Perceived Effectiveness of Home-Based Primary Care Teams in Veterans Health Administration.

BACKGROUND AND OBJECTIVES: Previous studies have shown that staff perception of team effectiveness is related to better health outcomes in various care settings. This study focused on the Veterans Health Administration's Home-Based Primary Care (HBPC) program. We examined variations in HBPC interdisciplinary teamwork (IDT) and identified modifiable team and program characteristics that may influence staff perceptions of team effectiveness. RESEARCH DESIGN: We used a broadly validated survey instrument to measure perceived team effectiveness, workplace conditions/resources, group culture, and respondents' characteristics. Surveys were initiated in January and completed in July, 2016. METHODS: Team membership rosters (n = 249) included 2,852 IDT members. The final analytical data set included 1,403 surveys (49%) from 221 (89%) teams. A generalized estimating equation model with logit link function, weighted by survey response rates, was used to examine factors associated with perceived team effectiveness. RESULTS: Respondents who served as primary care providers (PCPs) were 8% more likely (p = .0044) to view team's performance as highly effective compared to other team members. Teams with nurse practitioners serving as team leader reported 6% higher likelihood of high-perceived team effectiveness (p = .0234). High team effectiveness was 13% more likely in sites where the predominant culture was characterized as group/developmental, and 7%-8% more likely in sites with lower environmental stress and better resources and staffing, respectively. CONCLUSIONS AND IMPLICATIONS: Team effectiveness is an important indirect measure of HBPC teams' function. HBPC teams should examine their predominant culture, workplace stress, resources and staffing, and PCP leadership model as part of their quality improvement efforts.

Palliative care referral among patients hospitalized with advanced heart failure.

BACKGROUND: Many heart failure (HF) patients experience high symptom burden, but palliative care (PC) services have been used infrequently in this population. OBJECTIVE: The specific aim of this study was to identify individual-level factors associated with PC referral. METHODS: The study sample included adult patients hospitalized at an academic medical center with a primary diagnosis of HF between January 2005 and June 2010. Inpatient records were merged with the PC database to identify HF patients who received PC consultations. The analytical sample included 2647 HF admissions. We used descriptive statistics to characterize HF patients who received and did not receive PC services. Logistic regression analyses were used to identify patient characteristics that predict PC referral. RESULTS: Just over 6% of patients with HF were referred to PC during their hospitalization. We identified the following statistically significant determinants of PC referral: secondary diagnosis of Alzheimer's disease, receipt of thoracentesis, intensive care unit (ICU) stay, and prior HF-related hospitalizations. CONCLUSIONS: Currently, only a fraction of HF patients who are at high risk for morbidity and mortality receive PC services. Additional research is needed to identify factors associated with PC referral that can be prospectively identified, and to develop better prediction models to identify HF patients who may benefit from PC referral.

Seasonal influenza vaccination at school: a randomized controlled trial.

BACKGROUND: Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal. Primary care practices may not have the capacity to vaccinate all children during influenza vaccination season. No real-world models of school-located seasonal influenza (SLV-I) programs have been tested. PURPOSE: Determine the feasibility, sustainability, and impact of an SLV-I program providing influenza vaccination to elementary school children during the school day. DESIGN: In this pragmatic randomized controlled trial of SLV-I during two vaccination seasons, schools were randomly assigned to SLV-I versus standard of care. Seasonal influenza vaccine receipt, as recorded in the state immunization information system (IIS), was measured. SETTING/PARTICIPANTS: Intervention and control schools were located in a single western New York county. Participation (intervention or control) included the sole urban school district and suburban districts (five in Year 1, four in Year 2). INTERVENTION: After gathering parental consent and insurance information, live attenuated and inactivated seasonal influenza vaccines were offered in elementary schools during the school day. MAIN OUTCOME MEASURES: Data on receipt of ≥1 seasonal influenza vaccination in Year 1 (2009-2010) and Year 2 (2010-2011) were collected on all student grades K through 5 at intervention and control schools from the IIS in the Spring of 2010 and 2011, respectively. Additionally, coverage achieved through SLV-I was compared to coverage of children vaccinated elsewhere. Preliminary data analysis for Year 1 occurred in Spring 2010; final quantitative analysis for both years was completed in late Fall 2012. RESULTS: Results are shown for 2009-2010 and 2010-2011, respectively: Children enrolled in suburban SLV-I versus control schools had vaccination coverage of 47% vs 36%, and 52% vs 36% (p<0.0001 both years). In urban areas, coverage was 36% vs 26%, and 31% vs 25% (p<0.001 both years). On multilevel logistic analysis with three nested levels (student, school, school district) during both vaccination seasons, children were more likely to be vaccinated in SLV-I versus control schools; ORs were 1.6 (95% CI=1.4, 1.9; p<0.001) and 1.5 (95% CI=1.3, 1.8; p<0.001). CONCLUSIONS: Delivering influenza vaccine during school is a promising approach to improving pediatric influenza vaccination coverage. TRIAL REGISTRY: ClinicalTrials.govNCT01224301.

Hospitalizations in the Program of All-Inclusive Care for the Elderly.

OBJECTIVES: To measure the rates of hospitalization, readmission, and potentially avoidable hospitalization (PAH) in the Program of All-Inclusive Care for the Elderly (PACE). DESIGN: Retrospective study. SETTING PACE PARTICIPANTS: PACE enrollees. MEASUREMENTS: Hospitalization and PAH rates were measured per 1,000 person-years. Readmission was defined as any return to the hospital within 30 days of prior hospital discharge. PAHs were defined as hospitalizations for conditions that previously established criteria have identified as possibly preventable or manageable without hospitalization. RESULTS: Rate of hospitalization was 539/1,000, vs 962/1,000 for dually eligible aged or disabled waiver (ADW) enrollees. Thirty-day readmission was 19.3%, compared with 22.9% for the national population of dually eligible older enrollees. PAH rate was 100/1,000, compared with 250/1,000 for dually eligible ADW enrollees. Considerable variation was observed between sites. CONCLUSION: PACE enrollees experienced lower rates of hospitalization, readmission, and PAH than similar populations. Variations in hospitalization rates between PACE sites suggest opportunities for quality improvement.