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1.
J Ambul Care Manage ; 44(4): 293-303, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34319924

RESUMO

COVID-19 necessitated significant care redesign, including new ambulatory workflows to handle surge volumes, protect patients and staff, and ensure timely reliable care. Opportunities also exist to harvest lessons from workflow innovations to benefit routine care. We describe a dedicated COVID-19 ambulatory unit for closing testing and follow-up loops characterized by standardized workflows and electronic communication, documentation, and order placement. More than 85% of follow-ups were completed within 24 hours, with no observed staff, nor patient infections associated with unit operations. Identified issues include role confusion, staffing and gatekeeping bottlenecks, and patient reluctance to visit in person or discuss concerns with phone screeners.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , COVID-19/terapia , Continuidade da Assistência ao Paciente/organização & administração , Pneumonia Viral/terapia , Unidades de Cuidados Respiratórios/organização & administração , Adulto , Idoso , Boston/epidemiologia , COVID-19/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Encaminhamento e Consulta/estatística & dados numéricos , SARS-CoV-2 , Análise de Sistemas , Fluxo de Trabalho
2.
Ann Intern Med ; 174(7): 920-926, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33750188

RESUMO

BACKGROUND: Prior studies have reported that greater numbers of primary care physicians (PCPs) per population are associated with reduced population mortality, but the effect of increasing PCP density in areas of low density is poorly understood. OBJECTIVE: To estimate how alleviating PCP shortages might change life expectancy and mortality. DESIGN: Generalized additive models, mixed-effects models, and generalized estimating equations. SETTING: 3104 U.S. counties from 2010 to 2017. PARTICIPANTS: Children and adults. MEASUREMENTS: Age-adjusted life expectancy; all-cause mortality; and mortality due to cardiovascular disease, cancer, infectious disease, respiratory disease, and substance use or injury. RESULTS: Persons living in counties with less than 1 physician per 3500 persons in 2017 had a mean life expectancy that was 310.9 days shorter than for persons living in counties above that threshold. In the low-density counties (n = 1218), increasing the density of PCPs above the 1:3500 threshold would be expected to increase mean life expectancy by 22.4 days (median, 19.4 days [95% CI, 0.9 to 45.6 days]), and all such counties would require 17 651 more physicians, or about 14.5 more physicians per shortage county. If counties with less than 1 physician per 1500 persons (n = 2636) were to reach the 1:1500 threshold, life expectancy would be expected to increase by 56.3 days (median, 55.6 days [CI, 4.2 to 105.6 days]), and all such counties would require 95 754 more physicians, or about 36.3 more physicians per shortage county. LIMITATION: Some projections are based on extrapolations of the actual data. CONCLUSION: In counties with fewer PCPs per population, increases in PCP density would be expected to substantially improve life expectancy. PRIMARY FUNDING SOURCE: None.


Assuntos
Expectativa de Vida , Mortalidade , Médicos de Atenção Primária/provisão & distribuição , Adulto , Causas de Morte , Criança , Humanos , Modelos Estatísticos , Atenção Primária à Saúde/estatística & dados numéricos , Estados Unidos/epidemiologia
4.
Health Serv Res ; 55 Suppl 3: 1033-1048, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33284521

RESUMO

OBJECTIVE: Examine care integration-efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them-to understand whether and at which organizational level health systems impact care quality and staff experience. DATA SOURCES: Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019). STUDY DESIGN: We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression. PRINCIPAL FINDINGS: Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems-up to 38 percentage points (pp) lower (P < .001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P < .05). CONCLUSIONS: Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.


Assuntos
Atenção à Saúde/organização & administração , Eficiência Organizacional , Integração de Sistemas , Adulto , Continuidade da Assistência ao Paciente/organização & administração , Atenção à Saúde/normas , Registros Eletrônicos de Saúde/organização & administração , Pesquisa sobre Serviços de Saúde , Humanos , Satisfação no Emprego , Masculino , Pessoa de Meia-Idade , Modelos Organizacionais , Objetivos Organizacionais , Qualidade da Assistência à Saúde/normas , Estados Unidos
5.
Isr J Health Policy Res ; 9(1): 77, 2020 12 28.
Artigo em Inglês | MEDLINE | ID: mdl-33371896

RESUMO

The challenges wrought by the COVID-19 pandemic on health systems have tested primary care clinicians, who are on the front lines of care delivery. To ensure the longevity of the primary care workforce, strong interprofessional teams are one important solution to alleviating burnout and increasing clinician and patient satisfaction, but the pandemic has demonstrated that the operating manual needs to be adapted for virtual work. Essential principles of primary care, including preventative care, communication and collaboration, and building strong relationships, can be applied to strengthen virtual primary care teams.


Assuntos
Esgotamento Profissional/prevenção & controle , COVID-19/psicologia , COVID-19/terapia , Equipe de Assistência ao Paciente , Atenção Primária à Saúde/métodos , Atenção à Saúde/métodos , Humanos , Israel , Pandemias , SARS-CoV-2
6.
Ann Fam Med ; 18(6): 535-544, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33168682

RESUMO

PURPOSE: We sought to determine the financial impact to primary care practices of alternative strategies for offering buprenorphine-based treatment for opioid use disorder. METHODS: We interviewed 20 practice managers and identified 4 approaches to delivering buprenorphine-based treatment via primary care practice that differed in physician and nurse responsibilities. We used a microsimulation model to estimate how practice variations in patient type, payer, revenue, and cost across primary care practices nationwide would affect cost and revenue implications for each approach for the following types of practices: federally qualified health centers (FQHCs), non-FQHCs in urban high-poverty areas, non-FQHCs in rural high-poverty areas, and practices outside of high-poverty areas. RESULTS: The 4 approaches to buprenorphine-based treatment included physician-led visits with nurse-led logistical support; nurse-led visits with physician oversight; shared visits; and solo prescribing by physician alone. Net practice revenues would be expected to increase after introduction of any of the 4 approaches by $18,000 to $70,000 per full-time physician in the first year across practice type. Yet physician-led visits and shared medical appointments, both of which relied on nurse care managers, consistently produced the greatest net revenues ($29,000-$70,000 per physician in the first year). To ensure positive net revenues with any approach, providers would need to maintain at least 9 patients in treatment, with a no-show rate of <34%. CONCLUSIONS: Using a simulation model, we estimate that many types of primary care practices could financially sustain buprenorphine-based treatment if demand and no-show rate requirements are met, but a nurse care manager-based approach might be the most sustainable.

7.
Health Aff (Millwood) ; 39(9): 1605-1614, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32584605

RESUMO

As a result of the coronavirus disease 2019 (COVID-19) pandemic, virtually all in-person outpatient visits were canceled in many parts of the country between March and May 2020. We sought to estimate the potential impact of COVID-19 on the operating expenses and revenues of primary care practices. Using a microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements, including telemedicine visits, we estimated that over the course of calendar year 2020, primary care practices would be expected to lose 67,774 in gross revenue per full-time-equivalent physician (the difference between 2020 gross revenue with COVID-19 and the anticipated gross revenue if COVID-19 had not occurred). We further estimated that the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion. This could more than double if COVID-19 telemedicine payment policies are not sustained.


Assuntos
Infecções por Coronavirus/epidemiologia , Gastos em Saúde , Cobertura do Seguro/economia , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Atenção Primária à Saúde/economia , COVID-19 , Infecções por Coronavirus/economia , Infecções por Coronavirus/prevenção & controle , Atenção à Saúde/organização & administração , Feminino , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Modelos Econômicos , Pandemias/economia , Pandemias/prevenção & controle , Pneumonia Viral/economia , Pneumonia Viral/prevenção & controle , Atenção Primária à Saúde/estatística & dados numéricos , Estados Unidos
8.
Artigo em Inglês | MEDLINE | ID: mdl-32213882

RESUMO

Given the widespread lack of access to dental care for many vulnerable Americans, there is a growing realization that integrating dental and primary care may provide comprehensive care. We sought to model the financial impact of integrating dental care provision into a primary care practice. A microsimulation model was used to estimate changes in net revenue per practice by simulating patient visits to a primary dental practice within primary care practices, utilizing national survey and un-identified claims data from a nationwide health insurance plan. The impact of potential changes in utilization rates and payer distributions and hiring additional staff was also evaluated. When dental care services were provided in the primary care setting, annual net revenue changes per practice were -$92,053 (95% CI: -93,054, -91,052) in the first year and $104,626 (95% CI: 103,315, 105,316) in subsequent years. Net revenue per annum after the first year of integration remained positive as long as the overall utilization rates decreased by less than 25%. In settings with a high proportion of publicly insured patients, the net revenue change decreased but was still positive. Integrating primary dental and primary care providers would be financially viable, but this viability depends on demands of dental utilization and payer distributions.


Assuntos
Assistência Odontológica/economia , Atenção Primária à Saúde/economia , Humanos , Estados Unidos
11.
J Alzheimers Dis ; 70(3): 825-842, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31282418

RESUMO

BACKGROUND/OBJECTIVE: High levels of chronic stress negatively impact the hippocampus and are associated with increased incidence of mild cognitive impairment (MCI) and Alzheimer's disease. While mindfulness meditation may mitigate the effects of chronic stress, it is uncertain if adults with MCI have the capacity to learn mindfulness meditation. METHODS: 14 adults with MCI were randomized 2:1 to Mindfulness Based Stress Reduction (MBSR) or a wait-list control group. We conducted qualitative interviews with those who completed MBSR. Transcribed interviews were: a) coded using an emergent themes inductive approach informed by grounded theory; b) rated 0-10, with higher scores reflecting greater perceived benefit from, and understanding of, mindfulness meditation. Ratings were correlated with daily home practice times and baseline level of cognitive function. RESULTS: Seven themes emerged from the interviews: positive perceptions of class; development of mindfulness skills, including meta-cognition; importance of the group experience; enhanced well-being; shift in MCI perspective; decreased stress reactivity and increased relaxation; improvement in interpersonal skills. Ratings of perceived benefit and understanding ranged from 2-10 (mean = 7) and of 0-9.5 (mean = 6), respectively. Many participants experienced substantial benefit/understanding, some had moderate, and a few had minimal benefit/understanding. Understanding the key concepts of mindfulness was highly positively correlated with ≥20 minutes/day of home practice (r = 0.90) but not with baseline cognitive function (r = 0.13). CONCLUSIONS: Most adults with MCI were able to learn mindfulness meditation and had improved MCI acceptance, self-efficacy, and social engagement. Cognitive reserve may be enhanced through a mindfulness meditation program even in patients with MCI.


Assuntos
Doença de Alzheimer , Disfunção Cognitiva , Meditação , Atenção Plena/métodos , Terapia de Relaxamento/métodos , Idoso , Doença de Alzheimer/diagnóstico , Doença de Alzheimer/psicologia , Doença de Alzheimer/terapia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/psicologia , Disfunção Cognitiva/terapia , Reserva Cognitiva , Feminino , Humanos , Masculino , Meditação/métodos , Meditação/psicologia , Projetos Piloto , Habilidades Sociais , Estresse Psicológico/psicologia , Estresse Psicológico/terapia , Resultado do Tratamento
12.
Leadersh Health Serv (Bradf Engl) ; 32(2): 182-194, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-30945594

RESUMO

PURPOSE: Health care systems increasingly demand health professionals who can lead interdisciplinary teams. While physicians recognize the importance of leadership skills, few receive formal instruction in this area. This paper aims to describe how the Student Leadership Committee (SLC) at the Harvard Medical School Center for Primary Care responded to this need by creating a leadership curriculum for health professions students. DESIGN/METHODOLOGY/APPROACH: The SLC designed an applied longitudinal leadership curriculum and taught it to medical, dentistry, nursing, public health and business students during monthly meetings over two academic years. The perceptions of the curriculum were assessed via a retrospective survey and an assessment of team functioning. FINDINGS: Most teams met their project goals and students felt that their teams were effective. The participants reported increased confidence that they could create change in healthcare and an enhanced desire to hold leadership positions. The sessions that focused on operational skills were especially valued by the students. PRACTICAL IMPLICATIONS: This case study presents an effective approach to delivering leadership training to health professions students, which can be replicated by other institutions. SOCIAL IMPLICATIONS: Applied leadership training empowers health professions students to improve the health-care system and prepares them to be more effective leaders of the future health-care teams. The potential benefits of improved health-care leadership are numerous, including better patient care and improved job satisfaction among health-care workers. ORIGINALITY/VALUE: Leadership skills are often taught as abstract didactics. In contrast, the approach described here is applied to ongoing projects in an interdisciplinary setting, thereby preparing students for real-world leadership positions.


Assuntos
Currículo , Liderança , Inovação Organizacional , Objetivos Organizacionais , Estudantes de Ciências da Saúde , Humanos , Estudos Retrospectivos , Estados Unidos
13.
Fam Med ; 51(3): 251-261, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30861080

RESUMO

BACKGROUND AND OBJECTIVES: Despite recent improvements in access to health care, many Americans still lack access to dental care. There has been a national focus on interprofessional education and team-based care to work toward the integration of services including dental care into primary care. The purpose of this systematic review is to understand the impact of implementing oral health curricula in primary care training on measurable changes in primary care practice. METHODS: Researchers utilized a two-step process, first a scoping review and then using the PRISMA systematic review method to develop inclusion and exclusion criteria around audience, curricula, and outcomes to identify practice change due to oral health education curricula delivered in primary care clinician training. Researchers assessed titles, abstracts, and full texts and abstracted data for the review. RESULTS: Researchers reviewed 2,749 articles and found 12 meeting the systematic review criteria. The reported outcomes and evaluations differed for each of the 12 studies identified. Over 40% utilized self-reporting. Seven of the included studies tracked outcomes by checklists embedded in electronic health records changes to well-child visit forms, or chart audits, one of which also tracked billing reimbursements. CONCLUSIONS: Oral health curricula for primary care clinicians are too heterogeneous to determine the effects on practice behavior. Future research should focus on developing a clear evaluation framework for measuring practice level changes in primary care settings as a result of implementing an oral health curriculum.


Assuntos
Atenção à Saúde , Saúde Bucal/educação , Médicos de Atenção Primária , Instituições de Assistência Ambulatorial , Currículo , Assistência Odontológica/métodos , Educação em Odontologia/métodos , Humanos
14.
JAMA Intern Med ; 179(4): 506-514, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30776056

RESUMO

Importance: Recent US health care reforms incentivize improved population health outcomes and primary care functions. It remains unclear how much improving primary care physician supply can improve population health, independent of other health care and socioeconomic factors. Objectives: To identify primary care physician supply changes across US counties from 2005-2015 and associations between such changes and population mortality. Design, Setting, and Participants: This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018. Main Outcomes and Measures: Age-standardized life expectancy, cause-specific mortality, and restricted mean survival time. Results: Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply. Conclusions and Relevance: Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.


Assuntos
Expectativa de Vida/tendências , Médicos de Atenção Primária/provisão & distribuição , Vigilância da População , Idoso , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores Socioeconômicos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
15.
Health Aff (Millwood) ; 38(2): 237-245, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30715981

RESUMO

States are introducing regulations to slow health care spending growth, but which of these successfully reduce spending growth remains unclear. We studied Rhode Island's 2010 affordability standards, which imposed price controls-particularly inflation caps and diagnosis-based payments-on contracts between commercial insurers and hospitals and clinics and required commercial insurers to increase their spending on primary care and care coordination services. Using a difference-in-differences design, we compared spending among 38,001 commercially insured adults in Rhode Island to that among 38,001 matched adults in other states in the period 2007-16. Relative to quarterly fee-for-service (FFS) spending among the control group, quarterly FFS spending among the Rhode Island group decreased by $76 per enrollee after implementation of the policy, or a decline of 8.1 percent from 2009 spending. Quarterly non-FFS primary care coordination spending increased by $21 per enrollee. Total spending growth decreased, driven by lower prices concordant with the adoption of price controls. Quality measures were unaffected or improved. The Rhode Island experience indicates that states may be able to slow total commercial health care spending growth through price controls while maintaining quality.


Assuntos
Custos e Análise de Custo/economia , Gastos em Saúde/estatística & dados numéricos , Seguradoras/estatística & dados numéricos , Medicare , Adulto , Atenção à Saúde , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/tendências , Feminino , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Atenção Primária à Saúde/economia , Rhode Island , Estados Unidos
16.
Ann Fam Med ; 16(4): 308-313, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29987078

RESUMO

PURPOSE: To estimate the conditions under which team documentation-having a staff member enter history, place orders, and guide patients-would be financially viable at primary care practices, accounting for implementation costs. METHODS: We applied a validated microsimulation model of practice costs, revenues, and time use to data from 643 US primary care practices. We estimated critical threshold values for time saved from routine visits that would need to be redirected to new visits to avoid net revenue losses under: (1) a clerical documentation assistant (CDA) strategy where a scribe assists with recordkeeping; and (2) an advanced team-based care (ATBC) strategy where medical assistants perform history, documentation, counseling, and order entry. RESULTS: Using a fee-for-service model, we estimated that physicians would need to save 3.5 (95% CI, 3.3-3.7) minutes/encounter under a CDA strategy and 7.4 (95% CI, 4.3-10.5) minutes/encounter under an ATBC strategy to prevent net revenue losses. The redirected time would be expected to add 317 visit slots per year under CDA strategy, and 720 under ATBC strategy. Using a capitated payment model, physicians would need to empanel at least 127 (95% CI, 70-187) more patients under CDA and 227 (95% CI, 153-267) under ATBC to prevent revenue losses. Additional patient visits expected would be 279 (95% CI, 140-449) additional visit slots per year under CDA and 499 (95% CI, 454-641) under ATBC. CONCLUSIONS: Financial viability of team documentation under fee-for-service payment may require more physician time to be reallocated to patient encounters than under a capitated payment model.


Assuntos
Documentação/economia , Registros Eletrônicos de Saúde/normas , Atenção Primária à Saúde/métodos , Planos de Pagamento por Serviço Prestado , Humanos , Médicos de Atenção Primária , Atenção Primária à Saúde/normas
18.
Health Aff (Millwood) ; 36(9): 1599-1605, 2017 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-28874487

RESUMO

Capitated payments in the form of fixed monthly payments to cover all of the costs associated with delivering primary care could encourage primary care practices to transform the way they deliver care. Using a microsimulation model incorporating data from 969 US practices, we sought to understand whether shifting to team- and non-visit-based care is financially sustainable for practices under traditional fee-for-service, capitated payment, or a mix of the two. Practice revenues and costs were computed for fee-for-service payments and a range of capitated payments, before and after the substitution of team- and non-visit-based services for low-complexity in-person physician visits. The substitution produced financial losses for simulated practices under fee-for-service payment of $42,398 per full-time-equivalent physician per year; however, substitution produced financial gains under capitated payment in 95 percent of cases, if more than 63 percent of annual payments were capitated. Shifting to capitated payment might create an incentive for practices to increase their delivery of team- and non-visit-based primary care, if capitated payment levels were sufficiently high.


Assuntos
Capitação , Planos de Pagamento por Serviço Prestado/economia , Atenção Primária à Saúde/economia , Custos e Análise de Custo , Gastos em Saúde , Humanos , Modelos Econômicos , Equipe de Assistência ao Paciente/estatística & dados numéricos
19.
J Gen Intern Med ; 32(12): 1330-1341, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28900839

RESUMO

BACKGROUND: New payments from Medicare encourage behavioral health services to be integrated into primary care practice activities. OBJECTIVE: To evaluate the financial impact for primary care practices of integrating behavioral health services. DESIGN: Microsimulation model. PARTICIPANTS: We simulated patients and providers at federally qualified health centers (FQHCs), non-FQHCs in urban and rural high-poverty areas, and practices outside of high-poverty areas surveyed by the National Association of Community Health Centers, National Ambulatory Medical Care Survey, National Health and Nutrition Examination Survey, and National Health Interview Survey. INTERVENTIONS: A collaborative care model (CoCM), involving telephone-based follow-up from a behaviorist care manager, or a primary care behaviorist model (PCBM), involving an in-clinic behaviorist. MAIN MEASURES: Net revenue change per full-time physician. KEY RESULTS: When behavioral health integration services were offered only to Medicare patients, net revenue was higher under CoCM (averaging $25,026 per MD in year 1 and $28,548/year in subsequent years) than PCBM (-$7052 in year 1 and -$3706/year in subsequent years). When behavioral health integration services were offered to all patients and were reimbursed by Medicare and private payers, only practices adopting the CoCM approach consistently gained net revenues. The outcomes of the model were sensitive to rates of patient referral acceptance, presentation, and therapy completion, but the CoCM approach remained consistently financially viable whereas PCBM would not be in the long-run across practice types. CONCLUSIONS: New Medicare payments may offer financial viability for primary care practices to integrate behavioral health services, but this viability depends on the approach toward care integration.


Assuntos
Serviços Comunitários de Saúde Mental/economia , Prestação Integrada de Cuidados de Saúde/economia , Atenção Primária à Saúde/economia , Centros Comunitários de Saúde/economia , Centros Comunitários de Saúde/organização & administração , Serviços Comunitários de Saúde Mental/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Renda/estatística & dados numéricos , Medicare/economia , Modelos Econométricos , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Áreas de Pobreza , Atenção Primária à Saúde/organização & administração , Serviços de Saúde Rural/economia , Sensibilidade e Especificidade , Estados Unidos , Serviços Urbanos de Saúde/economia , Serviços Urbanos de Saúde/organização & administração
20.
Jt Comm J Qual Patient Saf ; 43(7): 338-350, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28648219

RESUMO

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer death, reducible by screening and early diagnosis, yet many patients fail to receive recommended screening. As part of an academic improvement collaborative, 25 primary care practices worked to improve CRC screening and diagnosis. METHODS: The project featured triannual learning sessions, monthly conference calls, practice coach support, and monthly reporting. The project phases included literature review and interviews with national leaders/organizations, development of driver diagrams to identify key factors and change ideas, project launch and practice team planning, and a practice improvement phase. RESULTS: The project activities included (1) inventory of barriers and best practices, (2) driver diagram to drive improvements, (3) list of changes to try, (4) compilation of lessons learned, and (5) five key changes to optimize screening and follow-up. Practices leveraged prior transformation efforts to track patients for screening and follow-up during and between office visits. By mapping processes, testing changes, and collecting data, sites targeted opportunities to improve quality, safety, efficiency, and patient and care team experience. Successful change interventions centered around partnering with gastroenterology, engaging leadership, leveraging registries and health information technology, promoting alternative screening options, and partnering with and supporting patients. Several practices achieved improvement in screening rates, while others demonstrated no change from baseline during the 10-month testing and implementation phase (July 2014-April 2015). CONCLUSION: The collaborative effectively engaged teams in a broad set of process improvements with key lessons learned related to barriers, information technology challenges, outreach challenges/strategies, and importance of stakeholder and patient engagement.


Assuntos
Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/prevenção & controle , Detecção Precoce de Câncer/métodos , Atenção Primária à Saúde/organização & administração , Desenvolvimento de Pessoal/organização & administração , Comunicação , Continuidade da Assistência ao Paciente/organização & administração , Comportamento Cooperativo , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Liderança , Equipe de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/normas , Desenvolvimento de Programas , Qualidade da Assistência à Saúde/organização & administração , Fluxo de Trabalho
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