Training Opportunities for Managers in Home Health, Hospice, and Community-Based Care Settings.

OBJECTIVE: The aim of this study was to identify areas for developing management skills-focused continuing education for managers working in home health, hospice, and community-based settings. BACKGROUND: Healthcare managers play a vital role in organizations, yet they have a range of management training. METHODS: Researchers conducted a cross-sectional survey of managers at a large Visiting Nurse Association. Descriptive and bivariate analyses were performed to examine confidence in management skills by respondent characteristic. Factor and cluster analyses were used to examine differences by role. RESULTS: For all 33 management tasks, managers with 6+ years of experience reported greater confidence than managers with 0 to 5 years of experience. Tasks with the lowest confidence were budgeting, interpreting annual reports, strategic planning, measuring organizational performance, and project planning. Managers were clustered into 5 "profiles." CONCLUSION: Management training is not 1-size-fits-all. Healthcare organizations should consider investing in training specific to the identified low-confidence areas and manager roles to better support and develop a robust management workforce.

Determinants and effectiveness of annual wellness visits among Medicare beneficiaries in 2020.

BACKGROUND: Annual wellness visits (AWVs) have the potential to improve general health and well-being, but little is known about the role of AWVs during the COVID-19 pandemic. OBJECTIVE: We examined the determinants and effectiveness of having an AWV among Medicare beneficiaries in 2020. METHODS: We employed a cross-sectional study design using data from the 2020 Medicare Current Beneficiary Survey. Our outcomes included AWV utilization, preventive care utilization, health status, and care satisfaction. To examine the determinants for having an AWV, we performed a linear regression model and explored the associations with other individual-level variables (demographic, socioeconomic, and health characteristics). To examine the effectiveness of having an AWV, we performed a linear regression model on each outcome measure while adjusting for individual-level variables. RESULTS: We found that there were several determinants of having an AWV. The four most notable determinants were having a usual source of care, enrolling in Medicare Advantage, being non-Hispanic Black, and being Hispanic. We also found that having an AWV was associated with increases in preventive care use (COVID vaccine, flu shot, pneumonia shot, and blood pressure measurement), but was limited in improving health status and care satisfaction. CONCLUSION: Our finding raises critical concerns about inequitable access to health care services for disease prevention and health promotion during the pandemic. Furthermore, the effectiveness of AWVs was mostly in increased preventive care use, suggesting a limited role in meeting the wellness needs of a diverse population of older adults.

Use of high- and low-value care among US adults by education levels.

BACKGROUND: Healthcare reform in the United States has focused on improving the value of health care, but there are some concerns about the inequitable delivery of value-based care. OBJECTIVE: We examine whether the receipt of high- and low-value care differs by education levels. METHODS: We employed a repeated cross-sectional study design using data from the 2010-2019 Medical Expenditure Panel Survey. Our outcomes included 8 high-value services across 3 categories and 9 low-value services across 3 categories. Our primary independent variable was education level: (i) no degree, (ii) high school diploma, and (iii) college graduate. We conducted a linear probability model while adjusting for individual-level characteristics and estimated the adjusted values of the outcomes for each education group. RESULTS: In almost all services, the use of high-value care was greater among more educated adults than less educated adults. Compared to those with no degree, those with a college degree were significantly more likely to receive all high-value services except for HbA1c measurement, ranging from blood pressure measurement (4.5 percentage points [95% CI: 3.9-5.1]) to colorectal cancer screening (15.6 percentage points [95% CI: 13.9-17.3]). However, there were no consistent patterns of the use of low-value care by education levels. CONCLUSION: Our findings suggest that more educated adults were more likely to receive high-value cancer screening, high-value diagnostic and preventive testing, and high-value diabetes care than less educated adults. These findings highlight the importance of implementing tailored policies to address education-based inequities in the delivery of high-value services in the United States.

Organizational Factors Associated with Guideline Concordance of Chronic Disease Care and Management Practices.

BACKGROUND: Guidelines for managing and preventing chronic disease tend to be well-known. Yet, translation of this evidence into practice is inconsistent. We identify a combination of factors that are connected to guideline concordant delivery of evidence-informed chronic disease care in primary care. METHODS: Cross-sectional observational study; purposively selected 22 practices to vary on size, ownership and geographic location, using National Quality Forum metrics to ensure practices had a ≥ 70% quality level for at least 2 of the following: aspirin use in high-risk individuals, blood pressure control, cholesterol and diabetes management. Interviewed 2 professionals (eg, medical director, practice manager) per practice (n = 44) to understand staffing and clinical operations. Analyzed data using an iterative and inductive approach. RESULTS: Community Health Centers (CHCs) employed interdisciplinary clinical teams that included a variety of professionals as compared with hospital-health systems (HHS) and clinician-owned practices. Despite this difference, practice members consistently reported a number of functions that may be connected to clinical chronic care quality, including: having engaged leadership; a culture of teamwork; engaging in team-based care; using data to inform quality improvement; empaneling patients; and managing the care of patient panels, with a focus on continuity and comprehensiveness, as well as having a commitment to the community. CONCLUSIONS: There are mutable organizational attributes connected-guideline concordant chronic disease care in primary care. Research and policy reform are needed to promote and study how to achieve widespread adoption of these functions and organizational attributes that may be central to achieving equity and improving chronic disease prevention.

Organizational Factors Associated with Guideline Concordance of Chronic Disease Care and Management Practices.

BACKGROUND: Guidelines for managing and preventing chronic disease tend to be well-known. Yet, translation of this evidence into practice is inconsistent. We identify a combination of factors that are connected to guideline concordant delivery of evidence-informed chronic disease care in primary care. METHODS: Cross-sectional observational study; purposively selected 22 practices to vary on size, ownership and geographic location, using National Quality Forum metrics to ensure practices had a ≥ 70% quality level for at least 2 of the following: aspirin use in high-risk individuals, blood pressure control, cholesterol and diabetes management. Interviewed 2 professionals (eg, medical director, practice manager) per practice (n = 44) to understand staffing and clinical operations. Analyzed data using an iterative and inductive approach. RESULTS: Community Health Centers (CHCs) employed interdisciplinary clinical teams that included a variety of professionals as compared with hospital-health systems (HHS) and clinician-owned practices. Despite this difference, practice members consistently reported a number of functions that may be connected to clinical chronic care quality, including: having engaged leadership; a culture of teamwork; engaging in team-based care; using data to inform quality improvement; empaneling patients; and managing the care of patient panels, with a focus on continuity and comprehensiveness, as well as having a commitment to the community. CONCLUSIONS: There are mutable organizational attributes connected-guideline concordant chronic disease care in primary care. Research and policy reform are needed to promote and study how to achieve widespread adoption of these functions and organizational attributes that may be central to achieving equity and improving chronic disease prevention.

Impact Of The New Jersey COVID-19 Temporary Emergency Reciprocity Licensure Program On Health Care Workforce Supply.

New Jersey's COVID-19 Temporary Emergency Reciprocity Licensure program provided temporary licenses to more than 31,000 out-of-state health care practitioners. As one of the first COVID-19 hot spots in the US, New Jersey is uniquely positioned to provide insights on enabling an out-of-state health care workforce through temporary licensure to address critical, ongoing concerns about health care workforce supply. In January 2021 we surveyed New Jersey temporary licensees. We analyzed more than 10,000 survey responses and found that practitioners who used the temporary license originated from every state in the US, provided both COVID-19- and non-COVID-19-related care, served a combination of new and existing patients, conversed with patients in at least thirty-six languages, and primarily used telehealth. Findings suggest that temporary licensure of out-of-state practitioners, along with telehealth waivers, may be a valuable, short-term solution to mitigating health care workforce shortages during public health emergencies.

Considerations Before Selecting a Stepped-Wedge Cluster Randomized Trial Design for a Practice Improvement Study.

PURPOSE: Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design's advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings. METHODS: The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design. RESULTS: All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends. CONCLUSIONS: The challenges experienced by EvidenceNOW grantees suggest that certain favorable real-world conditions constitute a context that increases the odds of a successful SW-CRT. An existing infrastructure can support the recruitment of many practices. Strong retention plans are needed to continue to engage sites waiting to start the intervention. Finally, study outcomes should be ones already captured in routine practice; otherwise, funders and investigators should assess the feasibility and cost of data collection.VISUAL ABSTRACT.

Patient Decision Aid Selection for Shared Decision Making: A Multicase Qualitative Study.

The patient decision aid (PDA) is a promising patient engagement tool for use in shared decision making (SDM). Selecting a PDA is an essential precursor to successful SDM implementation. Little is known regarding the organizational stakeholder process for assessing and selecting a PDA. We conducted a qualitative, multicase study within the context of a maternal health decision to identify the criteria used by stakeholders to select a PDA. We further explored the perceived value of PDA certification on PDA selection. We reported the PDA selection criteria within the domains of (1) Design and Functionality, (2) User Fit, (3) Context and Climate, (4) Support, and (5) Strategic Vision and found that certification was perceived to be a valuable screening mechanism for smaller health organizations. Health organizations and researchers may use our PDA selection criteria and conceptual model to plan future deployments of PDAs and patient engagement tools.

Ten Common Structures and Processes of High-Performing Primary Care Practices.

Structures (context of care delivery) and processes (actions aimed at delivery care) are posited to drive patient outcomes. Despite decades of primary care research, there remains a lack of evidence connecting specific structures/processes to patient outcomes to determine which of the numerous recommended structures/processes to prioritize for implementation. The objective of this study was to identify structures/processes most commonly present in high-performing primary care practices for chronic care management and prevention. We conducted key informant interviews with a national sample of 22 high-performing primary care practices. We identified the 10 most commonly present structures/processes in these practices, which largely enable 2 core functions: mobilizing staff to conduct patient outreach and helping practices avoid gaps in care. Given the costs of implementing and maintaining numerous structures/processes, our study provides a starting list for providers to prioritize and for researchers to investigate further for specific effects on patient outcomes.

A qualitative study of high-performing primary care practices during the COVID-19 pandemic.

BACKGROUND: Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations. METHODS: We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study. RESULTS: Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time. CONCLUSION: Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit.

Advancing mechanisms of implementation to accelerate sustainable evidence-based practice integration: protocol for generating a research agenda.

INTRODUCTION: Mechanisms explain how implementation strategies work. Implementation research requires careful operationalisation and empirical study of the causal pathway(s) by which strategies effect change, and factors that may amplify or weaken their effects. Understanding mechanisms is critically important to replicate findings, learn from negative studies or adapt an implementation strategy developed in one setting to another. Without understanding implementation mechanisms, it is difficult to design strategies to produce expected effects across contexts, which may have disproportionate effects on settings in which priority populations receive care. This manuscript outlines the protocol for an Agency for Healthcare Research and Quality-funded initiative to: (1) establish priorities for an agenda to guide research on implementation mechanisms in health and public health, and (2) disseminate the agenda to research, policy and practice audiences. METHODS AND ANALYSIS: A network of scientific experts will convene in 'Deep Dive' meetings across 3 years. A research agenda will be generated through analysis and synthesis of information from six sources: (1) systematic reviews, (2) network members' approaches to studying mechanisms, (3) new proposals presented in implementation proposal feedback sessions, (4) working group sessions conducted in a leading implementation research training institute, (5) breakout sessions at the Society for Implementation Research Collaboration's (SIRC) 2019 conference and (6) SIRC conference abstracts. Two members will extract mechanism-relevant text segments from each data source and a third member will generate statements as an input for concept mapping. Concept mapping will generate unique clusters of challenges, and the network will engage in a nominal group process to identify priorities for the research agenda. ETHICS AND DISSEMINATION: This initiative will yield an actionable research agenda to guide research to identify and test mechanisms of change for implementation strategies. The agenda will be disseminated via multiple channels to solicit feedback and promote rigorous research on implementation mechanisms.

Factors Affecting the Initiation of a Shared Decision Making Program in Obstetric Practices.

As healthcare systems progress toward initiatives that increase patient engagement, stakeholder hopes are that shared decision making (SDM) will become routine practice. Yet, there is limited empirical evidence to guide such SDM program implementations, particularly in obstetric practices. The first stage of any project implementation is the "initiation stage", in which project leaders define a project's purpose and stakeholders and structures are put in place to support the new initiative. Our study's objective was to identify factors affecting the initiation stage of an SDM program implementation project for TOLAC, trial of labor after Cesarean. We conducted a multiple-case study of an SDM program implementation in three obstetric settings in Washington State. The research design and analysis were guided by implementation science frameworks and project management literature. Data sources included interviews with key informants from the State, SDM tool vendors, and three project sites, as well as implementation documents. The study results provide insight into how the identified project implementation factors provide an essential foundation for informing project planning, execution, and reflection/evaluation. In this study, the State's decision aid certification program pressured the project sites to shape the project purpose and engage stakeholders that would meet immediate project requirements (specifically, state requirements). The study reveals that external demands may not be in perfect alignment with the internal necessities required for an SDM program's long-term viability and sustainability. Findings may be used by implementers and researchers to model and strategize the early stages of SDM program implementation projects, particularly in the obstetric setting.

Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post-COVID Era.

Policy Points Telehealth has many potential advantages during an infectious disease outbreak such as the COVID-19 pandemic, and the COVID-19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode. Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID-19 pandemic. Without proactive efforts to address both patient- and provider-related digital barriers associated with socioeconomic status, the wide-scale implementation of telehealth amid COVID-19 may reinforce disparities in health access in already marginalized and underserved communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. CONTEXT: The COVID-19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID-19 pandemic. METHODS: The study analyzed data about small primary care practices' telehealth use and barriers to telehealth use collected from rapid-response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid-April through mid-June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID-19 pandemic following New York State's stay-at-home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low-income, minority or immigrant areas that were more severely impacted by COVID-19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high-SVI or low-SVI areas. We then characterized respondents' telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only. FINDINGS: While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high-SVI areas were almost twice as likely as providers in low-SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high-SVI areas and 33.7% of providers in low-SVI areas (P <0.001). Providers in high-SVI areas also faced more patient-related barriers and fewer provider-related barriers than those in low-SVI areas. CONCLUSIONS: Between April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.

A practice facilitation-guided intervention in primary care settings to reduce cardiovascular disease risk: a cost analysis.

BACKGROUND: A stepped-wedge, cluster randomized controlled trial assessed the effectiveness of practice facilitation (PF) for adoption of guidelines for prevention and treatment of cardiovascular disease risk factors. This study estimated the associated cost of PF for guideline adoption in small, private primary care practices. METHODS: The cost analysis included categories for start-up costs, intervention costs, and practice staff costs for the implemented PF-guided intervention. We estimated the total 1-year costs to operate the program and calculated the mean and range of the cost-per-practice by quarter of the intervention. We estimated the lower and upper bounds for all salary expenses, rounding to the nearest $100. RESULTS: Total 1-year intervention costs for all 261 practices ranged from $7,900,000 to $10,200,000, with program and practice salaries comprising $6,600,000-$8,400,000 of the total. Start-up costs were a small proportion (3%) of the total 1-year costs. Excluding start-up costs, quarter 1 cost-per-practice was the most expensive at $20,400-$26,700, and quarter 4 was the least expensive at about $10,000. Practice staff time (compared with program staff time) was the majority of the staffing costs at 75-84%. CONCLUSIONS: The PF strategy costs approximately $10,000 per practice per quarter for program and practice costs, once implemented and running at highest efficiency. Whether this program is "worth it" to the decision-maker depends on the relative costs and effectiveness of their other options for improving cardiovascular risk reduction. TRIAL REGISTRATION: This study is retrospectively registered on January 5, 2016, at www.clinicaltrials.gov as NCT02646488 .

A Taxonomy for External Support for Practice Transformation.

BACKGROUND: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders. METHODS: The leaders of 8 grants from Agency for Research and Quality for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over 18 months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them. RESULTS: The taxonomy includes 1 domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another 5 domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions. CONCLUSIONS: This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between 3 areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research.

Organizational factors affecting successful physician-system integration: A qualitative study of Washington State health executives.

BACKGROUND: Health care delivery is moving toward a value-based environment, which calls for increased integration between physician groups and health systems. Health executives sit at a key nexus point for determining how and when physician-system integration occurs. PURPOSE: The objective of this study was to identify the organizational factors that health executives perceived to have made physician-system integration successful. METHODOLOGY/APPROACH: We used a multiple-case study research design. We conducted semistructured, qualitative interviews with 25 health executives in the roles of CEO, chief medical officer, chief financial officer and physician group chief executives from eight of Washington State's largest integrated delivery systems. To guide our analysis, we employed open systems theory and Porter's Value Chain to identify physician group and hospital factors that were integral to successful integration. RESULTS: Using the executives' perspectives, the factors grouped into three themes: (1) organizational structure-a mix of integration contracts united by common structural characteristics between physician groups and hospitals); (2) organizational culture-alignment of leadership between physician groups and hospitals; and (3) strategic resources-designated resources to establish and support care coordination activities. CONCLUSION: Our work indicates that health systems should focus on the pathway to integration success through the alignment of structure (not just the integration contract), culture, and resources and not on an end goal of the physician employment model. PRACTICE IMPLICATIONS: Health system executives are key drivers for when and how physician groups are integrated into health services organizations. This article provides executives with an evidence-based model to aid in formulating integration approaches that combine elements of organizational structure, organizational culture, and strategic resources.

Measuring Implementation Strategy Fidelity in HealthyHearts NYC: A Complex Intervention Using Practice Facilitation in Primary Care.

Few studies have assessed the fidelity of practice facilitation (PF) as an implementation strategy, and none have used an a priori definition or conceptual framework of fidelity to guide fidelity assessment. The authors adapted the Conceptual Framework for Implementation Fidelity to guide fidelity assessment in HealthyHearts NYC, an intervention that used PF to improve adoption of cardiovascular disease evidence-based guidelines in primary care practices. Data from a web-based tracking system of 257 practices measured fidelity using 4 categories: frequency, duration, content, and coverage. Almost all (94.2%) practices received at least the required 13 PF visits. Facilitators spent on average 26.3 hours at each site. Most practices (95.7%) completed all Task List items, and 71.2% were educated on all Chronic Care Model strategies. The majority (65.8%) received full coverage. This study provides a model that practice managers and implementers can use to evaluate fidelity of PF, and potentially other implementation strategies.

Attributes of High-Performing Small Practices in a Guideline Implementation: A Multiple-Case Study.

OBJECTIVE: HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. METHODS: A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. RESULTS: Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. CONCLUSIONS: These attributes may be important determinants of high performance, indicating not only a small practice's capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.

The Contribution of Physician-System Integrating Structure to Select Health System Outcomes.

Physician groups are increasingly being vertically integrated with hospitals and health systems; yet, the evidence on the impact of physician-system integration on health system outcomes is mixed. The objective of this study was to examine the impact of increased physician-system integration on select health system outcomes. We used a mixed-methods approach: (1) a fixed-effects multivariate mediation analysis; and (2) a qualitative analysis of interviews with health executives (n = 25). Our findings showed that hospitals spent $633 375.22 to $827 110.24 for each "level" increase in integration. This relationship was attenuated, however, by the presence of care coordination mechanisms.