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2.
Am J Surg ; 219(2): 299-303, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31928779

RESUMO

BACKGROUND: Safety-net hospitals frequently underperform on surgical quality measures. To achieve equitable surgical care, creative strategies are needed to improve care for this vulnerable population. METHODS: We designed a trainee-led quality improvement (QI) program to promote evidence-based analgesia prescribing. The program included a collaborative resident leadership model and used educational interventions and performance feedback. RESULTS: Before the QI program, 48% of patients were discharged on acetaminophen post-operatively, and 0% were discharged on ibuprofen. In the most recent month since the QI program was launched, 100% of patients were discharged on acetaminophen, and 81% on ibuprofen. CONCLUSION: Our trainee-led quality improvement program demonstrates that surgical trainees can accelerate change and may be a powerful force for improving health equity through safer post-operative discharge prescribing practices at a safety-net hospital.


Assuntos
Analgésicos Opioides/uso terapêutico , Medicina Baseada em Evidências/educação , Epidemia de Opioides/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Melhoria de Qualidade , Provedores de Redes de Segurança/organização & administração , Adulto , Uso de Medicamentos , Educação de Pós-Graduação em Medicina/métodos , Feminino , Humanos , Internato e Residência/métodos , Masculino , Manejo da Dor/métodos , Dor Pós-Operatória/diagnóstico , Guias de Prática Clínica como Assunto , Medição de Risco , Estados Unidos
5.
Rev. psicol. trab. organ. (1999) ; 35(3): 183-193, dic. 2019. tab
Artigo em Inglês | IBECS | ID: ibc-188136

RESUMO

In three studies we examined, from an attachment perspective, the utility and the validity of a scale assessing followers' perceptions of leaders as security providers (LSPS). Based on the literature, we designed a 15-item scale tapping the five functions of a security-enhancing attachment figure (secure base, safe haven, proximity seeking, emotional ties, and separation distress) within organizational contexts. The scale showed acceptable reliability and a one-factor structure in all the studies. In Study 1 (N = 237), the LSPS was positively associated with transformational leadership and inversely associated with passive-avoidant leadership. Moreover, employees' perceptions of their leader as a security provider made a unique contribution to their satisfaction with the manager and perception of the manager's efficacy. In Study 2 (N = 263), the LSPS was positively associated with authentic leadership. Employees' ratings of their leader on the LSPS were positively associated with employees' organizational identification, work engagement, and work satisfaction. In Study 3 (N = 263), we found that employees' perceptions of their leader as a security provider had a protective effect on their job burnout. The findings indicate that research on the follower-leader relationship can benefit from the adoption of an attachment perspective


A través de tres estudios examinamos desde una perspectiva basada en la teoría del apego la utilidad y la validez de una escala que mide la percepción que los seguidores tienen de sus líderes como proveedores de seguridad LSPS. Con base en estudios previos, se diseñó una escala de 15 elementos que cubrían las cinco funciones de la figura de apego que aumenta la seguridad (base segura, puerto seguro, búsqueda de proximidad, lazos emocionales y malestar por la separación) en contextos organizativos. En todos los estudios la escala mostraba una fiabilidad aceptable y una estructura unifactorial. En el estudio 1 (N = 237), se encontró que las puntuaciones en la escala LSPS estaban positivamente relacionadas con el liderazgo transformacional y negativamente con el liderazgo pasivo-evitador. En el estudio 2 (N = 263), se encontró que la escala LSPS estaba positivamente relacionada con el liderazgo auténtico y con la identificación organizacional, la implicación en el trabajo y la satisfacción en el trabajo de los empleados. Finalmente, en el estudio 3 (N = 263) se encontró que las percepciones de los empleados de su líder como proveedor de seguridad tenían un efecto protector sobre el burnout. Estos hallazgos en su conjunto indican que la investigación de las relaciones entre líderes y seguidores puede beneficiarse si se adopta una perspectiva basada en el apego


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Liderança , Gestão da Segurança/organização & administração , Provedores de Redes de Segurança/organização & administração , Engajamento no Trabalho , Esgotamento Profissional/prevenção & controle , Relações Trabalhistas , Processos Grupais , Esgotamento Profissional/epidemiologia , Autorrelato/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos
6.
PLoS One ; 14(12): e0225540, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31851666

RESUMO

BACKGROUND: Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies. OBJECTIVE: Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression. DESIGN: 9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit). SETTING: Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers. PARTICIPANTS: 159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms. INTERVENTIONS: IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks. MEASUREMENTS: Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization. RESULTS: There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls. LIMITATIONS: Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV. CONCLUSION: Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group. TRIAL REGISTRATION: clinicaltrials.gov NCT02262377.


Assuntos
Dor Crônica/terapia , Depressão/terapia , Medicina Integrativa/métodos , Atenção Plena/métodos , Visita a Consultório Médico , Centros Médicos Acadêmicos/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor Crônica/diagnóstico , Dor Crônica/psicologia , Centros Comunitários de Saúde/organização & administração , Depressão/diagnóstico , Depressão/psicologia , Feminino , Humanos , Medicina Integrativa/organização & administração , Masculino , Pessoa de Meia-Idade , Medição da Dor , Questionário de Saúde do Paciente , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/organização & administração , Provedores de Redes de Segurança/organização & administração , Índice de Gravidade de Doença , Método Simples-Cego , Centros de Atenção Terciária/organização & administração , Resultado do Tratamento , Adulto Jovem
7.
Int J Health Care Qual Assur ; 32(2): 321-331, 2019 Mar 11.
Artigo em Inglês | MEDLINE | ID: mdl-31017063

RESUMO

PURPOSE: The purpose of this paper is to determine the experience participating in a health promotion program for refugee and asylum seekers and torture survivors in a safety net clinical setting. DESIGN/METHODOLOGY/APPROACH: Refugee and asylum seeker torture survivors participated in a seven-week health promotion program at a safety-net clinic. Participants interviewed before, during and after the program was designed to improve and maintain health promotion program quality. FINDINGS: Six major themes emerged: social networks; tools/techniques/skills; wellness planning; spiritualism; health maintenance; and social/group interaction. Preliminary results suggest that this multi-pronged approach is feasible and acceptable to foreign-born torture survivors. RESEARCH LIMITATIONS/IMPLICATIONS: Torture impacts many facets of one's life. A program which addresses health from a multidisciplinary perspective has promise to facilitate healing. PRACTICAL IMPLICATIONS: The impact of torture and human rights violations significantly affects many facets of peoples' lives including emotional, social, physical and spiritual dimensions. Therefore a program which utilizes a multidisciplinary integrated bio-psychosocial and spiritual approach has the potential to simultaneously address many domains facilitating healing. ORIGINALITY/VALUE: BeWell, a bio-psychosocio-spiritual health promotion strategy aimed at improving health service quality and increasing patient satisfaction to support positive health outcomes by implementing in-classroom/person modules for patients, to the authors' knowledge is unique in its efforts to encompass multiple domains simultaneously and fully integrate an approach to wellbeing.


Assuntos
Promoção da Saúde/organização & administração , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Refugiados/educação , Refugiados/psicologia , Provedores de Redes de Segurança/organização & administração , Feminino , Direitos Humanos , Humanos , Relações Interpessoais , Masculino , Projetos Piloto , Rede Social , Espiritualismo , Tortura/psicologia
8.
Int J Health Care Qual Assur ; 32(2): 534-546, 2019 Mar 11.
Artigo em Inglês | MEDLINE | ID: mdl-31017065

RESUMO

PURPOSE: The purpose of this paper is to examine the relationship between patients' provider communication effectiveness and courteousness with patients' satisfaction and trust at free clinics. DESIGN/METHODOLOGY/APPROACH: This cross-sectional survey (n=507), based on the Consumer Assessment of Healthcare Providers and Systems instrument, was conducted in two Southeastern US free clinics. Latent class analysis (LCA) was used to identify patient subgroups (clusters) with similar but not immediately visible characteristics. FINDINGS: Across the items assessing provider communication effectiveness and courteousness, five distinct clusters based on patient satisfaction, trust and socio-demographics were identified. In clusters where communication and courteousness ratings were consistent, trust and satisfaction ratings were aligned with these domains, e.g., 54 percent rated communication and courteousness highly, which was associated with high patient satisfaction and trust. When communication effectiveness and courteousness ratings diverged (e.g., low communication effectiveness but high courteousness), patient trust and satisfaction ratings aligned with communication effectiveness ratings. In all clusters, the association was greater for communication effectiveness than for provider courteousness. Thus, provider courteousness was important but secondary to communication effectiveness. PRACTICAL IMPLICATIONS: Investment in patient-centered communication training for providers will improve patient satisfaction and trust. ORIGINALITY/VALUE: The study is the first to examine individual provider communication components and how they relate to patient satisfaction and trust in free clinics. LCA helped to more fully examine communication constructs, which may be beneficial for more nuanced quality improvement efforts.


Assuntos
Comunicação , Assistência Centrada no Paciente/organização & administração , Provedores de Redes de Segurança/organização & administração , Adolescente , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Grupos Minoritários , Satisfação do Paciente , Assistência Centrada no Paciente/normas , Relações Médico-Paciente , Provedores de Redes de Segurança/normas , Fatores Socioeconômicos , Confiança , Adulto Jovem
9.
PLoS One ; 14(3): e0213745, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30870475

RESUMO

PURPOSE: Safety-net health systems, which serve a disproportionate share of patients at high risk for hepatitis C virus (HCV) infection, may use revenue generated by the federal drug discount pricing program, known as 340B, to support multidisciplinary care. Budgetary impacts of repealing the drug-pricing program are unknown. Our objective was to conduct a budgetary impact analysis of a multidisciplinary primary care-based HCV treatment program, with and without 340B support. METHODS: We conducted a budgetary impact analysis from the perspective of a large safety-net medical center in Boston, Massachusetts. Participants included 302 HCV-infected patients (mean age 45, 75% male, 53% white, 77% Medicaid) referred to the primary care-based HCV treatment program from 2015-2016. Main measures included costs and revenues associated with the treatment program. Our main outcomes were net cost with and without 340B Drug Pricing support. RESULTS: Total program costs were $942,770, while revenues totaled $1.2 million. With the 340B Drug Pricing Program the hospital received a net revenue of $930 per patient referred to the HCV treatment program. In the absence of the 340B program, the hospital would lose $370 per patient referred. Ninety-seven percent (68/70) of patients who initiated treatment in the program achieved a sustained virologic response (SVR) at a net cost of $4,150 each, among this patient subset. CONCLUSIONS: The 340B Drug Pricing Program enabled a safety-net hospital to deliver effective primary care-based HCV treatment using a multidisciplinary care team. Efforts to sustain the 340B program could enable dissemination of similar HCV treatment models elsewhere.


Assuntos
Orçamentos/normas , Custos e Análise de Custo/estatística & dados numéricos , Custos de Medicamentos/estatística & dados numéricos , Hepatite C/economia , Medicamentos sob Prescrição/economia , Atenção Primária à Saúde/estatística & dados numéricos , Provedores de Redes de Segurança/organização & administração , Custos de Medicamentos/legislação & jurisprudência , Feminino , Programas Governamentais , Hepacivirus/efeitos dos fármacos , Hepatite C/tratamento farmacológico , Humanos , Masculino , Medicaid , Pessoa de Meia-Idade , Provedores de Redes de Segurança/economia , Estados Unidos
11.
Health Serv Res ; 54(2): 327-336, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30848491

RESUMO

OBJECTIVE: Medicare's Hospital Readmissions Reduction Program (HRRP) does not account for social risk factors in risk adjustment, and this may lead the program to unfairly penalize safety-net hospitals. Our objective was to determine the impact of adjusting for social risk factors on HRRP penalties. STUDY DESIGN: Retrospective cohort study. DATA SOURCES/STUDY SETTING: Claims data for 2 952 605 fee-for-service Medicare beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF) or pneumonia from December 2012 to November 2015. PRINCIPAL FINDINGS: Poverty, disability, housing instability, residence in a disadvantaged neighborhood, and hospital population from a disadvantaged neighborhood were associated with higher readmission rates. Under current program specifications, safety-net hospitals had higher readmission ratios (AMI, 1.020 vs 0.986 for the most affluent hospitals; pneumonia, 1.031 vs 0.984; and CHF, 1.037 vs 0.977). Adding social factors to risk adjustment cut these differences in half. Over half the safety-net hospitals saw their penalty decline; 4-7.5 percent went from having a penalty to having no penalty. These changes translated into a $17 million reduction in penalties to safety-net hospitals. CONCLUSIONS: Accounting for social risk can have a major financial impact on safety-net hospitals. Adjustment for these factors could reduce negative unintended consequences of the HRRP.


Assuntos
Medicare/organização & administração , Readmissão do Paciente/estatística & dados numéricos , Risco Ajustado/organização & administração , Provedores de Redes de Segurança/organização & administração , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Pessoas com Deficiência/estatística & dados numéricos , Economia Hospitalar , Feminino , Disparidades nos Níveis de Saúde , Insuficiência Cardíaca/epidemiologia , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Medicare/normas , Infarto do Miocárdio/epidemiologia , Readmissão do Paciente/economia , Pneumonia/epidemiologia , Melhoria de Qualidade/organização & administração , Características de Residência/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Provedores de Redes de Segurança/normas , Fatores Socioeconômicos , Estados Unidos
12.
J Surg Res ; 236: 124-128, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30694746

RESUMO

BACKGROUND: Hospitals are looking for effective methods to track outcomes that are risk-adjusted for patient population characteristics. This is especially relevant for safety net hospitals (SNHs) servicing high-risk populations and in an era of quality-based reimbursement incentives. One such program with these goals is the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This is an institution-based quality audit whereby we determined the presence and consistency of charted data required to compute perioperative risk in the ACS NSQIP risk calculator. MATERIALS AND METHODS: A retrospective chart review of 28 elective colorectal procedures was performed at an urban, academic SNH over a 1-y period. For each case, it was determined whether the required NSQIP variables were readily presented via preoperative documentation. Univariate and bivariate statistics were employed to compare data field completion rates. RESULTS: Of the 28 reviewed patient charts, none (n = 0) had all preoperative risk documentation required to complete an ACS NSQIP risk analysis. 89.3% of charts (n = 25) had ≤ 55% of required data to complete a risk assessment. However on bivariate analysis, demographic variables were more likely to have been recorded (P < 0.001) than other risk factors. CONCLUSIONS: Preoperative risk assessment and corresponding charting practices at the SNH reviewed was fragmented and incomplete. There was lack of definitive documentation of risk factors and preoperative interventions used to modulate risk. Under current reimbursement models such as the MACRA Quality Payment Program, these findings are crucial for like-institutions to consider to critically evaluate their own documentation practices.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Provedores de Redes de Segurança/organização & administração , Colo/cirurgia , Estudos de Viabilidade , Humanos , Período Perioperatório/estatística & dados numéricos , Projetos Piloto , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade , Reto/cirurgia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Provedores de Redes de Segurança/estatística & dados numéricos , Estados Unidos/epidemiologia
13.
Soc Work Health Care ; 58(1): 14-31, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30130473

RESUMO

This article presents the perceptions parents have of the causative and curative factors for their child's externalized behaviors and what treatment they prefer to receive from their primary care integrated behavioral health team. This is a qualitative study, using interpretative phenomenological analysis. Semi-structured interviews were conducted with a purposive sample of 12 parents representing 14 patients with a disruptive behavior disorder (DBD) who sought care from their primary care physician for treatment of the DBD. Participants spoke of uncertainty of the cause of the DBD and the desire to find parenting approaches that augment the effectiveness of pharmacological intervention provided by the primary care team. Parents' responses suggest that they are eager for more education about their child's DBD and how to engage at-home management of the symptoms. Discussion focused on the import of considering the voices of these parents when implementing brief parent management training programs in integrated behavioral health primary care programs.


Assuntos
Transtornos de Deficit da Atenção e do Comportamento Disruptivo/terapia , Pais/educação , Pais/psicologia , Atenção Primária à Saúde/organização & administração , Serviço Social/organização & administração , Adolescente , Criança , Emoções , Feminino , Humanos , Entrevistas como Assunto , Masculino , Relações Pais-Filho , Poder Familiar/psicologia , Equipe de Assistência ao Paciente/organização & administração , Pesquisa Qualitativa , Provedores de Redes de Segurança/organização & administração , Fatores Socioeconômicos
14.
Healthc (Amst) ; 7(1): 22-29, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30552044

RESUMO

BACKGROUND: Team-based care is an innovative approach to primary care in which groups of health care professionals work collaboratively to manage care for groups of patients. Safety-net organizations face specific barriers to implementing health care innovations. More research is needed that documents the dynamics that inform implementation and sustainment of innovative practices in the safety net. METHODS: We conducted qualitative fieldwork, including purposeful observation and semi-structured and informal interviews, to explore the implementation of care teams in safety-net clinics in California. Field notes and transcripts were analyzed using an inductive approach to identify overarching themes across sites. RESULTS: Salient themes across clinics suggest that 1) well-designed physical layouts that promote sustained patterns of structured and spontaneous communication and collaboration are critical to creating high-functioning teams; 2) implementation of team-based care relies on a relaxing of the traditional clinic hierarchy into an agile organizational structure that empowers all clinic staff-most notably medical assistants-by facilitating an ethos of collaborative decision-making, interdependence, and shared responsibility; and 3) resource constraints related to recruitment and retention of qualified staff are key barriers to implementation. CONCLUSIONS: Team-based care has the potential to improve patient outcomes, strengthen relationships and well-being among clinic staff, and expand staff roles to facilitate collective accomplishment of work goals. To successfully launch and sustain care teams in safety-net clinics, greater commitments to creating well-designed spaces and a re-envisioning of the training and compensation for medical assistants that reflects the valuable role these individuals can play appear to be necessary.


Assuntos
Pessoal de Saúde/psicologia , Equipe de Assistência ao Paciente/tendências , Atenção Primária à Saúde/métodos , Provedores de Redes de Segurança/métodos , California , Humanos , Entrevistas como Assunto/métodos , Atenção Primária à Saúde/organização & administração , Pesquisa Qualitativa , Provedores de Redes de Segurança/organização & administração
15.
Am J Health Promot ; 33(2): 289-292, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29986597

RESUMO

PURPOSE: The National Diabetes Prevention Program (NDPP) is a widely disseminated lifestyle intervention. Attendance is problematic, leading to suboptimal weight loss, especially among racial/ethnic minority participants. We conducted a novel "presession" protocol to improve engagement of diverse NDPP candidates, comparing NDPP participants who attended a presession to those who did not on attendance and weight loss outcomes. DESIGN: Longitudinal cohort study. SETTING: A safety net health-care system. PARTICIPANTS: A total of 1140 patients with diabetes risks (58.9% Hispanic, 19.8% non-Hispanic black, 61.8% low income). INTERVENTION: The NDPP has been delivered in a Denver, Colorado health-care system since 2013. The program included 22 to 25 sessions over 1 year. Beginning September 2016, individuals were required to attend a presession before enrollment that focused on (1) increasing risk awareness, (2) motivational interviewing to participate in the NDPP, and (3) problem-solving around engagement barriers. MEASURES: Duration and intensity of NDPP attendance and weight loss. ANALYSIS: Outcomes of 75 presession participants who enrolled in the NDPP were compared to 1065 prior participants using analysis of covariance and multivariable logistic regression. RESULTS: Presession participants stayed in the NDPP 99.8 days longer ( P < .001) and attended 14.3% more sessions ( P < .001) on average than those without a presession. Presession participants lost 2.0% more weight ( P < .001) and were 3.5 times more likely to achieve the 5% weight loss target ( P < .001). CONCLUSION: Presessions may improve NDPP outcomes for individuals from diverse backgrounds. A full-scale trial is needed to determine whether presessions reliably improve NDPP effectiveness.


Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Promoção da Saúde/organização & administração , Provedores de Redes de Segurança/organização & administração , Perda de Peso , Conscientização , Peso Corporal , Grupos de Populações Continentais , Feminino , Humanos , Estilo de Vida , Estudos Longitudinais , Masculino , Resolução de Problemas , Fatores Socioeconômicos
16.
Addict Sci Clin Pract ; 13(1): 27, 2018 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-30547847

RESUMO

BACKGROUND: Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. METHODS/DESIGN: Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. DISCUSSION: The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.


Assuntos
Doença Crônica/terapia , Pessoas em Situação de Rua , Aceitação pelo Paciente de Cuidados de Saúde , Equipe de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Provedores de Redes de Segurança/organização & administração , Adulto , Planejamento Antecipado de Cuidados/organização & administração , Idoso , Comorbidade , Comportamento Cooperativo , Feminino , Humanos , Relações Interinstitucionais , Masculino , Pessoa de Meia-Idade , Entrevista Motivacional/organização & administração , Planejamento de Assistência ao Paciente , Satisfação do Paciente , Projetos de Pesquisa , Serviço Social/organização & administração , Fatores Socioeconômicos , Serviços Urbanos de Saúde
17.
Am J Prev Med ; 55(6 Suppl 2): S214-S221, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30454676

RESUMO

The California Tobacco Control Program is the longest standing, publicly funded tobacco control program in the U.S. California's adult smoking rate declined from 23.7% (1989) to 11% (2016) but California still has more than 3 million smokers dispersed over 58 counties, requiring a coordinated approach to further tobacco control. Early California Tobacco Control Program success is rooted in public health policy strategies and a statewide media campaign that shifted social norms. In 2009, concepts for a coordinated approach were introduced by the California Tobacco Control Program in the state's first tobacco quit plan. The state quit plan called for public health's tobacco control programs to engage healthcare systems and insurers to work more directly with the California Smoker's Helpline (Helpline). With California's Medicaid (Medi-Cal) program expansion and the implementation of electronic medical record systems, health care plans and providers received additional support for system changes. Simultaneous with these changes, coordinated tobacco control efforts began, including California's Medi-Cal Incentives to Quit Smoking project (2012-2015). In the Medi-Cal Incentives to Quit Smoking project, safety-net providers and Medi-Cal plans were outreached and engaged to promote incentives for Medi-Cal members to utilize Helpline services. In another effort, UC Quits (2013-2015), the five University of California health systems used electronic medical record tools to promote tobacco treatments and electronic referrals to the Helpline. Now, as tobacco prevention is increasingly prioritized for quality improvement, California Tobacco Control Program is funding CA Quits, a statewide tobacco-cessation learning collaborative and technical assistance resource to promote integration of tobacco treatment services and quality improvement activities into safety-net health systems. CA Quits, in coordination with the Helpline, will connect public health departments, Medi-Cal plans, and safety-net providers to accelerate health systems change for tobacco-cessation treatment throughout the state. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.


Assuntos
Implementação de Plano de Saúde/organização & administração , Promoção da Saúde/organização & administração , Medicaid/economia , Abandono do Hábito de Fumar/métodos , Fumar/terapia , Adulto , California/epidemiologia , Implementação de Plano de Saúde/economia , Implementação de Plano de Saúde/métodos , Política de Saúde , Promoção da Saúde/economia , Promoção da Saúde/métodos , Linhas Diretas/métodos , Linhas Diretas/organização & administração , Linhas Diretas/estatística & dados numéricos , Humanos , Medicaid/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Prevalência , Melhoria de Qualidade , Encaminhamento e Consulta , Provedores de Redes de Segurança/economia , Provedores de Redes de Segurança/métodos , Provedores de Redes de Segurança/organização & administração , Fumantes/estatística & dados numéricos , Fumar/epidemiologia , Abandono do Hábito de Fumar/economia , Abandono do Hábito de Fumar/estatística & dados numéricos , Prevenção do Hábito de Fumar/economia , Prevenção do Hábito de Fumar/métodos , Prevenção do Hábito de Fumar/organização & administração , Estados Unidos
18.
Jt Comm J Qual Patient Saf ; 44(12): 731-740, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30064959

RESUMO

BACKGROUND: Health centers provide care to vulnerable and high-need populations. Recent investments have promoted use of health information technology (HIT) capabilities for improving care coordination and quality of care in health centers. This study examined factors associated with use of these HIT capabilities and the association between these capabilities and quality of care in a census of health centers in the United States. METHODS: Cross-sectional secondary data from the 2015 Health Resources and Services Administration's Uniform Data System was used to examine 6 measures of HIT capability related to care coordination and clinical decision support and 16 measures of quality (12 process measures, 3 outcome measures, 1 composite measure) for health centers in the United States. Adjusted logistic regressions were used to examine health center characteristics associated with use of HIT capabilities, and adjusted linear regressions were used to examine associations between HIT capabilities and quality of care. RESULTS: Many health centers reported using HIT for care coordination activities, including coordinating enabling services (67.3%) or engaging patients (81.0%). Health center size and medical home recognition were associated with significantly greater odds of using HIT for enabling services and engaging patients. These HIT capabilities were associated with higher overall quality and higher rates of six process measures (adult screening and maternal and child health) and hemoglobin A1c control. CONCLUSION: Use of HIT for such activities as arranging enabling services and engaging patients are underleveraged tools for care coordination. There may be opportunities to further improve quality of care for vulnerable patients by promoting health centers' use of these HIT capabilities.


Assuntos
Sistemas de Informação em Saúde/estatística & dados numéricos , Administração dos Cuidados ao Paciente/organização & administração , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Melhoria de Qualidade/organização & administração , Provedores de Redes de Segurança/organização & administração , Provedores de Redes de Segurança/estatística & dados numéricos , Continuidade da Assistência ao Paciente/organização & administração , Estudos Transversais , Registros Eletrônicos de Saúde/organização & administração , Registros Eletrônicos de Saúde/estatística & dados numéricos , Humanos , Assistência Centrada no Paciente/organização & administração , Características de Residência , Fatores Socioeconômicos , Estados Unidos
19.
J Prim Care Community Health ; 9: 2150132718792154, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30079790

RESUMO

BACKGROUND: Telephone consultation is widely used in primary care and can provide an effective and efficient alternative for the in-person visit. Gouverneur Health, a safety-net primary care practice in New York City serving a predominately immigrant population, evaluated the feasibility and physician and patient acceptability of a telephone visit initiative in 2015. MEASURES: Patient and physician surveys, and physician focus groups. RESULTS: Though only 85 of 270 scheduled telephone visits (31%) were completed, 84% of patients reported being highly satisfied with their telephone visit. Half of physicians opted to participate in the pilot. Among participating physicians, all reported they were able to communicate adequately and safely care for patients over the telephone. CONCLUSIONS: Participating patients and physicians in a linguistically and culturally diverse urban safety-net primary care clinic were highly satisfied with the use of telephone visits, though completion of the visits was low. Lessons learned from this implementation can be used to expand access and provision of high-quality primary care to other vulnerable populations.


Assuntos
Atitude do Pessoal de Saúde , Satisfação do Paciente , Atenção Primária à Saúde/organização & administração , Provedores de Redes de Segurança/organização & administração , Telefone , Diversidade Cultural , Humanos , Cidade de Nova Iorque , Fatores Socioeconômicos , Serviços Urbanos de Saúde/organização & administração
20.
BMC Health Serv Res ; 18(1): 617, 2018 08 07.
Artigo em Inglês | MEDLINE | ID: mdl-30086743

RESUMO

BACKGROUND: Novel telemedicine platforms have expanded access to critical retinal screening into primary care settings. This increased access has contributed to improved retinal screening uptake for diabetic patients, particularly those treated in Federally Qualified Health Centers ('safety net' clinics). The aim of this study was to understand how the implementation of telemedical screening for diabetic retinopathy within primary care settings is improving the delivery of critical preventative services, while also introducing changes into clinic workflows and creating additional tasks and responsibilities within resource-constrained clinics. METHODS: A qualitative approach was employed to track workflows and perspectives from a range of medical personnel involved in the telemedicine platform for diabetic retinopathy screening and subsequent follow-up treatment. Data were collected through semi-structured interviews and participant observation at three geographically-dispersed Federally Qualified Health Centers in California. Qualitative analysis was performed using standard thematic analytic approaches within a qualitative data analysis software program. RESULTS: The introduction of telemedicine platforms, such as diabetic retinopathy screening, into primary care settings is creating additional strain on medical personnel across the diabetes eye care management spectrum. Central issues are related to scheduling patients, issuing referrals for follow-up care and treatment, and challenges to improving adherence to treatment and diabetes management. These issues are overcome in many cases through workarounds, or when medical staff work outside of their job descriptions, purview, and permission to move patients through the diabetes management continuum. CONCLUSIONS: This study demonstrates how the implementation of a novel telemedical platform for diabetic retinopathy screening contributes to the phenomenon of workarounds that account for additional tasks and patient volume. These workarounds should not be considered a sustainable model of health care delivery, but rather as an initial step to understanding where issues are and how clinics can adapt to the inclusion of telemedicine and ultimately increase access to care. The presence of workarounds suggests that as telemedicine is expanded, adequate resources, as well as collaborative, cross-sectoral co-design of new workflows must be simultaneously provided. Systematic bolstering of resources would contribute to more consistent success of telemedicine screening platforms and improved treatment and prevention of disease-related complications.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Retinopatia Diabética/diagnóstico , Telemedicina , California , Diabetes Mellitus/terapia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Programas de Rastreamento , Recursos Humanos em Hospital , Atenção Primária à Saúde/organização & administração , Pesquisa Qualitativa , Provedores de Redes de Segurança/organização & administração , Software , Fluxo de Trabalho
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