Fostering evidence-based quality improvement for patient-centered medical homes: Initiating local quality councils to transform primary care.

BACKGROUND: Although the patient-centered medical home endorses quality improvement principles, methods for supporting ongoing, systematic primary care quality improvement have not been evaluated. We introduced primary care quality councils at six Veterans Health Administration sites as an organizational intervention with three key design elements: (a) fostering interdisciplinary quality improvement leadership, (b) establishing a structured quality improvement process, and (c) facilitating organizationally aligned frontline quality improvement innovation. PURPOSE: Our evaluation objectives were to (a) assess design element implementation, (b) describe implementation barriers and facilitators, and (c) assess successful quality improvement project completion and spread. METHODOLOGY/APPROACH: We analyzed administrative records and conducted interviews with 85 organizational leaders. We developed and applied criteria for assessing design element implementation using hybrid deductive/inductive analytic techniques. RESULTS: All quality councils implemented interdisciplinary leadership and a structured quality improvement process, and all but one completed at least one quality improvement project and a toolkit for spreading improvements. Quality councils were perceived as most effective when service line leaders had well-functioning interdisciplinary communication. Matching positions within leadership hierarchies with appropriate supportive roles facilitated frontline quality improvement efforts. Two key resources were (a) a dedicated internal facilitator with project management, data collection, and presentation skills and (b) support for preparing customized data reports for identifying and addressing practice level quality issues. CONCLUSIONS: Overall, quality councils successfully cultivated interdisciplinary, multilevel primary care quality improvement leadership with accountability mechanisms and generated frontline innovations suitable for spread. Practice level performance data and quality improvement project management support were critical. PRACTICE IMPLICATIONS: In order to successfully facilitate systematic, sustainable primary care quality improvement, regional and executive health care system leaders should engage interdisciplinary practice level leadership in a priority-setting process that encourages frontline innovation and establish local structures such as quality councils to coordinate quality improvement initiatives, ensure accountability, and promote spread of best practices.

Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics.

BACKGROUND: Collaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs. METHODS: This nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews. RESULTS: Adoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn. CONCLUSIONS: Provider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs. TRIAL REGISTRATION: Clinical trial # NCT00317018.

Steps for implementing collaborative care programs for depression.

Numerous studies have demonstrated that collaborative care (care management) for depression improves outcomes, yet few clinics have implemented this evidence-based practice. To promote adoption of this best practice, our objective was to describe the steps needed to tailor collaborative care models for local needs, resources, and priorities while maintaining fidelity to the evidence base. Based on lessons learned from 2 multisite Veterans Affairs implementation studies conducted in 2 different clinical, organizational, and geographic contexts, we describe in detail the steps needed to adapt an evidence-based collaborative care program for depression for local context while maintaining highly fidelity to the research evidence. These steps represent a detailed checklist of decisions and action items that can be used as a tool to plan the implementation of a collaborative care model for depression. We also identify other tools (eg, decision support systems, suicide risk assessment) and resources (eg, training materials) that will support implementation efforts. These implementation tools should help clinicians and administrators develop informed strategies for rolling out collaborative care models for depression.

Electrophoretic characterization of species of fibronectin bearing sequences from the N-terminal heparin-binding domain in synovial fluid samples from patients with osteoarthritis and rheumatoid arthritis.

Fragments of fibronectin (FN) corresponding to the N-terminal heparin-binding domain have been observed to promote catabolic chondrocytic gene expression and chondrolysis. We therefore characterized FN species that include sequences from this domain in samples of arthritic synovial fluid using one-and two-dimensional (1D and 2D) Western blot analysis. We detected similar assortments of species, ranging from ~47 to greater than 200 kDa, in samples obtained from patients with osteoarthritis (n = 9) versus rheumatoid arthritis (n = 10). One of the predominant forms, with an apparent molecular weight of ~170 kDa, typically resolved in 2D electrophoresis into a cluster of subspecies. These exhibited reduced binding to gelatin in comparison with a more prevalent species of ~200+ kDa and were also recognized by a monoclonal antibody to the central cell-binding domain (CBD). When considered together with our previous analyses of synovial fluid FN species containing the alternatively spliced EIIIA segment, these observations indicate that the ~170-kDa species includes sequences from four FN domains that have previously, in isolation, been observed to promote catabolic responses by chondrocytes in vitro: the N-terminal heparin-binding domain, the gelatin-binding domain, the central CBD, and the EIIIA segment. The ~170-kDa N-terminal species of FN may therefore be both a participant in joint destructive processes and a biomarker with which to gauge activity of the arthritic process.