Measuring the Impact of Primary Care Team Composition on Patient Activation Utilizing Electronic Health Record Big Data Analytics.

Purpose: Team-based care has been linked to key outcomes associated with the Quadruple Aim and a key driver of high-value patient-centered care. Use of the electronic health record (EHR) and machine learning have significant potential to overcome previous barriers to studying the impact of teams, including delays in accessing data to improve teamwork and optimize patient outcomes. Methods: This study utilized a large EHR dataset (n=316,542) from an urban health system to explore the relationship between team composition and patient activation, a key driver of patient engagement. Teams were operationalized using consensus definitions of teamwork from the literature. Patient activation was measured using the Patient Activation Measure (PAM). Results from multilevel regression analyses were compared to machine learning analyses using multinomial logistic regression to calculate propensity scores for the effect of team composition on PAM scores. Under the machine learning approach, a causal inference model with generalized overlap weighting was used to calculate the average treatment effect of teamwork. Results: Seventeen different team types were observed in the data from the analyzed sample (n=12,448). Team sizes ranged from 2 to 5 members. After controlling for confounding variables in both analyses, more diverse, multidisciplinary teams (team size of 4 or more) were observed to have improved patient activation scores. Conclusions: This is the first study to explore the relationship between team composition and patient activation using the EHR and big data analytics. Implications for further research using EHR data and machine learning to study teams and other patient-centered care are promising and could be used to advance team science.

The Arizona Nexus: the first five years.

Arizona Nexus is a pioneer Nexus Innovations Network (NIN) member with the National Center for Interprofessional Practice and Education (National Center) and a statewide collaborative with members from five public and private universities and six health care organizations in Arizona. The Arizona Nexus grew from the request of interprofessional champions at two public state universities, Arizona State University (ASU) and the University of Arizona (UA), to be part of the University of Minnesota's application and vision for the first National Center cohort. Culture change, shared vision, resources, and leadership are factors that have been in play in the development and growth of the Arizona Nexus. In this case study, we tell the story of the Arizona Nexus, key landmarks in its development and how these four factors contributed to its growth and success. For the Arizona Nexus, the next five years and beyond will embody action. Building from the hard-won and exciting foundation we have built in our first five years, we are determined to accelerate the growth of interprofessional practice and education, inspire continued growth of academic and clinical partnerships, and use the knowledge, skills and creative thinking of all professions to improve and transform health care.

A Theory-Based Approach for Identifying Nurse and Team Member Contributions in the Electronic Health Record.

INTRODUCTION: Team-based care delivered by an interprofessional team has been shown to be an effective strategy for caring for diverse, complex patient populations. Interprofessional teams can improve outcomes, reduce costs, and enhance the patient experience through patient-centered care. Nurses are essential members of healthcare teams within and across settings. BACKGROUND: It is imperative for practicing nurses, educators, and researchers to be able to identify and report the contributions of nurses to team performance and care outcomes to prepare students for high-performance teamwork to improve practice and influence healthcare policy. Currently, the work of many nurses and other team members is not discoverable in electronic health records. Methods used to identify all members of the healthcare team may not be aligned with theories and definitions of teamwork embedded in emerging nursing and interprofessional accreditation guidelines. PURPOSE: This paper describes a promising new, theoretically grounded approach to identify team members, including nurses, in electronic health records. METHODS: Using operational constructs from a common team definition, grounded in theory, primary care teams were data mined from EHR data to find the hidden members of the team. DISCUSSION/CONCLUSION: Further testing and use of this approach have the potential to provide a robust strategy to identify and distinguish each team member's contributions to clinical outcomes while laying the foundation for a meaningful study of teams in large data sets like the electronic health record. CLINICAL RELEVANCE: New strategies to study nursing and team member contributions utilizing EHR data may lead to improved clinical outcomes. A better understanding of how teams are structured may enhance the understanding of each team member's contribution to outcomes and lead to more equitable recognition and reimbursement for all team members.

Engagement With the Plan of Care Among Older Adults With Multiple Cardiac Diagnoses.

Aging adults depend on complex treatment plans to manage chronic conditions, yet little is known about their ability to perform the sophisticated behaviors required of technologically engaged patients. This qualitative descriptive study describes engagement with the plan of care. Forty chronically ill adults participated in this study, which involved an observation of the clinical encounter and an interview. Data were collected and analyzed simultaneously in keeping with principles of qualitative research. Multiple techniques were used to test conclusions and findings were constructed as thematic sentences, including the following: I act in ways that support my health, I manage my health-related information, I make visits with my doctor part of my routine, I participate in treatment planning. Older adults work to achieve self-management to the best of their ability, shunning the use of health information technology (HIT) and demonstrating a preference for provider-created treatment plans.

Holistic Admissions and Underrepresented Minorities in Physician Assistant Programs.

PURPOSE: The purpose of this study was to assess holistic review use in physician assistant (PA) programs and determine whether a relationship between holistic review and underrepresented minority (URM) matriculation exists. METHODS: Using data from the 2016-2017 Physician Assistant Education Association annual survey of PA programs, we examined the frequency of holistic review use across PA programs. Bivariate correlation analyses and binary logistic regression were used to examine relationships between holistic review practices and program percentages of first-year underrepresented racial and ethnic minority students. RESULTS: Most PA programs (169/219 [77.2%]) reported using holistic review, and its use modestly correlated with percentage of students who were underrepresented racial minorities (rho = 0.16, 95% confidence interval [CI] = 0.02-0.30) or Hispanic (rho = 0.20, 95% CI = 0.06-0.33). Using several holistic review elements related to program commitment to diversity modestly correlated with percentage of students who were underrepresented racial minorities (rho = 0.25, 95% CI = 0.10-0.39) or African American (rho = 0.20, 95% CI = 0.04-0.34). Additionally, the odds of a first-year student being an underrepresented racial or ethnic minority were slightly higher in PA programs using holistic review (OR = 1.56, 95% CI = 1.23-1.99 and OR 1.33, 95% CI = 1.09-1.62, respectively). CONCLUSIONS: PA program use of holistic review practices was modestly associated with percentage of URM students. Further research is needed to identify elements that are most effective.

COVID-19 and team-based healthcare: The essentiality of theory-driven research.

There is evidence to suggest enhanced teamness, heightened interprofessional values and practices, and even the potential for dilution of occupational status hierarchies within healthcare practice and delivery during the time of COVID-19. It is essential that we study these emergent changes using the lens of multilevel theory to better understand these recent developments and their current and future implications for interprofessional practice, education, and policy. Within this article, we first offer a brief overview of secondary data to highlight these COVID-19-specific shifts to provide context and perspective. We then outline prominent micro, meso, and macro-level theories, and propose accompanying rudimentary hypotheses and related general research questions to help guide, and ideally accelerate IPE and IPCP research related to this crisis. Our goal is to not only spotlight key areas for future research during and post COVID-19 but also provide a "starter kit" to encourage more theory-driven research (and theory-expansion) in the IPE and IPCP fields.

Team-Based Care and Patient Satisfaction in the Hospital Setting: A Systematic Review.

PURPOSE: Limited research examining the relationship between team-based models of care and patient satisfaction in the hospital setting is available. The purpose of this literature review was to explore this relationship as well as the relationships between team composition, team-based interventions, patient satisfaction, and other outcomes of care when measured as part of the study. METHODS: A systematic appraisal of research studies published through February 2017 was conducted using PubMed, Cochrane Library, CINAHL, Embase, Ovid, gray literature and Google Scholar. Inclusion criteria were 1) experimental (randomized control trials), quasi-experimental, or non-experimental (cross-sectional) study design; 2) team-based care interventions; 3) hospital setting; 4) patient satisfaction measured as an outcome; and 5) published in English. RESULTS: The literature search yielded 15,247 citations. In total, 142 articles were retrieved for full-text screening; 21 studies met inclusion criteria. Overall, 57% of the studies identified a statistically significant improvement in patient satisfaction associated with team-based care. Team-based care interventions ranged from single team activities such as multidisciplinary rounds to comprehensive team-based models of care. Patient satisfaction scores were greater with teams that had more than two professions and more comprehensive team-based models. About one-quarter of studies that measured patient satisfaction and at least one additional outcome demonstrated improvement in both. CONCLUSIONS: Team-based care may positively affect patient satisfaction. Team composition and type of team intervention appears to influence the strength of the relationship. Improvements in satisfaction are not consistently accompanied by improvements in other outcomes.

Palliative Nursing Summit: Nurses Leading Change and Transforming Care: The Nurse's Role in Coordination of Care and Transition Management.

The Hospice and Palliative Nurses Association Palliative Nursing Summit (Summit) "Nurses Leading Change and Transforming Care" brought nurses from numerous specialties together to discuss collaboration in advancing primary palliative nursing. Nursing leadership was highlighted, and the future of integrating primary palliative care was emphasized. Three workshop groups held discussions on key collaborative topics of communication/advance care planning, pain and symptom management, and coordination of care/transition management (CCTM). Nursing has historically led the way in CCTM, especially in acute- and long-term-care settings. The philosophy and principles of CCTM are in direct alignment with the values and guidelines for quality palliative care. Goals of CCTM include the achievement of optimal health, equal access to care, and appropriate utilization of health care resources, balanced with the patient's right to self-determination. This article presents an overview of the patient and family outcomes and nursing actions identified by the group regarding CCTM.

Exploring the nature of interprofessional collaboration and family member involvement in an intensive care context.

Little is known about the nature of interprofessional collaboration on intensive care units (ICUs), despite its recognition as a key component of patient safety and quality improvement initiatives. This comparative ethnographic study addresses this gap in knowledge and explores the different factors that influence collaborative work in the ICU. It aims to develop an empirically grounded team diagnostic tool, and associated interventions to strengthen team-based care and patient family involvement. This iterative study is comprised of three phases: a scoping review, a multi-site ethnographic study in eight ICUs over 2 years; and the development of a diagnostic tool and associated interprofessional intervention-development. This study's multi-site design and the richness and breadth of its data maximize its potential to improve clinical outcomes through an enhanced understanding of interprofessional dynamics and how patient family members in ICU settings are best included in care processes. Our research dissemination strategy, as well as the diagnostic tool and associated educational interventions developed from this study will help transfer the study's findings to other settings.

Studio-based learning in interprofessional education.

The recent growth of interprofessional education (IPE) in healthcare has been accompanied by exploration of teaching strategies to improve its effectiveness. Experts in IPE advise faculty to explore teaching models from other disciplines outside of healthcare. Studio-based learning (SBL) in design education embodies many of the features that are integral to effective IPE. Students work in teams to design new processes and products to solve complex and real-life problems. The purpose of this paper is to describe features of SBL that enhance IPE and examine student experiences of interprofessional learning from three healthcare design studios. Findings from an exploratory case study of these design studios involving students from a range of professions suggest that the students transition through learning stages in SBL that may enhance IPE. The paper goes on to discuss the unique features of SBL and how they offer new and complementary strategies for building interprofessional curricula.

Designing for competence: spaces that enhance collaboration readiness in healthcare.

Many universities in the United States are investing in classrooms and campuses designed to increase collaboration and teamwork among the health professions. To date, we know little about whether these learning spaces are having the intended impact on student performance. Recent advances in the identification of interprofessional teamwork competencies provide a much-needed step toward a defined outcome metric. Rigorous study of the relationship between design and student competence in collaboration also requires clear specification of design concepts and development of testable frameworks. Such theory-based evaluation is crucial for design to become an integral part of interprofessional education strategies and initiatives. Current classroom and campus designs were analyzed for common themes and features in collaborative spaces as a starting place for specification of design concepts and model development. Four major themes were identified: flexibility, visual transparency/proximity, technology and environmental infrastructure. Potential models linking this preliminary set of design concepts to student competencies are proposed and used to generate hypotheses for future study of the impact of collaborative design spaces on student outcomes.

The importance of health information technology in care coordination and transitional care.

Care coordination and transitional care services are strategically important for achieving the priorities of better care, better health, and reduced costs embodied in the National Strategy for Quality Improvement in Health Care (National Quality Strategy [NQS]). Some of the most vulnerable times in a person's care occur with changes in condition as well as movement within and between settings of care. The American Academy of Nursing (AAN) believes it is essential to facilitate the coordination of care and transitions by using health information technology (HIT) to collect, share, and analyze data that communicate patient-centered information among patients, families, and care providers across communities. HIT makes information accessible, actionable, timely, customizable, and portable. Rapid access to information also creates efficiencies in care by eliminating redundancies and illuminating health history and prior care. The adoption of electronic health records (EHRs) and information systems can enable care coordination to be more effective but only when a number of essential elements are addressed to reflect the team-based nature of care coordination as well as a focus on the individual's needs and preferences. To that end, the AAN offers a set of recommendations to guide the development of the infrastructure, standards, content, and measures for electronically enabled care coordination and transitions in care as well as research needed to build the evidence base to assess outcomes of the associated interventions.

Avoidability of hospital transfers of nursing home residents: perspectives of frontline staff.

OBJECTIVES: To describe nursing home (NH) staff perceptions of avoidability of hospital transfers of NH residents. DESIGN: Mixed methods qualitative and quantitative analysis of 1,347 quality improvement (QI) review tools completed by staff at 26 NHs and transcripts of conference calls. SETTING: Twenty-six NHs in three states participating in the Interventions to Reduce Acute Care Transfers (INTERACT II) QI project. PARTICIPANTS: Site coordinators and staff who participated in project orientation and conference calls and completed QI tools. MEASUREMENTS: NH and hospitalization data collected for the INTERACT II project. An interprofessional team coded and quantified reasons for hospital transfer on 1,347 QI review tools. RESULTS: Staff rated 76% of the transfers in the QI review tools as not avoidable. Common reasons for transfers rated as unavoidable were acute change in resident status, family insistence, and physician order for transfer. These same reasons were given for transfers rated as avoidable. Avoidable ratings were associated with a broader set of reasons and recommendations for improvement, including earlier identification and management of changes in clinical status, earlier discussion with family members about advance directives, and more-comprehensive communication with physicians. NHs that were more actively engaged in the INTERACT II interventions rated more transfers as avoidable. Percentage of transfers rated avoidable was not correlated with change in hospitalization rates. CONCLUSION: NH staff rated fewer hospital transfers as avoidable than published estimates. Greater attention to the complex array of reasons that staff provide for hospital transfer should be considered in strategies to reduce avoidable hospitalizations of NH residents.

Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project.

A substantial proportion of hospitalizations of nursing home (NH) residents may be avoidable. Medicare payment reforms, such as bundled payments for episodes of care and value-based purchasing, will change incentives that favor hospitalization but could result in care quality problems if NHs lack the resources and training to identify and manage acute conditions proactively. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist NH staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 NHs in three states in a 6-month quality improvement initiative that provided tools, on-site education, and teleconferences every 2 weeks facilitated by an experienced nurse practitioner. There was a 17% reduction in self-reported hospital admissions in these 25 NHs from the same 6-month period in the previous year. The group of 17 NHs rated as engaged in the initiative had a 24% reduction, compared with 6% in the group of eight NHs rated as not engaged and 3% in a comparison group of 11 NHs. The average cost of the 6-month implementation was $7,700 per NH. The projected savings to Medicare in a 100-bed NH were approximately $125,000 per year. Despite challenges in implementation and caveats about the accuracy of self-reported hospitalization rates and the characteristics of the participating NHs, the trends in these results suggest that INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.