The Impact of Delivery Reform on Health Information Exchange with Behavioral Health Providers: Results from a National Representative Survey of Ambulatory Physicians.

Health information exchange (HIE) is an effective way to coordinate care, but HIE between health and behavioral health providers is limited. Recent delivery reform models, including the Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) prioritize interprofessional collaboration, but little is known about their impact on behavioral health HIE. This study explores whether delivery reform participation affects behavioral health HIE among ambulatory health providers using pooled 2015-2019 data from the National Electronic Health Record Survey, a nationally representative survey of ambulatory physicians' technology use (n = 8,703). The independent variable in this analysis was provider participation in ACO, PCMH, Hybrid ACO-PCMH, or standard care. The dependent variable was HIE with behavioral health providers. Chi square analysis estimated unweighted rates of behavioral health HIE across reform models. Logistic regression estimated the impact of delivery reform participation on rates of behavioral health HIE. Unweighted estimates indicated that Hybrid ACO-PCMH providers had the highest rates of HIE (n = 330, 33%). In the fully adjust model, rates of HIE were higher among ACO (AOR = 2.66, p < .01), PCMH (AOR = 4.73, p < .001) and Hybrid ACO-PCMH participants (AOR = 5.55, p < .001) compared to standard care, but they did not significantly vary between delivery models. Physicians infrequently engage in HIE with behavioral health providers. Compared to standard care, higher rates of HIE were found across all models of delivery reform. More work is needed to identify common elements of delivery reform models that are most effective in supporting this behavior.

Towards a universal model of family centered care: a scoping review.

BACKGROUND: Families play an important role meeting the care needs of individuals who require assistance due to illness and/or disability. Yet, without adequate support their own health and wellbeing can be compromised. The literature highlights the need for a move to family-centered care to improve the well-being of those with illness and/or disability and their family caregivers. The objective of this paper was to explore existing models of family-centered care to determine the key components of existing models and to identify gaps in the literature. METHODS: A scoping review guided by Arksey & O'Malley (2005) examined family-centered care models for diverse illness and age populations. We searched MEDLINE, PsycINFO, CINAHL and EMBASE for research published between 1990 to August 1, 2018. Articles describing the development of a family-centered model in any patient population and/or healthcare field or on the development and evaluation of a family-centered service delivery intervention were included. RESULTS: The search identified 14,393 papers of which 55 met our criteria and were included. Family-centered care models are most commonly available for pediatric patient populations (n = 40). Across all family-centered care models, the consistent goal is to develop and implement patient care plans within the context of families. Key components to facilitate family-centered care include: 1) collaboration between family members and health care providers, 2) consideration of family contexts, 3) policies and procedures, and 4) patient, family, and health care professional education. Some of these aspects are universal and some of these are illness specific. CONCLUSIONS: The review identified core aspects of family-centred care models (e.g., development of a care plan in the context of families) that can be applied to all populations and care contexts and some aspects that are illness specific (e.g., illness-specific education). This review identified areas in need of further research specifically related to the relationship between care plan decision making and privacy over medical records within models of family centred care. Few studies have evaluated the impact of the various models on patient, family, or health system outcomes. Findings can inform movement towards a universal model of family-centered care for all populations and care contexts.

Relationship-focused vs. Structural Activities in Medical Home Measurement in Pediatrics.

Objectives The Family-Centered Medical Home (FCMH) has become a model of effective and efficient primary care. However, efforts to measure the FCMH may ignore its complexity. We sought to determine whether U.S. primary care pediatricians view structure-focused and relationship-focused practice activities of the FCMH as distinct constructs and how these constructs are associated with practice functions. Methods We analyzed data from the 2012 American Academy of Pediatrics Periodic Survey of Fellows #79 (n = 572) addressing opinions and practice activities related to the FCMH. Through a modified Delphi expert process, we selected items believed to be primarily structure-focused and items that were relationship-focused. Confirmatory factor analysis was used to test whether these constructs were distinct. Separate structural equation models assessed whether structure-focused and relationship-focused activities predicted three broader survey items: (1) interest in FCMH; (2) application for FCMH recognition; and (3) whether a team meets to discuss FCMH improvements. Results The initial two-factor model did not fit well, but improved with movement of two items from the structure to the relationship-focused group. The two factors correlated at r = 0.70. Respondents with increased relationship-focused activities had statistically higher odds of having medium/high interest in FCMH, and having a team meet to discuss FCMH improvements. Respondents with increased structure-focused activities also had higher odds of having team meetings to discuss FCMH improvements, but lower odds of applying for FCMH recognition. Conclusions for Practice The FCMH is multi-dimensional, with relationship- and structure-focused activities differentially linked to pediatrician reports of broader FCMH functions.

Visibility and meanings of partnership in health care for older people who need support to live at home.

INTRODUCTION: Problems experienced by older people with complex needs to live at home have been reported in the literature. This qualitative study builds on previous research and investigates enduring issues older people face when interacting with healthcare services. AIM: To gain an in-depth understanding of what is involved in providing good quality health care for older people who need support to live at home. METHODOLOGICAL DESIGN: We adopted an interpretive descriptive approach and conducted semi-structured interviews with older people (n = 7), carers (n = 8) and key informants (n = 11). Initial and secondary analysis of qualitative data was completed. FINDINGS: Major themes emerged about meanings of partnership in health care, and invisibility of the older person as a partner in health care. Partnership in health care was understood to mean being treated as an equal, being involved in decision-making, and making contributions which impact on health care and health systems. The metaphorical concept of 'invisibility' related to the older person not being seen and heard as a partner in health care, as well as being a recipient of care. CONCLUSIONS: We concluded that older people who need support to live at home are not highly visible to health providers, policymakers and researchers as a central partner and consumer to be meaningfully engaged in shaping their health care. Opportunities to address persistent issues with quality of health care may in future be achieved through stronger partnerships between older people and health providers, to find new ways to improve the quality of care for older people.

[Medical homes and poles including pharmacists: An inventory]. / Maisons et pôles de santé pluriprofessionnels incluant des pharmaciens : un état des lieux.

INTRODUCTION: The current restructuring of primary healthcare aims toward the creation of coordinated practices, which involves new roles for pharmacists. The objectives of this study were to identify all the French multidisciplinary medical homes and poles (MMHs and MMPs) with pharmacists currently active, and to describe how they are organized and operate. METHODS: This study focused on metropolitan MMHs and MMPs, active during the second semester of 2013, which include one or several pharmacists. These centers were identified through information provided by French regional health authorities (Agences régionales de santé, ARS) and the French medical homes medical poles federation (Fédération française des maisons et pôles de santé). Data were collected via an electronic questionnaire. RESULTS: Pharmacists were active in 60 centers in total, namely 35 MMHs and 25 MMPs. These were mostly set up as sociétés interprofessionnelles de soins ambulatoires (SISA, a type of company), with the help of government funding, typically from the ARS, in buildings owned by local government agencies. Pharmacists were systematically invited to attend interprofessional meetings held in the MMHs and MMPs, and multimodal treatment protocols were often in place. Pharmacists had no access to shared clerical services in MMHs, and rarely in MMPs, and their access to medical records was inconsistent in the two types of structures. CONCLUSION: Pharmacists are currently active in nearly one in four MMHs and MMPs but are still only partially integrated therein.

Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents.

INTRODUCTION: The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. AIM: We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs? PROGRAM DESCRIPTION: The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs). RESULTS: The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs. DISCUSSION: The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Is the deck stacked against fundamental health human resources redesign in Canada?

Contemporary healthcare is a sobering spectacle. It costs a lot and doesn't deliver much at the margins. But even if deep and open-minded reflection and analysis were to propose a reboot, the odds are very long against it. It is next to impossible to alter deeply entrenched patterns and entitlements. It will take nothing less than a collective commitment on the part of professions, governments, educators, accreditors, employers and a whole host of others to create an agile, responsive and integrated health human resources model for Canada.

Policy and evidence in Canadian health human resources planning.

The health human resources supply in Canada swings reactively between over- and under-supply. There are numerous policy actors in this arena, each of whom could contribute to good data collection and an agreed-on process for decision-making. This could form the basis for evidence-informed policy. Absent these tools for pan-Canadian health human resources policy development, smaller health jurisdictions are experimenting with quality improvement initiatives which, when properly evaluated, can discover useful methods of aligning patient and community needs with healthcare resources.

Closing the primary care gap.

Millions of new patients soon will flood health care systems, exacerbating a nationwide shortage of primary care physicians. This gatefold explores how nurse practitioners and physician assistants can help to fill the void.

Impact of unit practice councils on culture and outcomes.

This article describes positive outcomes in culture, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, employee engagement, and clinical quality as a result of using shared governance, specifically unit practice councils (UPC) or staff councils, to implement Relationship-Based Care (RBC).

Patient centred care - are international medical graduates 'expert novices'?

BACKGROUND: Depending on their previous training, international medical graduates (IMGs) may be unfamiliar with patient centred care (PCC). This study explores the PCC skills that IMGs demonstrated during observed role play. METHODS: Qualitative observational data were collected during an IMG communication skills course and IMGs' perceptions of PCC were explored in semistructured interviews. Analysis followed principles of grounded theory and focused specifically on the elements of Candlin's (2002) quality of discourse. RESULTS: Many of the IMGs observed in this study used discourse features that identify them as novices in PCC: they framed consultations as interviews as opposed to conversations, maintained topic control instead of allowing digressions, and focused on achieving simple coherence rather than seeing the consultation as a whole. DISCUSSION: This study suggests that some IMGs may be novices in PCC while being experts in medical knowledge. A view of IMGs as 'expert novices' may be useful to inform the development of bridging courses.

A perspective on changing dynamics in nursing over the past 20 years.

The quest to provide individuals with good quality health care has been a long-term goal in which the contribution of health professionals, specifically nurses, has been vital. However, over the years ever-increasing demands from both the government and the general public for higher levels of performance, combined with problems associated with the long-standing issue of staff shortages, and the constant drive for cost-effectiveness, has meant achieving this objective has become more difficult.

Mapping the Status of Healthcare Improvement Science through a Narrative Review in Six European Countries.

With the aim to explore how improvement science is understood, taught, practiced, and its impact on quality healthcare across Europe, the Improvement Science Training for European Healthcare Workers (ISTEW) project "Improvement Science Training for European Healthcare Workers" was funded by the European Commission and integrated by 7 teams from different European countries. As part of the project, a narrative literature review was conducted between 2008 and 2019, including documents in all partners' languages from 26 databases. Data collection and analysis involved a common database. Validation took place through partners' discussions. Referring to healthcare improvement science (HIS), a variety of terms, tools, and techniques were reported with no baseline definition or specific framework. All partner teams were informed about the non-existence of a specific term equivalent to HIS in their mother languages, except for the English-speaking countries. A lack of consensus, regarding the understanding and implementation of HIS into the healthcare and educational contexts was found. Our findings have brought to light the gap existing in HIS within Europe, far from other nations, such as the US, where there is a clearer HIS picture. As a consequence, the authors suggest further developing the standardization of HIS understanding and education in Europe.