Developing a pathway for high-value, patient-centered total joint arthroplasty.

BACKGROUND: Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed. QUESTIONS/PURPOSES: The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA. METHODS: We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9). RESULTS: The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level. CONCLUSIONS: We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation. LEVEL OF EVIDENCE: Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Interpretations of integration in early accountable care organizations.

CONTEXT: It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together? METHODS: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. FINDINGS: In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not "integration"; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change. CONCLUSIONS: The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. "Soft integration" may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations.

A pilot evaluation of the In SHAPE individualized health promotion intervention for adults with mental illness.

This pilot study examined whether participation in the individualized, community-integrated In SHAPE health promotion program would result in improved physical activity and dietary behaviors, health indicators, and psychological functioning or symptoms in 76 adults with schizophrenia, bipolar disorder, major depression, or other mental disorders. Over a 9-month period, participation was associated with increased exercise, vigorous activity, and leisurely walking (P < .01), and a trend toward improved readiness to reduce caloric intake (P = .053). Participants demonstrated a reduction in waist circumference (P < .05), but no change in BMI. Satisfaction with fitness (P < .001) and mental health functioning (P < .05) improved, and severity of negative symptoms decreased (P < .01). This study demonstrated the feasibility and potential effectiveness of the In SHAPE program, which consisted of exercise and dietary modification. Based on these promising results, randomized controlled trials of the In SHAPE program are necessary to establish its effectiveness compared with usual care and alternative approaches to enhancing fitness.

Improving mental health assessment and service planning practices for older adults: a controlled comparison study.

This study evaluated the effectiveness of a guided assessment and service planning intervention in improving the clinical practices of non-physician community mental health providers caring for older persons. Thirteen agencies, 44 clinicians, and 100 consumers (age 60 and older) were assigned to the intervention or a comparison group receiving usual care. Baseline interviews of clinicians and chart reviews found that clinicians' routine evaluation and service planning practices showed inattention to key domains such as substance abuse (over 33% of clinicians), suicide risk and dangerous behaviors (over 40%), and caregiver burden and risk of neglect or abuse (over 75%). At 1-year follow-up, the intervention was associated with increased rates of routine assessments of major symptom, functioning, and support domains. There was also significant improvement in the specificity of treatment planning within the intervention condition. Implications for quality improvement are discussed.