Community paramedic hospital reduction and mitigation program: study protocol for a randomized pragmatic clinical trial.

BACKGROUND: New patient-centered models of care are needed to individualize care and reduce high-cost care, including emergency department (ED) visits and hospitalizations for low- and intermediate-acuity conditions that could be managed outside the hospital setting. Community paramedics (CPs) have advanced training in low- and high-acuity care and are equipped to manage a wide range of health conditions, deliver patient education, and address social determinants of health in the home setting. The objective of this trial is to evaluate the effectiveness and implementation of the Care Anywhere with Community Paramedics (CACP) program with respect to shortening and preventing acute care utilization. METHODS: This is a pragmatic, hybrid type 1, two-group, parallel-arm, 1:1 randomized clinical trial of CACP versus usual care that includes formative evaluation methods and assessment of implementation outcomes. It is being conducted in two sites in the US Midwest, which include small metropolitan areas and rural areas. Eligible patients are ≥ 18 years old; referred from an outpatient, ED, or hospital setting; clinically appropriate for ambulatory care with CP support; and residing within CP service areas of the referral sites. Aim 1 uses formative data collection with key clinical stakeholders and rapid qualitative analysis to identify potential facilitators/barriers to implementation and refine workflows in the 3-month period before trial enrollment commences (i.e., pre-implementation). Aim 2 uses mixed methods to evaluate CACP effectiveness, compared to usual care, by the number of days spent alive outside of the ED or hospital during the first 30 days following randomization (primary outcome), as well as self-reported quality of life and treatment burden, emergency medical services use, ED visits, hospitalizations, skilled nursing facility utilization, and adverse events (secondary outcomes). Implementation outcomes will be measured using the RE-AIM framework and include an assessment of perceived sustainability and metrics on equity in implementation. Aim 3 uses qualitative methods to understand patient, CP, and health care team perceptions of the intervention and recommendations for further refinement. In an effort to conduct a rigorous evaluation but also speed translation to practice, the planned duration of the trial is 15 months from the study launch to the end of enrollment. DISCUSSION: This study will provide robust and timely evidence for the effectiveness of the CACP program, which may pave the way for large-scale implementation. Implementation outcomes will inform any needed refinements and best practices for scale-up and sustainability. TRIAL REGISTRATION: ClinicalTrials.gov NCT05232799. Registered on 10 February 2022.

Evaluating Patient and Family Experience Among Spanish-Speaking and LatinX Patients: a Scoping Review of Existing Instruments.

INTRODUCTION: LatinX populations are rapidly growing in the USA, but still report lower levels of patient centered care and satisfaction when compared to their non-LatinX white counterparts. This review encompasses literature which describes patient experience instruments that (1) evaluate LatinX experience, (2) have validated Spanish versions, or (3) measure language-concordant care experiences. METHODS: A scoping review of literature in Ovid Medline, CINAHL, and PsycINFO was conducted. Articles were excluded if they were not applicable to the health care industry, did not include a patient experience instrument, or did not include LatinX or Spanish-speaking individuals within their study population. Data extraction was performed for concepts measured, study size, population, health care setting, and languages validated. RESULTS: This review identified 224 manuscripts. Of these, 81 met full inclusion criteria and represented 60 unique instruments. These covered six categories: general patient experience (43%, n = 26/60), experiences of discrimination/mistrust (12%, n = 7/60), cultural factors (10%, n = 6/60), patient-provider relationship (10%, n = 6/60), and communication (8%, n = 5/60). The remaining instruments measured multiple categories (17%, n = 10/60). Just over one third of instruments (n = 24, 5 pediatric, 19 adult) were validated in Spanish and an additional 14 (23%) were validated in English alone. Finally, 4 (7%) instruments were identified which were developed for use in a language concordant setting. CONCLUSION: Many instruments were identified which evaluate LatinX patient experience; however, none was both validated in Spanish and measured in all key categories of experience described above. Additionally, few instruments were developed for holistic evaluation of patient experience in pediatric or language concordant care settings.

Analysing the attributes of Comprehensive Cancer Centres and Cancer Centres across Europe to identify key hallmarks.

There is a persistent variation in cancer outcomes among and within European countries suggesting (among other causes) inequalities in access to or delivery of high-quality cancer care. European policy (EU Cancer Mission and Europe's Beating Cancer Plan) is currently moving towards a mission-oriented approach addressing these inequalities. In this study, we used the quantitative and qualitative data of the Organisation of European Cancer Institutes' Accreditation and Designation Programme, relating to 40 large European cancer centres, to describe their current compliance with quality standards, to identify the hallmarks common to all centres and to show the distinctive features of Comprehensive Cancer Centres. All Comprehensive Cancer Centres and Cancer Centres accredited by the Organisation of European Cancer Institutes show good compliance with quality standards related to care, multidisciplinarity and patient centredness. However, Comprehensive Cancer Centres on average showed significantly better scores on indicators related to the volume, quality and integration of translational research, such as high-impact publications, clinical trial activity (especially in phase I and phase IIa trials) and filing more patents as early indicators of innovation. However, irrespective of their size, centres show significant variability regarding effective governance when functioning as entities within larger hospitals.

A patient-centric pathway for testicular cancer - A multicentre study investigating the uptake of semen cryopreservation and impact on treatment.

BACKGROUND: The option of semen cryopreservation following a diagnosis of testicular cancer shows a variable uptake with the option to cryopreserve before surgery often dependent on the preference of the treating clinician and the fertility laboratory resources available. OBJECTIVES: To assess whether the introduction of a patient-centric pathway for managing suspected testicular cancer increases the uptake of semen cryopreservation and the impact of this on surgical waiting times. MATERIALS AND METHODS: A multicentre retrospective analysis of patients treated as part of a patient-centric pathway was conducted for suspected testicular cancer at two specialist centres within a one-stop testicular clinic. Clinical information, including semen cryopreservation acceptance rate, time intervals to surgery and CT scan, TNM stage, histology and age, was recorded from an institutional database. RESULTS: Eighty nine patients (median age: 34 years (range: 14-89)) underwent orchidectomy for suspected testicular cancer over a 15-month period after the introduction of a patient-centric testicular cancer pathway at two UK centres. The overall uptake of semen cryopreservation was 68.5% (n = 61) with all men under the age of 33 years accepting this option. A microdissection oncoTESE was performed in 9/61 (14.8%) patients who attempted cryopreservation but were found to be azoospermic. Pre-operative CT imaging was completed for 85.4% of patients, and the median time from initial outpatient consultation to orchidectomy was 9 days. DISCUSSION AND CONCLUSIONS: A patient-centric pathway ensures that the uptake of semen cryopreservation remains high particularly for those men within the common age for paternity. It also identifies men who may benefit from microdissection oncoTESE for complex cases such as tumours in solitary testicles, bilateral tumours or an atrophic contralateral testicle as well as those diagnosed with de novo azoospermia. The additional time taken for semen cryopreservation to be performed did not significantly delay orchidectomy or influence the decisions for adjuvant treatment.

Identifying optimal indicators and purposes of population segmentation through engagement of key stakeholders: a qualitative study.

BACKGROUND: Various population segmentation tools have been developed to inform the design of interventions that improve population health. However, there has been little consensus on the core indicators and purposes of population segmentation. The existing frameworks were further limited by their applicability in different practice settings involving stakeholders at all levels. The aim of this study was to generate a comprehensive set of indicators and purposes of population segmentation based on the experience and perspectives of key stakeholders involved in population health. METHODS: We conducted in-depth semi-structured interviews using purposive sampling with key stakeholders (e.g. government officials, healthcare professionals, social service providers, researchers) involved in population health at three distinct levels (micro, meso, macro) in Singapore. The interviews were audio-recorded and transcribed verbatim. Thematic content analysis was undertaken using NVivo 12. RESULTS: A total of 25 interviews were conducted. Eight core indicators (demographic characteristics, economic characteristics, behavioural characteristics, disease state, functional status, organisation of care, psychosocial factors and service needs of patients) and 21 sub-indicators were identified. Age and financial status were commonly stated as important indicators that could potentially be used for population segmentation across three levels of participants. Six intended purposes for population segmentation included improving health outcomes, planning for resource allocation, optimising healthcare utilisation, enhancing psychosocial and behavioural outcomes, strengthening preventive efforts and driving policy changes. There was consensus that planning for resource allocation and improving health outcomes were considered two of the most important purposes for population segmentation. CONCLUSIONS: Our findings shed light on the need for a more person-centric population segmentation framework that incorporates upstream and holistic indicators to be able to measure population health outcomes and to plan for appropriate resource allocation. Core elements of the framework may apply to other healthcare settings and systems responsible for improving population health. TRIAL REGISTRATION: The study was approved by the SingHealth Institutional Review Board (CIRB Reference number: 2017/2597).

Woman-Centred Induction of Labour (the WOCIL project).

Induction of labour (IOL) is a common obstetric intervention. 32% of women are induced per year in our obstetric unit. We were experiencing delays in starting IOLs due to unit activity, protracted inpatient stay and dissatisfaction among staff and service users. We used quality improvement (QI) methodology to identify inefficiencies and root causes and used a bottom-up approach in planning improvements. After optimising our IOL processes, we introduced misoprostol vaginal insert (MVI) as it was faster acting than traditional dinoprostone. We compared 207 women who had MVI with 172 women who had dinoprostone prior to MVI introduction. There was a reduction of IOL start to delivery time, from a mean of 30 hours to 21 hours. Fewer women required oxytocin and of those who did, required oxytocin for fewer hours. We also found a reduction in caesarean section rates in women undergoing IOL, statistically significant in nulliparous women (41%-25%, p=0.03). There was a higher uterine tachysystole and hyperstimulation rate with MVI use and introduction should be accompanied by education of staff. We did not find any increase in neonatal admissions, maternal haemorrhage or other serious adverse events. In summary, MVI is a useful drug in helping high volume units with high IOL rates, reduced bed occupancy and improved flow of women. We would recommend a holistic QI approach to change management, as safe use of the drug requires optimisation of the IOL processes as well as staff engagement, due to rapid flow of women through the IOL pathway and increased hyperstimulation rates.

Impact of a pharmacist in improving quality measures that affect payments to physicians.

OBJECTIVES: The objective was to assess the impact of a pharmacist embedded within a primary care practice on quality measures of the Merit-Based Incentive Payment System (MIPS) and patient-centered medical home (PCMH) by characterizing (1) measure achievement after pharmacist involvement in care and (2) measure achievement separately for patients seen by the pharmacist and patients not seen by the pharmacist. SETTING: Multidisciplinary primary care practice in Charlotte, North Carolina. PRACTICE DESCRIPTION: Pharmacists from an independent community pharmacy are highly integrated into the clinic. Pharmacists work alongside providers to furnish comprehensive care with a team-based approach. The initial focus for the pharmacist was on the Medicare annual wellness visits (AWV) and chronic care management (CCM). PRACTICE INNOVATION: Quality measure achievement during face-to-face AWV, telephone-call CCM, or both. EVALUATION: From January 1, 2017, to February 2, 2018, 193 patients had an AWV, CCM, or both from the pharmacist. Measure achievement was characterized with the use of descriptive statistics. RESULTS: When characterizing quality measures before, during, and after pharmacist intervention for the clinic population, achievement of some measures improved and others worsened. However, for every measure evaluated, the cohort of patients seen by the pharmacist had a greater proportion of patients achieving the quality measure than the cohort of patients not seen by the pharmacist. The greatest differences were observed for influenza vaccination (41% of pharmacist cohort vs. 10% of nonpharmacist cohort), hemoglobin A1C control less than 9% (94% of pharmacist cohort vs. 67% of nonpharmacist cohort), and colorectal cancer screening (55% of pharmacist cohort vs. 28% of nonpharmacist cohort). CONCLUSION: Pharmacist provision of clinical services may increase the likelihood of quality measure achievement. The pharmacist integration model addressed gaps in care that appeared to positively affect MIPS and PCMH quality measures. This has the potential to increase reimbursement through value-based payment models.

Early weight loss outcomes from a newly established hospital-affiliated specialized obesity care delivery model in Central Florida.

SIGNIFICANCE: We evaluated weight loss outcomes in a newly established hospital-affiliated, physician-directed multidisciplinary, and personalized obesity care model. METHODS: Fifty established patients in a specialized obesity medicine practice underwent intensive lifestyle intervention ±adjunctive pharmacotherapy (46/50) for >6 consecutive months and when required, psychological intervention. We identified demographics, obesity-related comorbidities, anthropometric changes over time, and laboratory screen. Psychosocial status was determined using Beck Depression Inventory-II (BDI-II), Brownell-Stunkard Weight-Loss Readiness Test, and Impact of Weight on Quality of Life-Lite (IWQOL). RESULTS: Patient characteristics (mean ± SD) were: 70% female; age 47.0 ± 16.4 y; weight 111.55 ± 32.8 kg; BMI 39.3 ± 8.8 kg/m2; % body fat 45.5 ± 6.3. Patients had attempted at least one diet prior to seeking tertiary obesity care and averaged 2.5 major co-morbidities. In regards to health status, 74% were insulin resistant [HOMA]; 12% had Type 2 DM (HbA1c > 6.5%); 46% were hypertensive; 48% had dyslipidemia, 38% were vitamin D deficient; 44% were depressed (BDI-II). Weight loss at 3 and 6 months averaged -4.18 and -7.88 kg and percentage changes in BMI a respective -4.39 and -7.74% (p < 0.0001). Forty percentage were early responders (ER), having lost ≥ 5% of their initial weight 3 months into the program. Total weight loss for ER vs. non-responders (NR) at 3 months was -7.90 and -1.71 kg, respectively (p < 0.0001) and mean % BMI changes from baseline were a respective -7.77 and -1.88%. CONCLUSIONS: Organized hospital-affiliated specialized obesity care delivery models can be successful in personalized obesity treatment. These types of medical programs for complicated obesity are likely to reduce impediments to addressing obesity effectively.

Evidence that patient-centered medical homes are effective in reducing emergency department admissions for patients with depression.

The patient-centered medical home (PCMH) has increasingly been touted as one means of integrating behavioral health and primary care and more holistically caring for patients with chronic disease. With its whole person orientation, the PCMH presents an opportunity to reduce emergency department visits for patients with depression by focusing on the patient and his/her health care needs, facilitating communication among providers and patients, and improving patients' access to care providers across settings. This study examines the relationship between PCMH capacity - defined as the ability to offer a service identified as a component part of the PCMH - and the number of emergency department visits for patients with depression. Health plan claims data, self-report data from physician practices on their PCMH characteristics, and the Area Resource File were analyzed. Results show that overall PCMH capacity is associated with fewer emergency department visits for patients with depression, and interpersonal aspects of the PCMH in particular, were associated with fewer emergency department visits while technical capabilities were not. Interpersonal activities that facilitate care coordination, patient engagement, and connect patients with community resources might be more effective in keeping patients out of the emergency department for unnecessary reasons as compared to technical activities focused on reporting and information management.

Trauma-informed care in a patient-centered medical home for adolescent mothers and their children.

Adolescent mothers experience higher rates of trauma and abuse, as well as increased risks for mental health disorders, compared to adolescent girls who are not mothers, making them a particularly vulnerable population and contributing to them feeling less supported by or allied with their medical provider. Women with a history of childhood abuse face increased rates of obstetric complications; their infants are at increased risk for low birthweight, developmental and intellectual delays, and behavioral problems. Trauma-informed care has become widespread in mental health settings; however, this model has not been as commonly applied to other settings, such as patient-centered medical homes (PCMHs). The Colorado Adolescent Maternity Program (CAMP) is an obstetric and pediatric medical home for pregnant and parenting adolescent girls through age 22 and their children located within Children's Hospital Colorado. With the integration of behavioral health into CAMP, and given the prevalence of trauma histories among adolescent mothers reported in the literature, programmatic and operational changes to clinical care were made using the Substance Abuse and Mental Health Services Administration's six key principles of a trauma-informed approach. Data showed that nearly 30% of participants reported a history of trauma. Following the inclusion of trauma-informed principles, patients had significantly higher rates of attendance at prenatal appointments (p < .001) and significantly lower rates of low birthweight babies (p = .02). Future programmatic changes and long-term assessment outcomes of this trauma-informed approach in a PCMH are also discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A pilot study assessing patient-centred care in patients with chronic health conditions attending chiropractic practice.

OBJECTIVES: The primary aim of this pilot study was to determine the feasibility of conducting a mixed- methods study assessing the extent patients with chronic health conditions perceive chiropractic care to be patient-centred. DESIGN: A sequential mixed methods feasibility study with a quantitative priority. SETTING: Two private chiropractic clinics in Calgary, Alberta, Canada. MAIN OUTCOME MEASURES: Feasibility outcomes included pilot study participation, consent and completion rates. Demographic and health information and a modified version of the Patient Assessment of Chronic Illness Care (PACIC). RESULTS: Over three weeks, 90 participants were recruited, 86 enrolled, and 78 provided complete data, with only one who commented on the clarity of paperwork. Included participants were on average 47.1 years of age and 60.3% were female. They had an average of 1.8 chronic conditions with 60% having chronic spinal pain. They reported seeing an average of 2.9 other health professionals for their chronic health condition and averaged 12.9 chiropractic visits in the past year. The average overall modified PACIC score was 3.29 on a 5-point scale. Higher scores were seen on the 'patient activation', 'delivery system design/decision support', and 'problem solving/contextual' subscales, with lower scores seen on the 'goal-setting/tailoring' and 'follow-up/coordination' subscales. Interview data generally supported those findings. CONCLUSIONS: The pilot study results support the feasibility of the methods for a subsequent large-scale study. These preliminary results suggest that the degree of patient-centredness compares favourably to similar studies in primary medical care.

Parents' Perception of Receiving Family-Centered Care for Their Children with Physical Disabilities: A Meta-Analysis.

AIMS: Understanding parent perceptions of family-centered care (FCC) is important to improve processes and outcomes of children's services. OBJECTIVE: A systematic review and meta-analysis of research on the Measures of Processes of Care (MPOC-20) were performed to determine the extent parents of children with physical disabilities perceive they received FCC. METHODS: A comprehensive literature search was conducted using four databases. A total of 129 studies were retrieved; 15 met the criteria for the synthesis. Meta-analysis involving 2,582 mothers and fathers of children with physical disabilities mainly cerebral palsy was conducted for the five scales of the MPOC-20. RESULTS: Aggregated mean ratings varied from 5.0 to 5.5 for Providing Specific Information about the Child; Coordinated and Comprehensive Care; and Respectful and Supportive Care (relational behaviors) and Enabling and Partnership (participatory behaviors) indicating that, on average, parents rated FCC as having been provided to "a fairly great extent." The aggregated mean rating was 4.1 for Providing General Information, indicating FCC was provided "to a moderate extent." CONCLUSIONS: Service providers are encouraged to focus on child and family needs for general information. Research is needed to better understand parent perspectives of service provider participatory behaviors which are important for engaging families in intervention processes.

How health leaders can benefit from predictive analytics.

Predictive analytics can support a better integrated health system providing continuous, coordinated, and comprehensive person-centred care to those who could benefit most. In addition to dollars saved, using a predictive model in healthcare can generate opportunities for meaningful improvements in efficiency, productivity, costs, and better population health with targeted interventions toward patients at risk.

Implementing a patient-centred outcome measure in daily routine in a specialist palliative care inpatient hospital unit: An observational study.

BACKGROUND: Gathering clinical evidence data on patients' palliative care needs is paramount to identify changes in outcomes over time and maintaining on-going quality improvement. Implementation of patient-centred outcome measures has been widely recommended. The routine use of these instruments in daily practice is challenging and not widespread. AIM: To implement a patient-centred outcome measure in daily practice and fulfil one quality indicator: improve pain during the 72 h after admission, in at least 75% of patients. DESIGN: An observational prospective study. The Palliative care Outcome Scale was used at admission (T0), third day (T1) and weekly. SETTING/PARTICIPANTS: Hospital palliative care unit with 17 individual rooms. All patients admitted to the unit were included in the study. RESULTS: Preliminary results ( N = 84) revealed inconsistent and missing data (14%). Symptoms were sub-optimally controlled by T1. Processes changed, and only a team member could apply Palliative care Outcome Scale. Doctors were encouraged to grasp the meaning of Palliative care Outcome Scale results for each patient. The post-pilot included 317 patients. No missing data occurred. There was an improvement in most items between T0 and T1: 'pain' and 'other symptoms' presented statistical significant differences ( p < 0.05). CONCLUSION: Implementing a patient-centred outcome measure in a hospital palliative care service is feasible and improves quality of care. Controlling high pain at T0 improved (>80%) by T1. Results became more consistent and symptom control was improved overall. Patients are evaluated based on holistic domains by an interdisciplinary team and we have added a much needed measure to help guide improvement of the quality of care provided.

Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden.

BACKGROUND: The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care. OBJECTIVE: We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care. DESIGN, SUBJECTS AND MAIN MEASURES: This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility. KEY RESULTS: Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter. CONCLUSIONS: Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

A cross-sectional study on person-centred communication in the care of older people: the COMHOME study protocol.

INTRODUCTION: This paper presents an international cross-sectional study on person-centred communication with older people receiving healthcare (COMHOME). Person-centred care relies on effective communication, but few studies have explored this with a specific focus on older people. The main aim of the COMHOME study is to generate knowledge on person-centred communication with older people (>65 years) in home healthcare services, radiographic and optometric practice. METHODS AND ANALYSIS: This study will explore the communication between care providers and older persons in home care services. Home healthcare visits will be audiorecorded (n=500) in Norway, the Netherlands and Sweden. Analyses will be performed with the Verona Coding Definitions for Emotional Sequences (VR-CoDES), the Roter Interaction Analysis System (RIAS) and qualitative methods. The content of the communication, communicative challenging situations as well as empathy, power distance, decision-making, preservation of dignity and respect will be explored. In Norway, an additional 100 encounters, 50 in optometric practice (video recorded) and 50 in radiographic practice (audiorecorded), will be analysed. Furthermore, healthcare providers' self-reported communication skills, empathy, mindfulness and emotional intelligence in relation to observed person-centred communication skills will be assessed using well-established standardised instruments. ETHICS AND DISSEMINATION: Depending on national legislation, approval of either the central ethical committees (eg, nation or university), the national data protection officials or the local ethical committees (eg, units of home healthcare) was obtained. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. The research findings will add knowledge to improve services provided to this vulnerable group of patients. Additionally, the findings will underpin a training programme for healthcare students and care providers focusing on communication with older people.

Development of a measure to assess healthcare providers' implementation of patient-centered care.

BACKGROUND: Patient-centered care (PCC) is a vaguely defined element of high-quality care, which precludes its consistent and precise operationalization. A conceptualization of PCC was derived from the literature and guided the development of an instrument to assess implementation of PCC by healthcare providers. The items of the instrument capture specific activities that reflect three components of PCC: holistic, collaborative, and responsive care. This paper reports on the measure's content and construct validity and reliability. METHODS: Content validity was evaluated in a sample of 11 nurse practitioners who rated the relevance of each items' content in reflecting the respective component of PCC. The content validity index (CVI) was estimated. Construct validity and internal consistency reliability were examined in a survey of 149 nurse practitioners employed in acute care institutions, using factor analysis and the KR-20 coefficient, respectively. RESULTS: The CVIs were 100% for the three subscales assessing the holistic, collaborative, and responsive care components of PCC. The items in each subscale loaded on one factor. The KR-20 coefficients were .66, .70, and .42, respectively. Overall, the majority (>70%) of respondents indicated performance of the activities comprising the three components of PCC. LINKING EVIDENCE TO ACTION: The PCC measure demonstrated acceptable psychometric properties. The low variance in responses, which is anticipated for instruments assessing fidelity of intervention implementation, accounts for the low reliability coefficients. Additional testing of the measure's psychometric properties in different groups of healthcare providers is warranted. The measure can be used to monitor healthcare providers' implementation of PCC in their usual practice.

Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH.

PURPOSE: Telephone- and Internet-based communication are increasingly common in primary care, yet there is uncertainty about how these forms of communication affect demand for in-person office visits. We assessed whether use of copay-free secure messaging and telephone encounters was associated with office visit use in a population with diabetes. METHODS: We used an interrupted time series design with a patient-quarter unit of analysis. Secondary data from 2008-2011 spanned 3 periods before, during, and after a patient-centered medical home (PCMH) redesign in an integrated health care delivery system. We used linear regression models to estimate proportional changes in the use of primary care office visits associated with proportional increases in secure messaging and telephone encounters. RESULTS: The study included 18,486 adults with diabetes. The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the postimplementation periods, largely driven by increased secure messaging; quarterly office visit use declined by 8%. In adjusted regression analysis, 10% increases in secure message threads and telephone encounters were associated with increases of 1.25% (95% CI, 1.21%-1.29%) and 2.74% (95% CI, 2.70%-2.77%) in office visits, respectively. In an interaction model, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use for all study periods and patient subpopulations (P<.001). CONCLUSIONS: Before and after a medical home redesign, proportional increases in secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes. Our findings provide evidence on how new forms of patient-clinician communication may affect demand for office visits.