Operationalizing the Chronic Care Model with Goal-Oriented Care.

The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person's goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.

Peripheral Neuropathy in Older People Is Associated with Reduced Life Expectancy.

INTRODUCTION: We analyzed data from a prospective cohort of older primary care patients to determine whether the presence of peripheral neuropathy (PN) was associated with premature mortality and to investigate potential mechanisms. METHODS: PN was defined as the presence of 1 or more bilateral lower extremity sensory deficits detectable by physical examination. Mortality was determined from key contacts and Internet sources. Statistical models were used to evaluate the association between PN and mortality. RESULTS: Bilateral lower extremity neurological deficits were common, reaching 54% in those 85 and older. PN was strongly associated with earlier mortality. Mean survival time for those with PN was 10.8 years, compared with 13.9 years for subjects without PN. PN was also indirectly associated through impaired balance. CONCLUSIONS: In this relatively healthy cohort of older primary care patients, PN detectable by physical examination was extremely common and strongly associated with earlier mortality. One possible mechanism involves loss of balance, though our data were insufficient to determine whether poor balance led to injurious falls or to less-specific declines in health. These findings may warrant further studies to determine the causes of age-associated PN and potential impact of early detection and balance improvement and other fall prevention strategies.

Goal-Oriented Prevention: How to Fit a Square Peg into a Round Hole.

Prevention does not fit well within our problem-oriented medical paradigm in which the focus is on curing or ameliorating existing diseases. It is easier and more satisfying to solve existing problems than it is to advise and motivate patients to implement measures to prevent future problems that may or may not occur. Clinician motivation is further diminished by the time required to help people make lifestyle changes, the low reimbursement rate, and the fact that the benefits, if any, are often not apparent for years. Typical patient panel sizes make it difficult to provide all of the recommended disease-oriented preventive services and to also address the social and lifestyle factors that can impact future health problems. One solution to this square peg-round hole mismatch is to focus on the goals, life extension and prevention of future disabilities.

How Patient-Centered Medical Homes Can Bring Meaning to Health Care: A Call for Person-Centered Care.

The development of patient-centered medical homes in the United States was, among other things, an attempt to improve patients' experiences of care. This and other improvement strategies, however, have failed to confront a major barrier, our disease-oriented medical model. Focusing on diseases has contributed to subspecialization and reductionism, which, for patients, has increased medical complexity and made it more difficult to engage in collaborative decision making. The progressive uncoupling of disease prevention and management from other outcomes that may matter more to patients has contributed to the dehumanization of care. An alternative approach, person-centered care, focuses clinical care directly on the aspirations of those seeking assistance, rather than assuming that these aspirations will be achieved if the person's medical problems can be resolved. We recommend the adoption of 2 complementary person-centered approaches, narrative medicine and goal-oriented care, both of which view health problems as obstacles, challenges, and often opportunities for a longer, more fulfilling life. The transformation of primary care practices into patient-centered medical homes has been an important step forward. The next step will require those patient-centered medical homes to become person centered.

Failure of the Problem-Oriented Medical Paradigm and a Person-Centered Alternative.

Our problem-oriented approach to health care, though historically reasonable and undeniably impactful, is no longer well matched to the needs of an increasing number of patients and clinicians. This situation is due, in equal parts, to advances in medical science and technologies, the evolution of the health care system, and the changing health challenges faced by individuals and societies. The signs and symptoms of the failure of problem-oriented care include clinician demoralization and burnout; patient dissatisfaction and non-adherence; overdiagnosis and labeling; polypharmacy and iatrogenesis; unnecessary and unwanted end-of-life interventions; immoral and intolerable disparities in both health and health care; and inexorably rising health care costs. A new paradigm is needed, one that humanizes care while guiding the application of medical science to meet the unique needs and challenges of individual people. Shifting the focus of care from clinician-identified abnormalities to person-relevant goals would elevate the role of patients; individualize care planning; encourage prioritization, prevention, and end-of-life planning; and facilitate teamwork. Paradigm shifts are difficult, but the time has come for a reconceptualization of health and health care that can guide an overdue transformation of the health care system.

A Person-Centered Interdisciplinary Plan-of-Care Program for Dialysis: Implementation and Preliminary Testing.

RATIONALE & OBJECTIVE: Despite growing interest in individualizing care, routine dialysis processes, including the interdisciplinary plan of care, often fail to account for patient-identified priorities. To better align dialysis care with patient priorities and improve care planning experiences, we implemented a person-centered care plan program at a single clinic. We also sought to gain insight into key implementation considerations and areas for program improvement. STUDY DESIGN: 6-month quality improvement project with research substudy. SETTING & PARTICIPANTS: 49 hemodialysis patients and 14 care team members at a North Carolina dialysis clinic. QUALITY IMPROVEMENT ACTIVITIES: Implementation of My Dialysis Plan, a person-centered care plan program. OUTCOMES: Participant perspectives and care plan meeting characteristics (quality improvement); pre- to postprogram change in patient-reported autonomy support, patient-centeredness of care, and dialysis care individualization (research). ANALYTICAL APPROACH: We used the Consolidated Framework for Implementation Research to guide implementation and evaluation. We conducted pre-, intra-, and post-project interviews with clinic stakeholders (patients, clinic personnel, and medical providers) to identify implementation barriers, facilitators, and perceptions. We compared pre- and post-project care plan meeting content and patient-reported outcome survey scores. RESULTS: We conducted 54 care plans with 49 patients. Overall, care teams successfully used My Dialysis Plan to elicit and link patient priorities to actionable aspects of dialysis care. Participants identified interdisciplinary team commitment, accountability, and the structured yet flexible meeting approach as key implementation elements. Throughout the project, stakeholder input guided program modifications (eg, implementation practices and resources) to better meet clinic needs, but follow-up on care plan-identified action items remained challenging. Among the 28 substudy participants, there was no difference in pre- to post-project patient-reported outcome survey scores. LIMITATIONS: Single clinic implementation. CONCLUSIONS: My Dialysis Plan has the potential to enhance dialysis care individualization and care plan experiences. Evaluation of program impact on patient-reported and clinical outcomes is needed.

Goal-Oriented Care: A Catalyst for Person-Centred System Integration.

INTRODUCTION: Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation. DESCRIPTION: This case report presents three international cases of community-based primary health care models in Ottawa (Canada), Vermont (USA) and Flanders (Belgium) that adopted goal-oriented care to stimulate clinical, professional, organizational and system integration. The Rainbow Model of Integrated Care is used to demonstrate how goal-oriented care drove integration at all levels. DISCUSSION: The three cases demonstrate how goal-oriented care has the potential to catalyse integrated care. Exploration of these cases suggests that goal-oriented care can serve to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care. LESSONS LEARNED: By establishing a common vision and philosophy to drive shared processes, goal-oriented care can be a powerful tool to enable integrated care delivery. Offering plenty of opportunities for training in goal-oriented care within and across teams is essential to support this shift.

Development of a person-centered interdisciplinary plan-of-care program for dialysis.

BACKGROUND: Dialysis care often focuses on outcomes that are of lesser importance to patients than to clinicians. There is growing international interest in individualizing care based on patient priorities, but evidence-based approaches are lacking. The objective of this study was to develop a person-centered dialysis care planning program. To achieve this objective we performed qualitative interviews, responsively developed a novel care planning program and then assessed program content and burden. METHODS: We conducted 25 concept elicitation interviews with US hemodialysis patients, care partners and care providers, using thematic analysis to analyze transcripts. Interview findings and interdisciplinary stakeholder panel input informed the development of a new care planning program, My Dialysis Plan. We then conducted 19 cognitive debriefing interviews with patients, care partners and care providers to assess the program's content and face validities, comprehensibility and burden. RESULTS: We identified five themes in concept elicitation interviews: feeling boxed in by the system, navigating dual lives, acknowledging an evolving identity, respecting the individual as a whole person and increasing individualization to enhance care. We then developed a person-centered care planning program and supporting materials that underwent 32 stakeholder-informed iterations. Data from subsequent cognitive interviews led to program revisions intended to improve contextualization and understanding, decrease burden and facilitate implementation. CONCLUSIONS: My Dialysis Plan is a content-valid, person-centered dialysis care planning program that aims to promote care individualization. Investigation of the program's capacity to improve patient experiences and outcomes is needed.

Physicians' Response to Patients' Quality-of-Life Goals.

PURPOSE: Patients are able to participate in quality-of-life (QOL) discussions, but clinicians struggle to incorporate this information into encounters and shared decision making. We designed a study to determine if a clinician-initiated prompt could make patient visits more goal directed. METHODS: Patients were given a previsit questionnaire that included QOL questions. Physicians in the control were given no further prompting. The intervention physicians were prompted to ask a QOL question: what things are you unable to do because of your health problems today? A 2-pronged design was used: 1 prepost group where 3 physicians participated in 5 control and 5 intervention encounters (n = 30) and a randomized group in which 11 physicians and their patients were randomly assigned to control or intervention groups (n = 30). Video recordings of the encounters were reviewed to determine if QOL goals were mentioned and if they were utilized in decision making. RESULTS: Fifty-seven (95%) of the 60 patients provided written answers to at least 1 of the QOL questions on the intake form. QOL goals were mentioned during intervention encounters more often than in control groups. QOL information was used in shared decision making in only 4 of the 30 (13%) intervention encounters. CONCLUSIONS: Physicians were able to engage in QOL discussions with their patients, but did not translate that information to medical decision making. More research is needed to understand why clinicians opt not to use QOL information and how to make communication more goal directed.

Disseminating, implementing, and evaluating patient-centered outcomes to improve cardiovascular care using a stepped-wedge design: healthy hearts for Oklahoma.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the US and incurs high health care costs. While many initiatives promote the implementation of ABCS (aspirin therapy, blood pressure control, cholesterol management, and smoking cessation) measures, most primary care practices (PCPs) lack quality improvement (QI) support and resources to achieve meaningful targets. The Healthy Hearts for Oklahoma (H2O) Study proposes to build a QI infrastructure by (1) constructing a sustainable Oklahoma Primary Healthcare Improvement Collaborative (OPHIC) to support dissemination and implementation (D&I) of QI methods; (2) providing QI support in PCPs to better manage patients at risk for CVD events. Parallel to infrastructure building, H2O aims to conduct a comprehensive evaluation of the QI support D&I in primary care and assess the relationship between QI support uptake and changes in ABCS measures. METHODS: H2O has partnered with public health agencies and communities to build OPHIC and facilitate QI. H2O has 263 small primary care practices across Oklahoma that receive the bundled QI intervention to improve ABCS performance. A stepped-wedge designed is used to evaluate D&I of QI support. Changes in ABCS measures will be estimated as a function of various components of the QI support and capacity and readiness of PCPs to change. Notes from academic detailing and practice facilitation sessions will be analyzed to help interpret findings on ABCS performance. DISCUSSION: H2O program is designed to improve cardiovascular health and outcomes for more than 1.25 million Oklahomans. The infrastructure established as a result of this funding will help reach medically underserved Oklahomans, particularly among rural and tribal populations. Lessons learned from this project will guide future strategies for D&I of evidence-based practices in PCPs. Trained practice facilitators will continue to serve as critical resource to assists small, rural PCPs in adapting to the ever-changing health environment and continue to deliver quality care to their communities.

The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma.

PURPOSE: In primary care practices, sustainability of performance improvements and ability to deliver continuity of care to patients can be adversely affected by major disruptive events, such as relocations and changes in ownership, clinicians, and key staff. This study documented the rates of major disruptive events in a cohort of primary care practices in Oklahoma. METHODS: Practices were included if they had existed for 1 year before enrollment and remained in the project for at least 1 year after enrollment. Practice characteristics for 208 practices and major disruptive events during the preenrollment year were collected by survey. Postenrollment major disruptive events were prospectively collected by practice facilitators. We compiled frequency statistics and conducted bivariate analyses for each data set. RESULTS: Of 208 eligible practices, 81 (39%) were clinician owned, and 51 (25%) were health system owned. One hundred nine practices (52%) were in nonmetropolitan counties. One hundred seventy-five major disruptive events occurred in 120 (58%) practices during the preenrollment year, with 42 practices having experienced multiple events. During the first year of the project, 89 major disruptive events occurred in 67 (32%) practices, with 20 practices experiencing multiple events. The major disruptive events reported most often during both periods were loss of personnel and implementation of electronic health records and billing systems. Practice size was associated with occurrence of these events. CONCLUSIONS: During a 2-year period, major disruptive events occurred at an alarming rate, adversely affecting quality improvement efforts. Most reported events involved losses of clinicians and staff. More research is needed to identify and address the root causes of these events.

Goal-Directed Health Care: Redefining Health and Health Care in the Era of Value-Based Care.

Health care reform efforts have increasingly emphasized payment models that reward value (quality/cost). It seems appropriate, therefore, to examine what we value in health care, and that will require that we examine our definition of health. In spite of admonitions from the World Health Organization and others, our current health care system operates under the assumption that health represents the absence of health problems. While that perspective has led to incredible advances in medical science, it now may be adversely affecting value. Problem-oriented care is clearly one of the drivers of rising costs and it could be adversely affecting the quality of care, depending upon how quality is defined.  If we redefined health in terms of patient-centered goals, health care could be focused more directly on meaningful outcomes, reducing the number of irrelevant tests and treatments. Greater emphasis would be placed on prevention, meaningful activities, advance directives and personal growth and development. The role of patients within clinician-patient relationships would be elevated, strengthening therapeutic relationships. Reframing health in terms of health-related goals and directing the health care system to help people achieve them, could both improve quality and reduce costs. In the process, it could also make health care less mechanical and more humane.

Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms.

PURPOSE: Patient participation in clinical decision making improves outcomes, including quality of life (QOL), but the typical problem-oriented approach may impede consideration of functional goals. We wondered if patients could encourage primary care physicians to pay attention to their QOL goals by writing them on pre-encounter forms. METHODS: We conducted a randomized controlled trial comparing the impact of 2 different pre-visit questionnaires on the content of patient-physician encounters in a family medicine practice at an academic medical center. Using investigator-blinded block randomization, we arranged for 8 faculty and 8 resident physicians to participate in 2 intervention and 2 control videotaped encounters each for a total of 64 encounters. The intervention questionnaire included questions about QOL goals and concerns, while the control questionnaire asked about symptoms. Videotapes were reviewed to determine whether the patients' QOL goals were mentioned and whether they were used in decision making. We also scored encounters using Modified Flanders Interaction Analysis, which assesses and codifies patient and physician communication, and the Modified Carkhuff-Truax Scale, which measures empathy, attending, congruence, and positive regard. RESULTS: Patients were able to record QOL goals and concerns, but QOL issues were mentioned in only 2 of the 64 encounters, once by a patient and once by a physician. In neither case was this information used in decision making. More empathy was expressed by physicians during control encounters (P = .03). CONCLUSIONS: Patients were able to articulate their QOL goals on paper, but that did not prime them or their physicians to alter the process or content of the clinical encounters. In fact, providing QOL information was associated with reduced physician empathy.

Poison ivy: How effective are available treatments?

In this study, only one treatment approach significantly reduced pruritus. Three approaches were often associated with recurrences of rash or symptoms.

Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) intraindividual variability in older adults: Associations with disease and mortality.

UNLABELLED: Cognitive intraindividual variability (IIV), or dispersion, has been associated with pathological changes, including cognitive and functional decline. Dispersion is typically assessed with experimental cognitive measures or subtests selected from several batteries, and few studies have examined IIV from a single neuropsychological battery. METHOD: To address this gap, the current study examined the relationship between the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) IIV, mean cognitive performance, self-reported functioning, and death among 699 individuals between 64 and 94 years of age who were screened for neurological illness and living independently in the community. A coefficient of variation statistic served as the dispersion index and was derived by calculating the within-subject variability of the five RBANS indexes for each participant and dividing this value by the overall test battery mean. RESULTS: Results revealed that increased dispersion and poorer mean performance simultaneously predicted self-reported memory problems. In addition, participants with elevated dispersion at baseline had increased rates of death nine years later, although this lost significance after controlling for comorbid heart disease. Cluster analysis of the higher dispersion scores revealed four distinct profile patterns that did not differ on the outcome variables. CONCLUSIONS: Elevated RBANS dispersion is a proxy of co-occurring health problems and may be a useful metric of functional decline and death within community-dwelling geriatric populations.

Selective Serotonin Reuptake Inhibitors and Night Sweats in a Primary Care Population.

OBJECTIVE: Several small published case reports have suggested that selective serotonin reuptake inhibitors (SSRIs) can cause night sweats. The purpose of this study was to investigate this possibility further and to explore possible associations between night sweats and other commonly prescribed medications. DESIGN: Cross-sectional, secondary data analysis. SETTING: Data were obtained during the Oklahoma Longitudinal Assessment of the Health Outcomes of Mature Adults, a longitudinal cohort study carried out in the Oklahoma Physicians Resource/Research Network. PARTICIPANTS: 413 adult primary care patients aged 65-94 years. INTERVENTIONS: Current regular use of one of 35 classes of medication. MAIN OUTCOME MEASURES: At least moderate night sweats during the prior month. RESULTS: A total of 38 (9.2 %) reported night sweats. Age, gender, body mass index, and total number of medications taken regularly were not associated with night sweats. After adjusting for age and gender, SSRIs (odds ratio [OR] 3.01; 95 % confidence interval [CI] 1.26-7.19), angiotensin receptor blockers (ARBs) (OR 3.44; 95 % CI 1.36-8.69), and thyroid hormone supplements (OR 2.53; 95 % CI 1.24-5.15) were the only classes of medications associated with night sweats. CONCLUSIONS: Use of SSRIs may well be associated with night sweats in older patients. Associations found between night sweats and ARBs and thyroid supplements warrant further study.

Leveraging practice-based research networks to accelerate implementation and diffusion of chronic kidney disease guidelines in primary care practices: a prospective cohort study.

BACKGROUND: Four practice-based research networks (PBRNs) participated in a study to determine whether networks could increase dissemination, implementation, and diffusion of evidence-based treatment guidelines for chronic kidney disease by leveraging early adopter practices. METHODS: Motivated practices from four PBRNs received baseline and periodic performance feedback, academic detailing, and weekly practice facilitation for 6 months during wave I of the study. Each wave I practice then recruited two additional practices (wave II), which received performance feedback and academic detailing and participated in monthly local learning collaboratives led by the wave I clinicians. They received only monthly practice facilitation. The primary outcomes were adherence to primary care-relevant process-of-care recommendations from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines. Performance was determined retrospectively by medical records abstraction. Practice priority, change capacity, and care process content were measured before and after the interventions. RESULTS: Following the intervention, wave I practices increased the use of ACEIs/ARBs, discontinuation of NSAIDs, testing for anemia, and testing and/or treatment for vitamin D deficiency. Most were able to recruit two additional practices for wave II, and wave II practices also increased their use of ACEIs/ARBs and testing and/or treatment of vitamin D deficiency. CONCLUSIONS: With some assistance, early adopter practices can facilitate the diffusion of evidence-based approaches to other practices. PBRNs are well-positioned to replicate this process for other evidence-based innovations.

Extreme pain from brown recluse spider bites: model for cytokine-driven pain.

IMPORTANCE: Bites from the brown recluse spider (BRS) can cause extreme pain. We propose cytokine release as a cause of the discomfort and a central mechanism through glial cell upregulation to explain measured pain levels and time course. OBSERVATIONS: Twenty-three BRS bites were scored at a probable or documented level clinically, and an enzyme-linked immunosorbent assay was used to confirm the presence of BRS venom. The mean (SD) pain level in these cases 24 hours after the spider bite was severe: 6.74 (2.75) on a scale of 0 to 10. Narcotics may be needed to provide relief in some cases. The difference in pain level by anatomic region was not significant. Escalation observed in 22 of 23 cases, increasing from low/none to extreme within 24 hours, is consistent with a cytokine pain pattern, in which pain increases concomitantly with a temporal increase of inflammatory cytokines. CONCLUSIONS AND RELEVANCE: These findings in BRS bites support the hypothesis of cytokine release in inflammatory pain. A larger series is needed to confirm the findings reported here. The extreme pain from many BRS bites motivates us to find better prevention and treatment techniques.

Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial.

PURPOSE: Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. METHODS: In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions. RESULTS: Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. CONCLUSIONS: Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.