Patient selection strategies in an intensive primary care program.

BACKGROUND: Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context. METHODS: This study employs an exploratory sequential mixed-methods design. We analyzed qualitative interviews with 21 PIM team and facility leaders and electronic health record (EHR) data from 2,061 patients screened between July 2014 and September 2017 for PIM enrollment. Qualitative data were analyzed using a hybrid inductive/deductive approach. Quantitative data were analyzed using descriptive statistics. RESULTS: Of 1,887 patients identified for PIM services using standardized criteria, over half were deemed inappropriate for PIM services, either because of not having an ambulatory care sensitive condition, living situation, or were already receiving recommended care. Qualitative analysis found that team members considered standardized criteria to be a useful starting point but too broad to be relied on exclusively. Additional data collection through chart review and communication with the current primary care team was needed to adequately assess patient complexity. Qualitative analysis further found that differences in conceptualizing program goals led to conflicting opinions of which patients should be enrolled in PIM. CONCLUSIONS: A combined approach that includes clinical judgment, case review, standardized criteria, and targeted program goals are all needed to support appropriate patient selection processes.

Balancing the benefits of patient-clinician relationships with professional boundaries in Home-based Primary Care.

In the home care setting, boundaries may be difficult to identify when behavioral changes are made to accommodate the nature of care being delivered. In this secondary qualitative study, we examined how Home-based Primary Care (HBPC) clinicians understand role and relationship boundaries with patients and how these dynamics support patient care. The data set consisted of 14 semi-structured interviews with HBPC clinicians representing multiple disciplines and field observations of 6 HBPC team meetings. Using a directed approach to content analysis, we identified and described how HBPC clinicians worked to build relationships with patients, experienced challenges with emotional attachment, and negotiated boundaries in the patient-clinician relationship. Our findings illustrate how the home care setting is a site for which strong, therapeutic patient-clinician relationships can be developed while also highlighting the work that clinicians must do to balance addressing patient needs stemming from social isolation and adherence to their own professional boundaries.

Vaccine hesitancy among Veterans Affairs Health Care System employees.

Vaccine hesitancy undermines the control of the COVID-19 pandemic and has been observed in health care workers. As part of a quality improvement effort, we aimed to describe reasons for vaccine acceptance and hesitancy among employees in the Veteran Affairs Portland Health Care System (VAPORHCS). We administered an open-ended and web-based survey to all VAPORHCS employees in July 2021. Data were analyzed using a rapid usability framework, whereby qualitative data were synthesized into thematic categories to inform decision making. Among the 1157 employees who completed the survey, 88% reported that they had received the vaccine and 12% reported that they did not receive the vaccine. Over half (54%) of vaccinated respondents reported having initial hesitancy to the COVID-19 vaccine but overcame their hesitancy by deciding that the vaccine's benefits outweighed its risks. Reasons for COVID-19 vaccine acceptance were: 1) individual and community health; 2) protect vulnerable and unvaccinated family members; 3) promote patient and workplace safety; 4) scientific evidence. Reasons for COVID-19 vaccine hesitancy among unvaccinated employees were: 1) concerns with safety and risk profile of vaccine; 2) mistrust in vaccine development; 3) personal choice; 4) openness to future vaccination. These results provide information for tailored vaccine messaging efforts as well as emphasizes the need for trust-building between employees and health care organizations.

"The SUMMIT Team is All I Got": perspectives of medically and socially complex patients seen in intensive primary care.

Context: There is great interest in intensive primary care (IPC) interventions to address the needs of medically and socially complex patients, however it is unknown how these interventions impact patient experience. Objective: Describe the experience of patients on the Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT), an IPC for patients with complex needs at a federally qualified health center serving patients with high rates of homelessness. Study Design: Qualitative study using semi-structured interviews with 25 patients enrolled in the SUMMIT intervention. We conducted a thematic analysis using a hybrid inductive/deductive approach. Results: Prior to SUMMIT, patients often felt it was difficult to engage with the healthcare system, in part due to their complex medical conditions, but also factors including prior trauma, poverty, substance use, and providers' stigma. We identified four themes related to how and why patients felt SUMMIT improved their care: 1) Investment: Patients perceived the team as truly invested in them and expressed how the team walked side by side in their care journeys to overcome stigma, low-self efficacy, and prior negative experiences with the healthcare system 2) Family: Patients reported feeling a strong sense of family with SUMMIT team members and believed that the team had genuine duty and obligation toward them, interacting with them in a non-judgmental, culturally competent manner. 3) Feeling valued: Patients expressed that the team's flexible design, continuity of team membership, care coordination and addressing unmet needs and social determinants led them to feel valued and hope. 4) Evolution of self-efficacy: Patients experienced improved self-efficacy, and were able to engage with health care proactively, instead of avoiding care. Conclusion: Medically and socially complex patients experience trauma and stigma that shape perceptions of care. Patients appreciated humanizing interactions with team members along with the additional support SUMMIT provided to overcome barriers to care. They spoke of the team as family members who valued them and they recognized how the program had helped them take a more active role in improving their own health. Our findings suggest that effectiveness of IPC interventions may lie, in part, on the use of team members who have the skills and commitment to deliver non-judgemental, culturally competent, longitudinal relationship-focused care.

"Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care.

BACKGROUND: Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors. OBJECTIVE: Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery. DESIGN, SETTING, AND PARTICIPANTS: Between 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits. APPROACH: We employed an exploratory, content-driven approach to qualitative data analysis. RESULTS: Four thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having "eyes in the home" yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides. CONCLUSION AND RELEVANCE: HBPC providers emphasized the importance of having "eyes in the home" to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.

Capacity Building Together: Shifting Roles for Research and Implementation in Health Resilience Among American Indians in Arizona.

Community engagement has become a leading framework for supporting health equity. The process of engagement includes groups working together to continually identify and erode existing inequalities to promote a justice-oriented approach to health and wellness for all. Missing from the literature is a fine-grained study of processes that occur between and among project partners building the foundation for ongoing trust and reciprocity. Our project, Health Resilience among American Indians in Arizona, brought new and seasoned researchers together to collect and analyze data on healthcare provider knowledge and American Indian resilience. Four years after the conclusion of the project, central members of the team developed a postproject self-assessment to investigate lasting impacts of project participation using what we call an "Iterative Poly-knowledge Evaluation Cycle approach." Results highlight the value of flexibility of roles and organic change within projects, the importance of a focus on strengths rather than deficits, and the identification of lasting change on project team members at all levels to build and bolster multisectoral scaffolding for partnerships for health. We present this case study to contribute to an understanding of impacts of community-engaged, Indigenous research projects on people who work together toward challenging existing systems of inequality for better community health.

Building a Narrative of Equity: Weaving Indigenous Approaches into Community-Engaged Research.

In 2020, global injustice has taken center stage during the uprising of the Black Lives Matter movement and other social movements. Activists are calling attention to longstanding disparities in health outcomes and an urgent need for justice. Given the global socio-political moment, how can health researchers draw on current critical theory and social movements to create structures for equitable outcomes in health research and practice? Here, we demonstrate principles for effective health research and social justice work that builds on community-engaged approaches by weaving critical Indigenous approaches into structural project designs. Our project, "Health Resilience among American Indians in Arizona", brought new and seasoned researchers together to collect and analyze data on the knowledge of healthcare providers concerning American Indian health and well-being. Four years after the conclusion of the project, the team developed and created a post-project self-assessment to investigate lasting impacts of project participation. In this communication, we discuss the principles of defining and measuring the capacity to build together. This work responds to the call from Indigenous scholars and community leaders to build an internal narrative of change. While we will not present the full instrument, we will discuss building a strong foundation using the principles of engagement for planning and implementing justice and change.

Creating change, challenging structure: graduate and faculty perspectives on the implementation of an interprofessional education program in veterans affairs primary care.

Interprofessional clinical education programs have the potential to impact participants' professional expectations and practices related to team-based care. In this qualitative study, research team members interviewed 38 graduates and 19 faculty members from such an interprofessional training program, the Department of Veterans Affairs (VA) Centers of Excellence in Primary Care Education (CoEPCE). Semi-structured interviews with participants enquired about skills gained, impact on career expectations, and barriers to implementing interprofessional skills in the post-training workplace. Data were coded and analyzed using a hybrid inductive/deductive approach. Participants perceived that the program was successful in creating new norms of flattened team hierarchies, broadening graduates' understanding of role interaction, and teaching interactional skills involving teamwork. Participants reported organizational and systemic barriers to changing existing primary care practice. Interprofessional clinical education programs may help new professionals recognize and act on opportunities for improvement in existing practice. Healthcare employers must recognize changed expectations and provide opportunities for interprofessional collaboration to attract graduates from such programs.

Association of a Multisite Interprofessional Education Initiative With Quality of Primary Care.

Importance: Studies have shown that interprofessional education (IPE) improves learner proficiencies, but few have measured the association of IPE with patient outcomes, such as clinical quality. Objective: To estimate the association of a multisite IPE initiative with quality of care. Design, Setting, and Participants: This study used difference-in-differences analysis of US Department of Veterans Affairs (VA) electronic health record data from July 1, 2008, to June 30, 2015. Patients cared for by resident clinicians in 5 VA academic primary care clinics that participated in the Centers of Excellence in Primary Care Education (CoEPCE), an initiative designed to promote IPE among physician, nurse practitioner, pharmacist, and psychologist trainees, were compared with patients cared for by resident clinicians in 5 regionally matched non-CoEPCE clinics using data for the 3 academic years (ie, July 1 to June 30) before and 4 academic years after the CoEPCE launch. Analysis was conducted from January 18, 2018, to January 17, 2019. Main Outcomes and Measures: Among patients with diabetes, outcomes included annual hemoglobin A1c, poor hemoglobin A1c control (ie, <9% or unmeasured), and annual renal test; among patients 65 years and older, outcomes included prescription of high-risk medications; among patients with hypertension, outcomes included hypertension control (ie, blood pressure, <140/90 mm Hg); and among all patients, outcomes included timely mental health referrals, primary care mental health integrated visits, and hospitalizations for ambulatory care-sensitive conditions. Results: A total of 44 527 patients contributed 107 686 patient-years; 49 279 (45.8%) were CoEPCE resident patient-years (mean [SD] patient age, 59.3 [15.2] years; 26 206 [53.2%] white; 8073 [16.4%] women; mean [SD] patient Elixhauser comorbidity score, 12.9 [15.1]), and 58 407 (54.2%) were non-CoEPCE resident patient-years (mean [SD] patient age, 61.8 [15.3] years; 43 912 [75.2%] white; 4915 [8.4%] women; mean [SD] patient Elixhauser comorbidity score, 13.8 [15.7]). Compared with resident clinicians who did not participate in the CoEPCE initiative, CoEPCE training was associated with improvements in the proportion of patients with diabetes with poor hemoglobin A1c control (-4.6 percentage points; 95% CI, -7.5 to -1.8 percentage points; P < .001), annual renal testing among patients with diabetes (3.2 percentage points; 95% CI, 0.6 to 5.7 percentage points; P = .02), prescription of high-risk medications among patients 65 years and older (-2.3 percentage points; 95% CI, -4.0 to -0.6 percentage points; P = .01), and timely mental health referrals (1.6 percentage points; 95% CI, 0.6 to 2.6 percentage points; P = .002). Fewer patients cared for by CoEPCE resident clinicians had a hospitalization for an ambulatory care-sensitive condition compared with patients cared for by non-CoEPCE resident clinicians in non-CoEPCE clinics (-0.4 percentage points; 95% CI, -0.9 to 0.0 percentage points; P = .01). Sensitivity analyses with alternative comparison groups yielded similar results. Conclusions and Relevance: In this study, the CoEPCE initiative was associated with modest improvements in quality of care. Implementation of IPE was associated with improvements in patient outcomes and may potentiate delivery system reform efforts.

"It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU).

PURPOSE: High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients' needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work. METHODS: We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 "usual care" members. We conducted a thematic analysis, using an inductive approach, at a semantic level. RESULTS: Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient-health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients' individual situations. Participants' definitions of success focused more on improving patient engagement than reducing utilization or cost. CONCLUSION: FQHC staff working with HNHC patients perceive mismatch between the health care system and patients' clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.

Community Based Participatory Research (CBPR): A Dynamic Process of Health care, Provider Perceptions and American Indian Patients' Resilience.

American Indians are disproportionately affected by factors that lead to health disparities, however many Native people demonstrate resilience when faced with health risks. Study objectives were to use a resilience framework to identify wellness strategies among American Indian people and to assess health care provider perceptions of American Indian wellness. Participants included 39 American Indian adults who self-reported resilient change and 22 health care providers who served American Indian patients. Thematic categories across American Indian and health care provider data were identified: 1) relationships inform resilience; 2) prejudice stymies resilience; and 3) place shapes resilience. Results indicated the salience of relationships in demonstrating resilience. Identified challenges and supporters of resilience are discussed.

Experience and Context Shape Patient and Clinician Goals For Treatment of Rheumatoid Arthritis: A Qualitative Study.

OBJECTIVE: Alignment of patient and clinician goals, which is central to effective patient-centered care, has been linked to improved patient experience and outcomes but has not been explored in rheumatoid arthritis (RA). The aim of this study was to analyze goal conceptualization among RA patients and clinicians. METHODS: Seven focus groups and 1 semi-structured interview were conducted with RA patients and clinicians who were recruited from 4 rheumatology clinics. An interview guide was developed to explore goal concordance related to RA treatment. Researchers utilized a concurrent deductive-inductive data analysis approach. RESULTS: Nineteen patients (mean age 55 years, 74% female, 32% non-white, and 26% Spanish-speaking) and 18 clinicians (44% trainees, 44% female, 28% non-white) participated. Across clinician and patient focus groups, the 2 identified domains were patient knowledge of RA and psychosocial dynamics (stress) in RA treatment. Within the knowledge domain, 3 themes emerged: RA knowledge for informed choice, RA knowledge to ensure adherence and medication safety, and clinician assumption of patient inability to interpret information. Within the second domain of RA and stress, 2 themes emerged: patient illness experience informs treatment context in ways that are not shared by clinicians, and the impact of patient-clinician communication and decision-making on goal concordance. CONCLUSION: Knowledge is a shared goal, but RA patients and clinicians hold divergent attitudes towards this goal. While knowledge is integral to self-management and effective shared decision-making, mismatches in attitudes may lead to suboptimal communication. Tools to support patient goal-directed RA care may promote high quality patient-centered care and result in reduced disparities.

Task Delegation and Burnout Trade-offs Among Primary Care Providers and Nurses in Veterans Affairs Patient Aligned Care Teams (VA PACTs).

PURPOSE: Appropriate delegation of clinical tasks from primary care providers (PCPs) to other team members may reduce employee burnout in primary care. However, (1) the extent to which delegation occurs within multidisciplinary teams, (2) factors associated with greater delegation, and (3) whether delegation is associated with burnout are all unknown. METHODS: We performed a national cross-sectional survey of Veterans Affairs (VA) PCP-nurse dyads in Department of VA primary care clinics, 4 years into the VA's patient-centered medical home initiative. PCPs reported the extent to which they relied on other team members to complete 15 common primary care tasks; paired nurses reported how much they were relied on to complete the same tasks. A composite score of task delegation/reliance was developed by taking the average of the responses to the 15 questions. We performed multivariable regression to explore predictors of task delegation and burnout. RESULTS: Among 777 PCP-nurse dyads, PCPs reported delegating tasks less than nurses reported being relied on (PCP mean ± standard deviation composite delegation score, 2.97± 0.64 [range, 1-4]; nurse composite reliance score, 3.26 ± 0.50 [range, 1-4]). Approximately 48% of PCPs and 35% of nurses reported burnout. PCPs who reported more task delegation reported less burnout (odds ratio [OR], 0.62 per unit of delegation; 95% confidence interval [CI], 0.49-0.78), whereas nurses who reported being relied on more reported more burnout (OR, 1.83 per unit of reliance; 95% CI, 1.33-2.5). CONCLUSIONS: Task delegation was associated with less burnout for PCPs, whereas task reliance was associated with greater burnout for nurses. Strategies to improve work life in primary care by increasing PCP task delegation must consider the impact on nurses.

Sources of Distress in Primary Care Opioid Management and the Role of a Controlled Substance Review Group: A Qualitative Study.

Objective: The objective of the study was to explore provider perspectives surrounding opioid prescribing in the context of the early implementation of a multidisciplinary group, called the Controlled Substance Review Group, that provided structured opioid case discussion and consultation to primary care providers. Setting: A Veterans Health Administration primary care clinic in Portland, Oregon. Participants: 12 members of primary care clinic staff representing multiple disciplines with recent participation in the Controlled Substance Review Group. Methods: Six semistructured interviews with primary care providers, one focus group discussion with six Nurse Care Managers, and 28 structured observations of CSRG meetings were conducted. In an iterative process using applied thematic analysis, a trained qualitative researcher reviewed textual data for themes. Results: Four broad domains with associated themes emerged from the analysis: 1) challenges of pain management-objective pain measures, changing guidelines, lack of coordinated approach; 2) patient attachment to opioids-threats, entitlement, abandonment; 3) provider frustration-confrontation in clinic visits, lack of mental health engagement, complex social situation; and 4) role of the Controlled Substance Review Group-communication techniques, supporting mental health engagement, structured backing. Conclusions: Primary care providers experience stress associated with opioid prescribing, including the provision of appropriate pain management using opioid analgesics and difficult patient-provider communication. The Controlled Substance Review Group functions to support providers through assistance with decision-making and shared responsibility for decision outcomes.

Patient goals in rheumatoid arthritis care: A systematic review and qualitative synthesis.

OBJECTIVE: During the clinical encounter, rheumatoid arthritis (RA) patient goals for care often go unexplored. The aim of the present systematic review was to identify needs, goals and expectations of RA patients in order better to guide systematic elicitation of patient goals in clinical encounters. METHODS: An academic librarian searched MEDLINE, PsychINFO and the Cochrane Library using a specialized algorithm developed to identify articles about patient goals for RA care. Investigators screened search results according to prespecified inclusion criteria and then reviewed included articles and synthesized the evidence qualitatively, utilizing an inductive approach. RESULTS: A total of 909 titles were retrieved in the literature search, of which 871 were excluded after a title/abstract screen. Of the remaining 38, 22 papers were included in the final review. Investigators identified four major themes in the literature: (a) the bodily experience of RA; (b) achieving normalcy and maintaining wellness; (c) social connectedness and support; and (d) interpersonal and healthcare system interactions. CONCLUSION: Patients' goals when receiving care for RA are multidimensional and span several facets of everyday life. Goals for RA care should be collaboratively developed between patients and providers, with particular attention to the patient's life context and priorities.

Hiring the experts: best practices for community-engaged research.

Community-engaged approaches to research and practice continue to show success in addressing health equity and making long-term change for partnership relationships and structures of power. The usefulness of these approaches is either diminished or bolstered by community trust, which can be challenging for partnerships to achieve. In this research note we present an example process for recruiting, interviewing, and hiring community researchers as a starting place for capacity building and for laying the foundation for data collection and analysis in health-related community projects.

Implementing Qualitative Data Management Plans to Ensure Ethical Standards in Multi-Partner Centers.

Thorough data management is crucial for the protection of people who participate in research and the ability for researchers to share results with the public. The impact of inadequate adherence to data management is particularly evident in small field sites and among vulnerable populations partoicipating in Community-Based Participatory Research (CBPR). CBPR presents exciting opportunities for multimedia and multi-sectoral dissemination of research results and policy change, especially concerning the impact of research on health equity for underrepresented populations. In this article, we discuss how we defined data boundaries and protections to adhere to ethical standards while also prioritizing data dissemination while using CBPR with American Indians in Arizona. Although complex partnerships can introduce additional risks to data oversight, data management practices can also increase opportunities for wide-reaching dissemination. We hope to contribute to the literature on data sharing in multi-partnership projects to bolster the impact of dissemination while also protecting participants and populations who chose to collaborate in research and policy practices.