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1.
Am J Med Qual ; 35(1): 16-22, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31030525

RESUMO

Primary care practices often engage in quality improvement (QI) in order to stay current and meet quality benchmarks, but the extent to which turnover affects practices' QI ability is not well described. The authors examined qualitative data from practice staff and external facilitators participating in a large-scale QI initiative to understand the relationship between turnover and QI efforts. The examination found turnover can limit practices' ability to engage in QI activities in various ways. When a staff member leaves, remaining staff often absorb additional responsibilities, and QI momentum slows as new staff are trained or existing staff are reengaged. Turnover alters staff dynamics and can create barriers to constructive working relationships and team building. When key practice members leave, they can take with them institutional memory about QI purpose, processes, and long-term vision. Understanding how turnover affects QI may help practices, and those helping them with QI, manage the disruptive effects of turnover.

2.
Implement Sci ; 14(1): 100, 2019 12 05.
Artigo em Inglês | MEDLINE | ID: mdl-31805968

RESUMO

BACKGROUND: Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs). METHODS: This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs' EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes. RESULTS: Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes. CONCLUSIONS: Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics' ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

3.
J Dev Behav Pediatr ; 40(9): 669-678, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31599790

RESUMO

OBJECTIVE: Early childhood parenting interventions are increasingly delivered in primary care, but parental engagement with those interventions is often suboptimal. We sought to better understand parents' preferences for the content and delivery method of behavioral health guidance in pediatric primary care and to determine the relationship of those preferences with demographic characteristics, child behavior problems, and parenting style. METHODS: Participants were 396 parents of young children recruited from primary care offices. We collected measures of parental preferences (including behavioral topics, intervention strategies, and methods of delivery) for behavioral intervention in primary care, child behavior symptoms, parenting style, and demographic characteristics. Descriptive statistics were used to identify parents' most preferred behavioral topics and intervention delivery methods. We used a hierarchical regression approach to determine whether parenting style predicted parents' preferences beyond demographic and child-level factors. RESULTS: Nearly all parents (96%) endorsed a behavioral topic (e.g., aggression) as important. Most preferred to receive intervention during routine medical appointments. Child behavior problems correlated with parents' overall interest in behavioral guidance, but clinically significant symptoms did not differentiate interest in any single topic. Socioeconomic factors and negative parenting practices predicted some parental preferences. Notably, lax parenting generally predicted higher interest in behavioral intervention, whereas hostile and physically controlling parenting predicted lower interest. CONCLUSION: Most parents are interested in behavioral guidance as part of primary care, but their preferences for the content and delivery of that guidance vary by known socioeconomic, child, and parenting risk factors. Tailoring intervention to parents' preferences may increase engagement with available interventions.

5.
J Gerontol Nurs ; 45(9): 19-29, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31437287

RESUMO

In the current 3-month, two arm, unblinded, single site, pilot randomized controlled trial, 120 high fall risk hospitalized older adults (age ≥65) were contacted, and 67 participants were enrolled. The intervention arm received a brief motivational interviewing (MI) intervention. Both arms received routine hospital fall prevention protocols. Measurements were conducted at baseline, 2 days, 1 week, 1 month, and 3 months. MI intervention took approximately 21 minutes and was provided at beginning proficiency level. Approximately 66% of participants completed 3-month data collection. The intervention group reported a greater decrease in fear of falling after the intervention than the control arm (ß = -0.856 vs. ß = -0.236) and maintained fall prevention behaviors at 3 months (ß = 0.001 vs. ß = -0.083) (p < 0.05). The current study found brief MI for fall prevention in acute settings feasible and provided preliminary evidence for a positive impact of MI [Journal of Gerontological Nursing, 45(9), 19-29.].

6.
J Am Board Fam Med ; 32(4): 585-595, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31300579

RESUMO

INTRODUCTION: Primary care risk stratification (RS) has been shown to help practices better understand their patient populations' needs and may improve health outcomes and reduce expenditures by targeting and tailoring care to high-need patients. This study aims to understand key considerations practices faced and practice experiences as they began to implement RS models. METHODS: We conducted semistructured interviews about experiences in RS with 34 stakeholders from 15 primary care practices in Oregon and Colorado and qualitatively analyzed the data. RESULTS: Three decisions were important in shaping practices' experiences with RS: choosing established versus self-created algorithms or heuristics, clinical intuition, or a combination; selecting mechanisms for assigning risk scores; determining how to integrate RS approaches into care delivery. Practices using clinical intuition found stratification time-consuming and difficult to incorporate into existing workflows, but trusted risk scores more than those using algorithms. Trust in risk scores was influenced by data extraction capabilities; practices often lacked sufficient data to calculate their perceived optimal risk score. Displaying the scores to the care team was a major issue. Finally, obtaining buy-in from care team members was challenging, requiring repeated cycles of improvement and workflow integration. DISCUSSION: Practices used iterative approaches to RS implementation. As a result, procedural and algorithmic changes were introduced and were influenced by practices' health IT, staffing, and resource capacities. Practices were most successful when able to make iterative changes to their approaches, incorporated both automation and human process in RS, educated staff on the importance of RS, and had readily accessible risk scores.

7.
J Am Board Fam Med ; 32(3): 398-407, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31068404

RESUMO

PURPOSE: We assessed differences in structural characteristics, quality improvement processes, and cardiovascular preventive care by ownership type among 989 small to medium primary care practices. METHODS: This cross-sectional analysis used electronic health record and survey data collected between September 2015 and April 2017 as part of an evaluation of the EvidenceNOW: Advancing Heart Health in Primary Care Initiative by the Agency for Health Care Research and Quality. We compared physician-owned practices, health system or medical group practices, and Federally Qualified Health Centers (FQHC) by using 15 survey-based practice characteristic measures, 9 survey-based quality improvement process measures, and 4 electronic health record-based cardiovascular disease prevention quality measures, namely, aspirin prescription, blood pressure control, cholesterol management, and smoking cessation support (ABCS). RESULTS: Physician-owned practices were more likely to be solo (45.0% compared with 8.1%, P < .001 for health system practices and 12.8%, P = .009 for FQHCs) and less likely to have experienced a major change (eg, moved to a new location) in the last year (43.1% vs 65.4%, P = .01 and 72.1%, P = .001, respectively). FQHCs reported the highest use of quality improvement processes, followed by health system practices. ABCS performance was similar across ownership type, with the exception of smoking cessation support (51.0% for physician-owned practices vs 67.3%, P = .004 for health system practices and 69.3%, P = .004 for FQHCs). CONCLUSIONS: Primary care practice ownership was associated with differences in quality improvement process measures, with FQHCs reporting the highest use of such quality-improvement strategies. ABCS were mostly unrelated to ownership, suggesting a complex path between quality improvement strategies and outcomes.

8.
Implement Sci ; 14(1): 32, 2019 03 21.
Artigo em Inglês | MEDLINE | ID: mdl-30898133

RESUMO

BACKGROUND: The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice. METHODS: EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives' implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts. RESULTS: Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale. CONCLUSIONS: Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts. TRIAL REGISTRATION: Registered as Observational Study at www.clinicaltrials.gov ( NCT02560428 ).


Assuntos
Difusão de Inovações , Implementação de Plano de Saúde/organização & administração , Cardiopatias/prevenção & controle , Atenção Primária à Saúde/organização & administração , Fortalecimento Institucional , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/psicologia , Pessoal de Saúde/normas , Humanos , Informática Médica , Estados Unidos
9.
Geriatr Nurs ; 40(3): 290-295, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30595233

RESUMO

PURPOSE: To identify associations among patient fall risk factors, perceptions, and daily activities to improve patient engagement with fall prevention among hospitalized older adults. BACKGROUND: The risk of falling increases for older patients but few researchers have reported patient-centered measures on this topic. METHODS: Surveys and chart reviews of inpatients aged ≥ 65 with Morse Falls Scale scores of ≥ 45. Measurements included validated tools and the modified Fall Behavioral Scale-Inpatient (FaB-I). RESULTS: A fall within 3 months before hospitalization was associated with an increased level of importance to preventing falls and higher FaB-I score (more fall prevention behaviors) but decreased level of confidence related to preventing falls (p < 0.05). Perception measures (concern: r = 0.52; patient activation: r = 0.46) were positively associated with FaB-I (p < 0.001). CONCLUSIONS: Addressing patient-centered measures such as perceptions of and daily activities for fall prevention could add value to existing fall prevention programs.


Assuntos
Acidentes por Quedas/prevenção & controle , Hospitalização , Pacientes Internados/psicologia , Percepção , Acidentes por Quedas/estatística & dados numéricos , Idoso , Feminino , Humanos , Masculino , Fatores de Risco , Inquéritos e Questionários
10.
J Ambul Care Manage ; 42(1): 51-65, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30499901

RESUMO

Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors-guided by protocols or scripts-to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.

11.
J Innov Health Inform ; 25(3): 158-168, 2018 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-30398459

RESUMO

BACKGROUND: Electronic health records (EHRs) are a key tool for primary care practice. However, EHR functionality is not keeping pace with the evolving informational and decision-support needs of behavioral health clinicians (BHCs) working on integrated teams. OBJECTIVE: Describe workflows and tasks of BHCs working with integrated teams, identify their health information technology needs, and develop EHR tools to address them. METHOD: A mixed-methods, comparative-case study of six community health centers (CHCs) in Oregon, each with at least one BHC integrated in their primary care team. We observed clinical work and conducted interviews to understand workflows and clinical tasks, aiming to identify how effectively current EHRs supported integrated care delivery, including transitions, documentation, information sharing, and decision making. We analyzed these data and employed a user-centered design process to develop EHR tools addressing the identified needs. RESULTS: BHCs used the primary care EHR for documentation and communication with other team members, but the EHR lacked the functionality to fully support integrated care. Needs include the ability to: (1) automate and track paper-based screening; (2) document behavioral health history; (3) access patient social and medical history relevant to behavioral health issues, and (4) rapidly document and track progress on goals. To meet these needs, we engaged users and developed a set of EHR tools called the BH e-Suite. CONCLUSION: Integrated primary care teams, and particularly BHCs, have unique information needs, workflows and tasks. These needs can be met and supported by the EHR with a moderate level of modification.


Assuntos
Centros Comunitários de Saúde/organização & administração , Serviços Comunitários de Saúde Mental/organização & administração , Registros Eletrônicos de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Humanos , Informática Médica , Equipe de Assistência ao Paciente/organização & administração
12.
J Gen Intern Med ; 33(12): 2138-2146, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30276654

RESUMO

BACKGROUND: Burnout among primary care physicians, advanced practice clinicians (nurse practitioners and physician assistants [APCs]), and staff is common and associated with negative consequences for patient care, but the association of burnout with characteristics of primary care practices is unknown. OBJECTIVE: To examine the association between physician-, APC- and staff-reported burnout and specific structural, organizational, and contextual characteristics of smaller primary care practices. DESIGN: Cross-sectional analysis of survey data collected from 9/22/2015-6/19/2017. SETTING: Sample of smaller primary care practices in the USA participating in a national initiative focused on improving the delivery of cardiovascular preventive services. PARTICIPANTS: 10,284 physicians, APCs and staff from 1380 primary care practices. MAIN MEASURE: Burnout was assessed with a validated single-item measure. KEY RESULTS: Burnout was reported by 20.4% of respondents overall. In a multivariable analysis, burnout was slightly more common among physicians and APCs (physician vs. non-clinical staff, adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI], 1.05-1.49, APC vs. non-clinical staff, aOR = 1.34, 95% CI, 1.10-1.62). Other multivariable correlates of burnout included non-solo practice (2-5 physician/APCs vs. solo practice, aOR = 1.71; 95% CI, 1.35-2.16), health system affiliation (vs. physician/APC-owned practice, aOR = 1.42; 95%CI, 1.16-1.73), and Federally Qualified Health Center status (vs. physician/APC-owned practice, aOR = 1.36; 95%CI, 1.03-1.78). Neither the proportion of patients on Medicare or Medicaid, nor practice-level patient volume (patient visits per physician/APC per day) were significantly associated with burnout. In analyses stratified by professional category, practice size was not associated with burnout for APCs, and participation in an accountable care organization was associated with burnout for clinical and non-clinical staff. CONCLUSIONS: Burnout is prevalent among physicians, APCs, and staff in smaller primary care practices. Members of solo practices less commonly report burnout, while members of health system-owned practices and Federally Qualified Health Centers more commonly report burnout, suggesting that practice level autonomy may be a critical determinant of burnout.


Assuntos
Prática Avançada de Enfermagem/tendências , Esgotamento Profissional/psicologia , Médicos de Atenção Primária/psicologia , Médicos de Atenção Primária/tendências , Atenção Primária à Saúde/tendências , Esgotamento Profissional/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Assistentes Médicos/psicologia , Assistentes Médicos/tendências , Inquéritos e Questionários
13.
J Am Board Fam Med ; 31(5): 712-723, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30201667

RESUMO

BACKGROUND: Integrating behavioral health into primary care can improve care quality; however, most electronic health records are not designed to meet the needs of integrated teams. We worked with practices and behavioral health (BH) clinicians to design a suite of electronic health record tools to address these needs ("BH e-Suite"). The purpose of this article is to examine whether implementation of the BH e-Suite changes process of care, intermediate clinical outcomes, and patient experiences, and whether its use is acceptable to practice members and BH clinicians. METHODS: We conducted a convergent mixed-methods proof-of-concept study, implementing the BH e-Suite across 6 Oregon federally qualified community health centers ("intervention clinics"). We matched intervention clinics to 6 control clinics, based on location and patient panel characteristics, to assess whether process of care (Patient Health Questionnaire-9 [PHQ-9] and Generalized Anxiety Disorder-7 screening) and intermediate outcomes (PHQ-9, Generalized Anxiety Disorder-7 scores) changed postimplementation. Prepost patient surveys were used to assess changes in patient experience. To elucidate factors influencing implementation, we merged quantitative findings with structured observations, surveys, and interviews with practice members. RESULTS: Implementation improved process of care (PHQ-9 screening). During the course of the study, change in intermediate outcomes was not observed. Degree of BH e-Suite implementation varied: 2 clinics fully implemented, 2 partially implemented, and 2 practices did not implement at all. Initial practice conditions (eg, low resistance to change, higher capacity), process characteristics (eg, thoughtful planning), and individual characteristics (eg, high self-efficacy) were related to degree of implementation. CONCLUSIONS: Health information technology tools designed for behavioral health integration must fit the needs of clinics for the successful uptake and improvement in patient experiences. Research is needed to further assess the effectiveness of this tool in improving patient outcomes and to optimize broader dissemination of this tool among primary care clinics integrating behavioral health.


Assuntos
Registros Eletrônicos de Saúde , Serviços de Saúde Mental , Atenção Primária à Saúde , Adulto , Feminino , Implementação de Plano de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudo de Prova de Conceito
14.
J Health Care Poor Underserved ; 29(3): 949-963, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30122675

RESUMO

Several recent national initiatives have called for increased efforts to integrate social determinants of health (SDH) into health care settings using health information technology (HIT). However, there is limited evidence to guide the implementation of these recommendations in practice. Research is needed to understand what SDH information is most important to collect, how SDH information can be used to inform clinical care and referrals, and ultimately, whether and how integrating SDH screening and action into primary care affects individual and population health. We recently proposed a conceptual framework to illustrate how HIT can be used to bring SDH information into primary care. In this paper, we describe how we are putting this conceptual model into practice within the OCHIN network of community health centers by highlighting examples of ongoing research, identifying knowledge gaps, and outlining a roadmap of future research to move the field forward.


Assuntos
Informática Médica , Atenção Primária à Saúde , Determinantes Sociais da Saúde , Humanos , Modelos Organizacionais , Pesquisa/organização & administração
15.
Med Care ; 56 Suppl 10 Suppl 1: S58-S63, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30074953

RESUMO

BACKGROUND: Strategies to engage patients to improve and enhance research and clinical care are increasingly being implemented in the United States, yet little is known about best practices for or the impacts of meaningful patient engagement. OBJECTIVE: We describe and reflect on our patient stakeholder groups, engagement framework, experiences, and lessons learned in engaging patients in research, from generating proposal ideas to disseminating findings. SETTING: The ADVANCE (Accelerating Data Value Across a National Community Health Center Network) clinical data research network is the nation's largest clinical dataset on the safety net, with outpatient clinical data from 122 health systems (1109 clinics) in 23 states. RESULTS: Patients stakeholders codeveloped the ADVANCE engagement framework and its implementation in partnership with network leaders. In phase I of ADVANCE, patients were involved with designing studies (input on primary outcome measures and methods) and usability testing (of the patient portal). In phase II, the network is prioritizing research training, dissemination opportunities, an "ambassador" program to pair more experienced patient stakeholders with those less experienced, and evaluation of engagement activities and impacts. DISCUSSION: The ADVANCE framework for patient engagement has successfully involved a diverse group of patients in the design, implementation, and interpretation of comparative effectiveness research. Our experience and framework can be used by other organizations and research networks to support patient engagement activities.


Assuntos
Pesquisa Comparativa da Efetividade/organização & administração , Avaliação de Resultados da Assistência ao Paciente , Participação do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/organização & administração , Rede Social , Participação dos Interessados , Relações Comunidade-Instituição , Humanos , Estudos Interdisciplinares , Estados Unidos
16.
J Am Board Fam Med ; 31(3): 398-409, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29743223

RESUMO

PURPOSE: Practice facilitators ("facilitators") can play an important role in supporting primary care practices in performing quality improvement (QI), but they need complete and accurate clinical performance data from practices' electronic health records (EHR) to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform QI when complete or accurate performance data are not available. METHODS: Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality's initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for QI. RESULTS: We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust. CONCLUSION: Facilitators can use a range of strategies to help practices perform data-driven QI when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven QI that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support.


Assuntos
Registros Eletrônicos de Saúde/organização & administração , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade , Pesquisa Qualitativa , Estados Unidos
17.
BMC Health Serv Res ; 18(1): 354, 2018 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-29747644

RESUMO

BACKGROUND: Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children's coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children's insurance assistance. METHODS: We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). RESULTS: Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14-1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68-0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64-2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53-0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. CONCLUSIONS: This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02298361 ; retrospectively registered on November 5, 2014.


Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Cobertura do Seguro , Seguro Saúde/estatística & dados numéricos , Adolescente , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Criança , Pré-Escolar , Centros Comunitários de Saúde/estatística & dados numéricos , Confiabilidade dos Dados , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Lactente , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
18.
Health Aff (Millwood) ; 37(4): 635-643, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29608365

RESUMO

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.


Assuntos
Registros Eletrônicos de Saúde/normas , Uso Significativo , Atenção Primária à Saúde/normas , Melhoria de Qualidade/normas , Projetos de Pesquisa , Humanos
19.
Ann Fam Med ; 16(Suppl 1): S35-S43, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29632224

RESUMO

PURPOSE: Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS: In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS: The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION: There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.


Assuntos
Atenção Primária à Saúde/normas , Melhoria de Qualidade/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Estudos Transversais , Assistência à Saúde/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Atenção Primária à Saúde/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos , United States Agency for Healthcare Research and Quality
20.
Transl Behav Med ; 8(5): 649-659, 2018 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-29425354

RESUMO

Integrated behavioral health and primary care is a patient-centered approach designed to address a person's physical, emotional, and social healthcare needs. Increasingly, practices are integrating care to help achieve the Quadruple Aim, yet no studies have examined, using qualitative methods, patients' experiences of care in integrated settings. The purpose of this study was to examine patients' experiences of care in community-based settings integrating behavioral health and primary care. This is a qualitative study of 24 patients receiving care across five practices participating in Advancing Care Together (ACT). ACT was a 4-year demonstration project (2010-2014) of primary care and community mental health centers (CMHCs) integrating care. We conducted in-depth interviews in 2014 and a multidisciplinary team analyzed data using an inductive qualitative descriptive approach. Nineteen patients described receiving integrated care. Both primary care and CMHC patients felt cared for when the full spectrum of their needs, including physical, emotional, and social circumstances, were addressed. Patients perceived personal, interpersonal, and organizational benefits from integrated care. Interactions with integrated team members helped patients develop and/or improve coping skills; patients shared lessons learned with family and friends. Service proximity, provider continuity and trust, and a number of free initial behavioral health appointments supported patient access to, and engagement with, integrated care. In contrast, patients' prior experience, provider "mismatch," clinician turnover, and restrictive insurance coverage presented barriers in accessing and sustaining care. Patients in both primary care and CMHCs perceived similar benefits from integrated care related to personal growth, improved quality, and access to care. Policy makers and practice leadership should attend to proximity, continuity, trust, and cost/coverage as factors that can impede or facilitate engagement with integrated care.


Assuntos
Serviços de Saúde Comunitária , Centros Comunitários de Saúde Mental , Prestação Integrada de Cuidados de Saúde , Transtornos Mentais/terapia , Serviços de Saúde Mental , Satisfação do Paciente , Atenção Primária à Saúde , Adulto , Feminino , Humanos , Masculino , Pesquisa Qualitativa
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