Overcoming challenges to teamwork in patient-centered medical homes: a qualitative study.

BACKGROUND: There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. OBJECTIVE: The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy. APPROACH: Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork. PARTICIPANTS: Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served. KEY RESULTS: Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team "huddles" guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet). CONCLUSIONS: Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.

Support and strategies for change among small patient-centered medical home practices.

PURPOSE: We aimed to determine the motivations and barriers facing small practices that seek to adopt the patient-centered medical home (PCMH) model, as well as the type of help and strategies they use. METHODS: We surveyed lead physicians at practices with fewer than 5 physicians, stratified by state and level of National Committee for Quality Assurance PCMH recognition, using a Web-based survey with telephone, fax, and mail follow-up. The response rate was 59%, yielding a total sample of 249 practices from 23 states. RESULTS: Improving quality and patient experience were the strongest motivations for PCMH implementation; time and resources were the biggest barriers. Most practices participated in demonstration projects or received financial rewards for PCMH, and most received training or other kinds of help. Practices found training and help related to completing the PCMH application to be the most useful. Training for patients was both less common and less valued. The most commonly used strategies for practice transformation were staff training, systematizing processes of care, and quality measurement/goal setting. The least commonly endorsed strategy was involving patients in quality improvement. Practices with a higher level of PCMH recognition were more likely to have electronic health records, to report barriers, and to use measurement-based quality improvement strategies. CONCLUSIONS: To spread the adoption of the PCMH model among small practices, financial support, practical training, and other help are likely to continue to be important. Few practices involved patients in their implementation, so it would be helpful to test the impact of greater patient involvement in the PCMH.

Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change.

PURPOSE: We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS: Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS: The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS: These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

South Asian American perspectives on overweight, obesity, and the relationship between weight and health.

INTRODUCTION: Compared with other racial groups, South Asian adults develop type 2 diabetes and cardiovascular disease at a lower body mass index (BMI). Perceptions of weight and the effect of weight on health can influence weight-loss attempts but are not well described in this population. The objective of this study was to examine perceptions of weight appropriateness and the effect of weight on health among South Asian Americans. METHODS: We recruited 75 South Asian American adults from a single metropolitan area in the Midwestern United States. During individual, face-to-face interviews, we asked participants what they think about their weight and how weight affects their health. We measured their weight and height and calculated BMI. Each interview was audiotaped, transcribed verbatim, and translated into English. We conducted analyses using NVivo software. A second investigator coded 20% of interviews to verify coding consensus. RESULTS: Sixty-seven percent of participants were overweight or obese; 40% of overweight participants and 12% of obese participants perceived themselves to be normal weight or underweight. Forty-eight percent of overweight and 82% of obese participants believed their weight affected their health. Participants commonly cited physical problems as being associated with their weight, but few connected their weight with risk for chronic diseases. CONCLUSION: South Asian Americans may underestimate their weight status and the effect of their weight on their risk for chronic diseases. Interventions to promote weight loss among South Asian Americans should focus on modifying perceptions of normal weight and personalizing the relationship between overweight and chronic diseases.

Facilitators and Barriers to Implementing a Patient-Centered Oncology Care Model.

PURPOSE: Oncology practices often serve as the "medical home" for patients but may not have systems to support all aspects of patient-centered care. We piloted a new set of oncology medical home standards that call for accessible, continuous, coordinated, and team-based care. We examined how adoption of the standards varies across a variety of practices and compared practice self-report with external evaluation of implementation. METHODS: Five medical oncology practices in southeastern Pennsylvania implemented the standards from 2014 into 2016. Implementation support included training webinars and technical assistance. External reviewers evaluated practices' implementation of the standards. We conducted site visits to interview providers and patients. RESULTS: Between baseline and follow-up, practice self-assessments and independent audits showed practices increased implementation of the patient-centered oncology standards. The largest improvement was seen in continuous quality improvement (QI). Practices were less successful in implementing care coordination: achievement on two standards (access and evidence-based decision support) declined from baseline to follow-up. Qualitative analyses revealed that practices focused QI in five areas: goals of care, engaging patients in QI, financial counseling, symptom management, and care coordination. Interviewees talked about facilitators, such as leadership support and physician buy-in, and barriers to transformation, including inadequate resources and staffing. Health information technology both supported and limited implementation. CONCLUSION: Oncology practices showed some progress in their implementation of patient-centered care processes over the course of the pilot program. Systems for tracking and documenting improvement, training for staff and clinicians, leadership support, and alignment of financial incentives are critical to transformation.

Racial and ethnic differences in activities of daily living disability among the elderly: the case of Spanish speakers.

OBJECTIVE: To compare incident disability patterns across racial and ethnic groups. DESIGN: Prospective cohort study with 6-year follow-up (1998-2004). SETTING: National probability sample. PARTICIPANTS: A 1998 Health and Retirement Study sample of 12,288 non-Hispanic whites, 1952 African Americans, 575 Hispanics interviewed in Spanish (Hispanic-Spanish), and 518 Hispanics interviewed in English (Hispanic-English), older than 51 years, and free of disability at baseline. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Disability in activities of daily living (ADL) tasks (walking, dressing, transferring, bathing, toileting, feeding). RESULTS: Hispanic-Spanish reported disproportionately lower rates of walking disability (standardized rates, 4.31% vs Hispanic-English [8.57%], black [7.54%], white [7.20%]) despite higher reported Hispanic-Spanish frequencies of lower-extremity dysfunction than other racial and ethnic groups. Across the 6 ADL tasks, the development of walking disability was most frequent among Hispanic-English subjects, African Americans, and whites. In contrast, Hispanic-Spanish subjects reported dressing as the most frequent ADL task disability, whereas walking ranked fourth. CONCLUSIONS: Aggregating all Hispanics, regardless of interview language, may be inappropriate. Future research on linguistic group differences in self-reported health outcomes is necessary to ensure that health status measures will be appropriate for use in diverse racial and ethnic groups.

Health Quality Measures Addressing Disparities in Culturally and Linguistically Appropriate Services: What are Current Gaps?

PURPOSE: Disparities in health care persist among many at-risk groups. This study examines the current state of health quality measures addressing disparities and culturally and linguistically appropriate services (CLAS), and identifies important gaps in existing measures and their implementation. METHODS: We searched key quality reporting databases and websites to identify measures and structural program requirements addressing disparities or CLAS. We also conducted a dozen semi-structured interviews to obtain expert perspectives. RESULTS: Twenty-four measures and eight private or public-sector programs with relevant structural requirements were identified. Half the measures focused on language needs. Few measures were used in national reporting programs and adoption of requirements has been limited. Barriers to implementation included lack of data among health plans, lack of health workforce training, and challenges in defining cultural competence. CONCLUSIONS: Future efforts should seek to enhance implementation of existing quality measures addressing disparities and CLAS, and address barriers to their adoption.

Lessons From Early Implementation of a Patient-Centered Care Model in Oncology.

PURPOSE: Oncology practices may serve as the primary health provider for patients with cancer and the so-called neighbor during periods of transition and survivorship. New standards for patient-centered oncology practice articulate expectations for the primary health provider and neighbor roles. We report the implementation experiences of five oncology practices participating in a pilot of these standards. METHODS: For each practice, auditors reviewed workflows and documentation supporting the progress of the practice in meeting the oncology medical home standards. We also observed clinical encounters and practice workflow and interviewed clinicians, staff, and patients. RESULTS: Referral coordination and care management were the most demonstrated functions. The least commonly demonstrated functions related to tracking and coordination of tests and medications, as well as quality measurement and improvement. Some opportunities for structural and process improvement included improving the use of health information technology, care coordination, quality improvement, telephone triage, symptom management, patient education, financial counseling, and care team communication. Making patient-centered care a priority and motivation to change were cited as facilitators for transformation. CONCLUSION: The pilot oncology practices had many structures and processes in common, many of which were established during the early intervention period of this pilot. However, there was little standardization within and across practices in the way these processes were established and documented. Establishing structures for care coordination, quality improvement, and quality measurement should be priorities for practices considering transformation to a patient-centered model of care.

There's more than one way to build a medical home.

OBJECTIVES: The patient-centered medical home (PCMH) is a critical aspect of delivery system reform. The purpose of this study was to examine variations in achievement of PCMH requirements across different types of practices. STUDY DESIGN: We used data on the points awarded, by standard and element, to 2369 practices recognized by September 2013 under the National Committee for Quality Assurance PCMH program, 2011 version. METHODS: We tested for differences across practice types in the percentage of practices achieving full credit for 27 element scores using likelihood ratio χ2 tests with an adjustment for multiple comparisons. RESULTS: Of the practices, 45% were affiliated with health systems, 22.6% were community health centers, and 5.3% were military treatment facilities. The remaining practices were physician-owned, 10% with at least 5 clinicians and 17.3% with less than 5. Even among Level 3 practices, there were significant differences across the practice types in the percentage of practices achieving full credit for 19 of 27 elements. Different types of practices demonstrated strengths in different medical home capabilities. CONCLUSIONS: Even among practices with the highest level of PCMH achievement, there are variations in key medical home capabilities. While research is needed to identify PCMH components having the greatest impact on outcomes, this research shows that the NCQA model is flexible enough to adapt to the strengths and needs of practices and the patients they serve. Efforts to support widespread dissemination of the PCMH model and practice transformation should recognize and build on these variations.

Explanatory models of health and disease among South Asian immigrants in Chicago.

To identify concepts of health and disease as part of a study on designing culturally-targeted heart disease prevention messages for South Asians. We conducted qualitative, semi-structured interviews in English, Hindi and Urdu with 75 respondents from a federally qualified health center and at a community center for South Asian immigrants in Chicago, Illinois. Age ranged from 20 to 70 years; 60% were women; 60% held advanced degrees; 70% migrated to the US in the last 10 years; and 60% of the interviews were in Hindi or Urdu. Concepts of health and disease fell into four domains: behavioral, physical, psycho-social and spiritual. Muslim participants consistently evoked spiritual factors such as faith and prayer. Women more frequently included performing home duties and positive affect in their concept of health. Men more frequently cited behavioral factors such as smoking and drinking as the cause of disease. Many South Asians have a holistic conceptualization of health and disease, incorporating spiritual, physical and psycho-social factors. Health promotion strategies aimed at South Asians in the US should take into account this holistic model of health and disease, while also recognizing that variations exist within South Asians, by gender and religion.

Classification of health plans based on relative resource use and quality of care.

OBJECTIVE: To examine variation among commercial health plans in resource use and quality of care for patients with diabetes mellitus or cardiovascular disease. STUDY DESIGN: Cohort study using Healthcare Effectiveness Data and Information Set data submitted to the National Committee for Quality Assurance in 2008. METHODS: Composite measures were estimated for diabetes and cardiovascular disease resource use and quality of care. A "value" classification approach was defined. Obtained were descriptive statistics, Pearson product moment correlations between resource use and quality of care, and 90% confidence intervals around each health plan's composite measures of resource use and quality of care. Health plans were classified based on their results. RESULTS: For patients with diabetes, the correlation between combined medical care services resource use and composite quality of care is negative (-0.201, p = .008); the correlation between ambulatory pharmacy services resource use and composite quality of care is positive (0.162, p = .03). For patients with cardiovascular disease, no significant correlation was found between combined medical care services resource use and composite quality of care (-0.007, p = .94) or ambulatory pharmacy services resource use (0.170, p = .06). CONCLUSIONS: Measures of resource use and quality of care provide important information about the value of a health plan. Although our analysis did not determine causality, the statistically weak or absent correlations between resource use and quality of care suggest that health plans and practices can create higher value by improving quality of care without large increases in resource use or by maintaining the same quality of care with decreased resource use.

Patient-centered medical homes in the United States.

The concept of a medical home is receiving increased attention as a potential means to improve care and reduce costs. This study describes the characteristics and capabilities of practices that have achieved recognition of National Committee for Quality Assurance as a "patient-centered medical home" (PCMH). Both small and large practices demonstrate capabilities related to the goals of PCMH of accessible, coordinated, and patient-centered care; however, practices affiliated with larger organizations achieve higher levels of PCMH recognition compared with unaffiliated small practices. Efforts to support practices to implement medical home capabilities are needed, particularly in the use of data for population management and patient self-management.

Knowledge gaps and misconceptions about coronary heart disease among U.S. South Asians.

BACKGROUND: Although South Asians are at higher risk for coronary heart disease (CHD) than most other U.S. racial/ethnic groups, very little research has addressed this disparity. PURPOSE: As a first step in developing culturally targeted CHD prevention messages for this rapidly growing community, this study examined South Asians' knowledge and beliefs about CHD. METHODS: Analyses, conducted in 2009, were based on data collected from January to July 2008 in a cross-sectional study population of 270 South Asian adults in Illinois. Interviews were conducted in English, Hindi, or Urdu using a standardized questionnaire. Multivariate regression models were used to examine the associations between sociodemographics and CHD knowledge and attitudes about preventability. RESULTS: Eighty-one percent of respondents had one or more CHD risk factors. Most participants (89%) said they knew little or nothing about CHD. Stress was the most frequently mentioned risk factor (44%). Few mentioned controlling blood pressure (11%); cholesterol (10%); and diabetes (5%) for prevention. Fifty-three percent said that heart attacks are not preventable. Low education level, being interviewed in Urdu or Hindi, and low level of acculturation were associated with less knowledge and believing that CHD is not preventable. CONCLUSIONS: A majority of South Asians in this study believed that CHD is not preventable and had low awareness of modifiable risk factors. As a first step, CHD education should target the knowledge gaps that may affect risk factor control and behavior change. Educational messages may need to be somewhat different for subgroups (e.g., by education and language) to be maximally effective.