-success contracts. This comprehensive list of EBP financing strategies may help guide decision-making by behavioral health professionals, system leaders, and policymakers. The article also presents a research agenda for building on the current research literature by (1) advancing methods to evaluate financing strategies' effects, (2) partnering with stakeholders and decision-makers to examine promising financing strategies, (3) focusing on strategies and service systems with the greatest needs, (4) improving methods to guide the selection of financing strategies, and (5) paying greater attention to sustainable long-term financing of EBPs.

Urban Religious Congregations' Responses to Community Substance Use: An Exploratory Study of Four Cases.

Faith-based drug treatment programs are common, and many are implemented through congregations; however, little is documented about how congregations conceptualize and implement these programs. We use case study analysis to explore congregational approaches to drug treatment; qualitative findings emerged in three areas: (1) religion's role in congregational responses to substance use, (2) relationships between program participants and the broader congregation, and (3) interactions between congregational programs and the external community. Congregational approaches to drug treatment can be comprehensive, but work is needed to evaluate such efforts. Congregants' attitudes may influence whether program participants become members of a sustaining congregational community.

Examining differential performance of 3 medical home recognition programs.

OBJECTIVES: We examined differences in patient outcomes associated with 3 patient-centered medical home (PCMH) recognition programs-National Committee for Quality Assurance (NCQA) Level 3, The Joint Commission (TJC), and Accreditation Association for Ambulatory Health Care (AAAHC)-among Medicare beneficiaries receiving care at federally qualified health centers (FQHCs). STUDY DESIGN: We used data from CMS' FQHC Advanced Primary Care Practice Demonstration, in which participating FQHCs received assistance to achieve NCQA Level 3 PCMH recognition. We assessed the impact of the 3 recognition programs on utilization, quality, and Medicare expenditures using a sample of 1108 demonstration and comparison FQHCs. METHODS: Using propensity-weighted difference-in-differences analyses, we compared changes in outcomes over 3 years for beneficiaries attributed to FQHCs that achieved each type of recognition relative to beneficiaries attributed to FQHCs that did not achieve recognition. RESULTS: Recognized FQHCs, compared with nonrecognized FQHCs, were associated with significant 3-year changes in FQHC visits, non-FQHC primary care visits, specialty visits, emergency department (ED) visits, hospitalizations, a composite diabetes process measure, and Medicare expenditures. Changes varied in direction and strength by recognition type. In year 3, compared with nonrecognized sites, NCQA Level 3 sites were associated with greater increases in ambulatory visits and quality and greater reductions in hospitalizations and expenditures (P <.01), TJC sites were associated with significant reductions in ED visits and hospitalizations (P <.01), and AAAHC sites had changes in the opposite direction of what we anticipated. CONCLUSIONS: Heterogeneous changes in beneficiary utilization, quality, and expenditures by recognition type may be explained by differences in recognition criteria, evaluation processes, and documentation requirements.

Implementation of Medical Homes in Federally Qualified Health Centers.

BACKGROUND: From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS: We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period. RESULTS: Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences. CONCLUSIONS: Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.).

Using institutional theory to analyse hospital responses to external demands for finance and quality in five European countries.

OBJECTIVES: Given the impact of the global economic crisis, delivering better health care with limited finance grows more challenging. Through the lens of institutional theory, this paper explores pressures experienced by hospital leaders to improve quality and constrain spending, focusing on how they respond to these often competing demands. METHODS: An in-depth, multilevel analysis of health care quality policies and practices in five European countries including longitudinal case studies in a purposive sample of ten hospitals. RESULTS: How hospitals responded to the financial and quality challenges was dependent upon three factors: the coherence of demands from external institutions; managerial competence to align external demands with an overall quality improvement strategy, and managerial stability. Hospital leaders used diverse strategies and practices to manage conflicting external pressures. CONCLUSIONS: The development of hospital leaders' skills in translating external requirements into implementation plans with internal support is a complex, but crucial, task, if quality is to remain a priority during times of austerity. Increasing quality improvement skills within a hospital, developing a culture where quality improvement becomes embedded and linking cost reduction measures to improving care are all required.

Perspectives on Federal Funding for State Health Care-Associated Infection Programs: Achievements, Barriers, and Implications for Sustainability.

In September 2009, federal funding for health care-associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states-including state health department employees, representatives from partner organizations, and health care facility employees-were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.

The national response for preventing healthcare-associated infections: infrastructure development.

BACKGROUND: In 2009, the US Department of Health and Human Services (HHS) launched the Action Plan to Prevent Healthcare-associated Infections (HAIs). The Action Plan adopted national targets for reduction of specific infections, making HHS accountable for change across the healthcare system over which federal agencies have limited control. OBJECTIVES: This article examines the unique infrastructure developed through the Action Plan to support adoption of HAI prevention practices. RESEARCH DESIGN: Interviews of federal (n=32) and other stakeholders (n=38), reviews of agency documents and journal articles (n=260), and observations of interagency meetings (n=17) and multistakeholder conferences (n=17) over a 3-year evaluation period. MEASURES: We extract key progress and challenges in the development of national HAI prevention infrastructure--1 of the 4 system functions in our evaluation framework encompassing regulation, payment systems, safety culture, and dissemination and technical assistance. We then identify system properties--for example, coordination and alignment, accountability and incentives, etc.--that enabled or hindered progress within each key development. RESULTS: The Action Plan has developed a model of interagency coordination (including a dedicated "home" and culture of cooperation) at the federal level and infrastructure for stimulating change through the wider healthcare system (including transparency and financial incentives, support of state and regional HAI prevention capacity, changes in safety culture, and mechanisms for stakeholder engagement). Significant challenges to infrastructure development included many related to the same areas of progress. CONCLUSIONS: The Action Plan has built a foundation of infrastructure to expand prevention of HAIs and presents useful lessons for other large-scale improvement initiatives.

The national response for preventing healthcare-associated infections: data and monitoring.

BACKGROUND: Historically, the ability to accurately track healthcare-associated infections (HAIs) was hindered due to a lack of coordination among data sources and shortcomings in individual data sources. OBJECTIVES: This paper presents the results of the evaluation of the HAI data and the monitoring component of the Action Plan, focusing on context (goals), inputs, and processes. RESEARCH DESIGN: We used the Content-Input-Process-Product framework, together with the HAI prevention system framework, to describe the transformative processes associated with data and monitoring efforts. RESULTS: Six HAI priority conditions in the 2009 Action Plan created a focus for the selection of goals and activities. Key Action Plan decisions included a phased-in data and monitoring approach, commitment to linking the selection of priority HAIs to highly visible national 5-year prevention targets, and the development of a comprehensive HAI database inventory. Remaining challenges relate to data validation, resources, and the opportunity to integrate electronic health and laboratory records with other provider data systems. CONCLUSIONS: The Action Plan's data and monitoring program has developed a sound infrastructure that builds upon technological advances and embodies a firm commitment to prioritization, coordination and alignment, accountability and incentives, stakeholder engagement, and an awareness of the need for predictable resources. With time, and adequate resources, it is likely that the investment in data-related infrastructure during the Action Plan's initial years will reap great rewards.

The national response for preventing healthcare-associated infections: research and adoption of prevention practices.

BACKGROUND: Healthcare-associated infections (HAIs) have long been the subject of research and prevention practice. When findings show potential to significantly impact outcomes, clinicians, policymakers, safety experts, and stakeholders seek to bridge the gap between research and practice by identifying mechanisms and assigning responsibility for translating research to practice. OBJECTIVES: This paper describes progress and challenges in HAI research and prevention practices, as explained through an examination of Health and Human Services (HHS) Action Plan's goals, inputs, and implementation in each area. RESEARCH DESIGN: We used the Context-Input-Process-Product evaluation model, together with an HAI prevention system framework, to assess the transformative processes associated with HAI research and adoption of prevention practices. RESULTS: Since the introduction of the Action Plan, HHS has made substantial progress in prioritizing research projects, translating findings from those projects into practice, and designing and implementing research projects in multisite practice settings. Research has emphasized the basic science and epidemiology of HAIs, the identification of gaps in research, and implementation science. The basic, epidemiological, and implementation science communities have joined forces to better define mechanisms and responsibilities for translating HAI research into practice. Challenges include the ongoing need for better evidence about intervention effectiveness, the growing implementation burden on healthcare providers and organizations, and challenges implementing certain practices. CONCLUSIONS: Although these HAI research and prevention practice activities are complex spanning multiple system functions and properties, HHS is making progress so that the right methods for addressing complex HAI problems at the interface of patient safety and clinical practice can emerge.

The national response for preventing healthcare-associated infections: system capacity and sustainability for improvement.

BACKGROUND: Strengthening capacity across the healthcare system for improvement is critical to ensuring that past efforts and investments establish a foundation for sustaining progress in patient safety. OBJECTIVES: The objective of this analysis was to identify key system capacity issues for sustainability from evaluation of the Action Plan to prevent healthcare-associated infections, a major national initiative launched by the US Department of Health and Human Services in 2009. RESEARCH DESIGN: The analysis involves the review and synthesis of results across the components of a 3-year evaluation of the Action Plan, as described in the evaluation framework and detailed in separate analyses elsewhere in this special issue. Data collection methods included interviews with government and private stakeholders, document and literature reviews, and observations of meetings and conferences at multiple time points. MEASURES: Key developments in healthcare-associated infection prevention system capacity were extracted on the basis of "major activities" identified through multiple methods and organized into the level of progress based on perspectives of multiple stakeholders. Activities within each level were then examined and compared according to our evaluation's framework of 4 system functions and 5 system properties. RESULTS: Key system capacity and sustainability issues for the Action Plan to be addressed centered on coordination and alignment (among participating agencies, with other federal initiatives, and across levels of healthcare), infrastructure for data and accountability (including more efficient technologies and unintended consequences), cultural embedding of prevention practices, and uncertainty and variability in resources. CONCLUSIONS: Sustainability depends on improvements across system functions and properties and how they reinforce each other. Change is more robust if different system elements support and incentivize behavior in similar directions.

Approach for conducting the longitudinal program evaluation of the US Department of Health and Human Services National Action Plan to prevent healthcare-associated infections: roadmap to elimination.

BACKGROUND: In response to mounting evidence about skyrocketing morbidity, mortality, and costs associated with healthcare-associated infections (HAIs), in 2009, the US Department of Health and Human Services (HHS) issued the HHS HAI Action Plan to enhance collaboration and coordination and to strengthen the impact of national efforts to address HAIs. To optimize timely understanding of the Action Plan's approach and outcomes, as well as improve the likely success of this effort, HHS requested an independent longitudinal and formative program evaluation. OBJECTIVES: This article describes the evaluation approach to assessing HHS's progress and the challenges encountered as HHS attempted to transform the national strategy to HAI elimination. RESEARCH DESIGN: The Context-Input-Process-Product (CIPP) model, a structured-yet-flexible formative and summative evaluation tool, supported the assessment of: (1) the Context in which the Action Plan developed, (2) the Inputs and decisions made about selecting activities for implementation, (3) Processes or implementation of selected activities, and (4) Products and outcomes. MEASURES: A system framework consisting of 4 system functions and 5 system properties. RESULTS: The CIPP evaluation model provides a structure for tracking the components of the program, the relationship between components, and the way in which components change with time. The system framework allows the evaluation team to understand what the Action Plan is doing and how it aims to facilitate change in the healthcare system to address the problem of HAIs. CONCLUSIONS: With coordination and alignment becoming increasingly important among large programs within healthcare and other fields, program evaluations like this can inform the policy community about what works and why, and how future complex large-scale programs should be evaluated.

Social entrepreneurship in religious congregations' efforts to address health needs.

PURPOSE: Examine how religious congregations engage in social entrepreneurship as they strive to meet health-related needs in their communities. DESIGN: Multiple case studies. SETTING: Los Angeles County, California. PARTICIPANTS: Purposive sample of 14 congregations representing diverse races/ethnicities (African-American, Latino, and white) and faith traditions (Jewish and various Christian). METHOD: Congregations were recruited based on screening data and consultation of a community advisory board. In each congregation, researchers conducted interviews with clergy and lay leaders (n = 57); administered a congregational questionnaire; observed health activities, worship services, and neighborhood context; and reviewed archival information. Interviews were analyzed by using a qualitative, code-based approach. RESULTS: Congregations' health-related activities tended to be episodic, small in scale, and local in scope. Trust and social capital played important roles in congregations' health initiatives, providing a safe, confidential environment and leveraging resources from-and for-faith-based and secular organizations in their community networks. Congregations also served as "incubators" for members to engage in social entrepreneurship. CONCLUSION: Although the small scale of congregations' health initiatives suggest they may not have the capacity to provide the main infrastructure for service provision, congregations can complement the efforts of health and social providers with their unique strengths. Specifically, congregations are distinctive in their ability to identify unmet local needs, and congregations' position in their communities permit them to network in productive ways.

Implementation of the CALM intervention for anxiety disorders: a qualitative study.

BACKGROUND: Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) []) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed? METHODS: Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes. RESULTS: Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS. CONCLUSIONS: The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.

Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities.

Community partnered research and engagement strategies are gaining recognition as innovative approaches to improving health care systems and reducing health disparities in underserved communities. These strategies may have particular relevance for mental health interventions in low income, minority communities in which there often is stigma and silence surrounding conditions such as depression and difficulty in implementing improved access and quality of care. At the same time, there is a relative dearth of evidence on the effectiveness of specific community engagement interventions and on the design, process, and context of these interventions necessary for understanding their implementation and generalizability. This article evaluates one of a number of community engagement strategies employed in the Community Partners in Care (CPIC) study, the first randomized controlled trial of the role of community engagement in adapting and implementing evidence-based depression care. We specifically describe the unique goals and features of a community engagement kickoff conference as used in CPIC and provide evidence on the effectiveness of this type of intervention by analyzing its impact on: 1) stimulating a dialog sense of collective efficacy, and opportunities for learning and networking to address depression and depression care in the community; 2) activating interest and participation in CPIC's randomized trial of two different ways to implement evidence-based quality improvement programs for depression across diverse community agencies; and 3) introducing evidence-based toolkits and collaborative care models to potential participants in both intervention conditions and other community members. We evaluated the effectiveness of the conference through a community-partnered process in which both community and academic project members were involved in study design, data collection and analysis. Data sources include participant conference evaluation forms (n = 187 over two conferences; response rate 59%) and qualitative observation field notes of each conference session. Mixed methods for the analysis consist of descriptive statistics of conference evaluation form ratings, as well as thematic analysis of evaluation form write-in comments and qualitative observation notes. Results indicate the effectiveness of this type of event for each of the three main goals, and provide insights into intervention implementation and use of similar community engagement strategies for other studies.

Implementation and maintenance of quality improvement for treating depression in primary care.

OBJECTIVE: Little is known about the long-term success of quality improvement efforts for the treatment of depression in primary care. This study assessed factors associated with the successful implementation, maintenance, and spread of such efforts. METHODS: The authors conducted an independent process evaluation of data from monthly progress reports and 18-month telephone interviews from multidisciplinary quality improvement teams in 17 diverse primary care organizations that participated in the Institute for Healthcare Improvement's Breakthrough Series for Depression from February 2000 through March 2001. RESULTS: All sites made changes toward improving care in three of six categories: delivery system redesign, self-management strategies, and information systems. The changes that were most commonly viewed as major successes were delivery system changes (ten sites, or 59 percent) and information system changes (nine sites, or 53 percent); these types of changes were also the most often sustained over time (ten sites, or 59 percent, and 16 sites, or 94 percent, respectively). Fifteen sites made changes in decision support, community linkages, and health system support but were less likely to view these changes as major successes or to sustain them. Organizational structure and leadership support were the most common facilitators. Staff resistance, time constraints, and information technology were the most common barriers. Implementation strategies varied with sets of barriers. CONCLUSIONS: Despite substantial challenges, there was evidence of broad success at implementation and maintenance of quality improvement for depression treatment in primary care.