Encounter Preparedness, Satisfaction, and Performance Effects of Influence in Assertive Community Treatment (ACT) Teams.

Assertive community treatment (ACT) teams are linked to high quality outcomes for individuals with severe mental illness. This paper tests arguments that influence shared between team members is associated with better encounter preparedness, higher work satisfaction, and improved performance in ACT teams. Influence is conceptualized in three ways: the average level according to team members, the team's evaluation of the dispersion of team member influence, and as the person-organization fit of individual perception of empowerment. The study design is a retrospective observational design using survey data from a longitudinal study of 26 ACT teams (approximately 275 team members total) over 18 months. This study finds that average team influence and person-organization fit are positively correlated with encounter preparedness and satisfaction. Dispersion of influence was not significantly correlated with study outcomes. Influence in ACT teams has multiple dimensions, each with differential effects on team outcomes. These findings provide guidance as to how one might encourage equal and substantive contribution from ACT team members.

Staff Turnover in Assertive Community Treatment (Act) Teams: The Role of Team Climate.

Staff turnover in Assertive Community Treatment (ACT) teams can result in interrupted services and diminished support for clients. This paper examines the effect of team climate, defined as team members' shared perceptions of their work environment, on turnover and individual outcomes that mediate the climate-turnover relationship. We focus on two climate dimensions: safety and quality climate and constructive conflict climate. Using survey data collected from 26 ACT teams, our analyses highlight the importance of safety and quality climate in reducing turnover, and job satisfaction as the main mediator linking team climate to turnover. The findings offer practical implications for team management.

Modern Management Practices and Hospital Admissions.

We investigate whether the modern management practices and publicly reported performance measures are associated with choice of hospital for patients with acute myocardial infarction (AMI). We define and measure management practices at approximately half of US cardiac care units using a novel survey approach. A patient's choice of a hospital is modeled as a function of the hospital's performance on publicly reported quality measures and the quality of its management. The estimates, based on a grouped conditional logit specification, reveal that higher management scores and better performance on publicly reported quality measures are positively associated with hospital choice. Management practices appear to have a direct correlation with admissions for AMI--potentially through reputational effects--and indirect association, through better performance on publicly reported measures. Overall, a one standard deviation change in management practice scores is associated with an 8% increase in AMI admissions.

Improving chronic disease care by adding laypersons to the primary care team: a parallel randomized trial.

BACKGROUND: Improving the quality and efficiency of chronic disease care is an important goal. OBJECTIVE: To test whether patients with chronic disease working with lay "care guides" would achieve more evidence-based goals than those receiving usual care. DESIGN: Parallel-group randomized trial, stratified by clinic and conducted from July 2010 to April 2012. Patients were assigned in a 2:1 ratio to a care guide or usual care. Patients, providers, and persons assessing outcomes were not blinded to treatment assignment. (ClinicalTrials.gov: NCT01156974). SETTING: 6 primary care clinics in Minnesota. PATIENTS: Adults with hypertension, diabetes, or heart failure. INTERVENTION: 2135 patients were given disease-specific information about standard care goals and asked to work toward goals for 1 year, with or without the help of a care guide. Care guides were 12 laypersons who received brief training about these diseases and behavior change. MEASUREMENTS: The primary end point for each patient was change in percentage of goals met 1 year after enrollment. RESULTS: The percentage of goals met increased in both the care guide and usual care groups (changes from baseline, 10.0% and 3.9%, respectively). Patients with care guides achieved more goals than usual care patients (82.6% vs. 79.1%; odds ratio, 1.31 [95% CI, 1.16 to 1.47]; P < 0.001); reduced unmet goals by 30.1% compared with 12.6% for usual care patients; and improved more than usual care patients in meeting several individual goals, including not using tobacco. Estimated cost was $286 per patient per year. LIMITATIONS: Providers' usual care may have been influenced by contact with care guides. Last available data in the electronic health record were used to assess end points. CONCLUSION: Adding care guides to the primary care team can improve care for some patients with chronic disease at low cost.

Differential effects of professional leaders on health care teams in chronic disease management groups.

BACKGROUND: Leadership by health care professionals is likely to vary because of differences in the social contexts within which they are situated, socialization processes and societal expectations, education and training, and the way their professions define and operationalize key concepts such as teamwork, collaboration, and partnership. This research examines the effect of the nurse and physician leaders on interdependence and encounter preparedness in chronic disease management practice groups. PURPOSE: The aim of this study was to examine the effect of complementary leadership by nurses and physicians involved in jointly producing a health care service on care team functioning. METHODOLOGY: The design is a retrospective observational study based on survey data. The unit of analysis is heart failure care groups in U.S. Veterans Health Administration medical centers. Survey and administrative data were collected in 2009 from 68 Veterans Health Administration medical centers. Key variables include nurse and physician leadership, interdependence, psychological safety, coordination, and encounter preparedness. Reliability and validity of survey measures were assessed with exploratory factor analysis and Cronbach alphas. Multivariate analyses tested hypotheses. FINDINGS: Professional leadership by nurses and physicians is related to encounter preparedness by different paths. Nurse leadership is associated with greater team interdependence, and interdependence is positively associated with respect. Physician leadership is positively associated with greater psychological safety, respect, and shared goals but is not associated with interdependence. Respect is associated with involvement in learning activities, and shared goals are associated with coordination. Coordination and involvement in learning activities are positively associated with encounter preparedness. PRACTICE IMPLICATIONS: By focusing on increasing interdependence and a constructive climate, nurse and physician leaders have the opportunity to increase care coordination and involvement in learning activities.

Care guides: an examination of occupational conflict and role relationships in primary care.

BACKGROUND: Improving the efficiency and effectiveness of primary care treatment of patients with chronic illness is an important goal in reforming the U.S. health care system. Reducing occupational conflicts and creating interdependent primary care teams is crucial for the effective functioning of new models being developed to reorganize chronic care. Occupational conflict, role interdependence, and resistance to change in a proof-of-concept pilot test of one such model that uses a new kind of employee in the primary care office, a "care guide," were analyzed. Care guides are lay individuals who help chronic disease patients and their providers achieve standard health goals. PURPOSE: The aim of this study was to examine the development of occupational boundaries, interdependence of care guides and primary care team members, and acceptance by clinic employees of this new kind of health worker. METHODOLOGY/APPROACH: A mixed methods, pilot study was conducted using qualitative analysis; clinic, provider, and patient surveys; administrative data; and multivariate analysis. Qualitative analysis examined the emergence of the care guide role. Administrative data and surveys were used to examine patterns of interdependence between care guides, physicians, team members, and clinic staff; obtain physician evaluations of the care guide role; and evaluate the effect of care guides on patient perceptions of care coordination and follow-up. FINDINGS: Evaluation of implementation of the care guide model showed that (a) the care guide scope of practice was clearly defined; (b) interdependent relationships between care guides and providers were formed; (c) relational triads consisting of patient, care guide, and physician were created; (d) patients and providers were supported in managing chronic disease; and (e) resistance to this model among traditional employees was minimized. PRACTICE IMPLICATIONS: The feasibility of implementing a new care model for chronic disease management in the primary care setting, identifying factors associated with a positive organizational experience, was shown in this study.

Expertise Redundancy, Transactive Memory, and Team Performance in Interdisciplinary Care Teams.

OBJECTIVE: To examine how expertise redundancy and transactive memory (TM) in interdisciplinary care teams (ICTs) are related to team performance. DATA SOURCES/STUDY SETTING: Survey and administrative data were collected from 26 interdisciplinary mental health teams. STUDY DESIGN: The study used a longitudinal, observational design. Independent variables were measured at baseline, 6, and 12 months: expertise redundancy (the extent to which team members possess highly overlapping knowledge), TM accuracy (the extent to which team members accurately recognize experts in relevant knowledge domains), and TM consensus (the extent to which team members agree on who is expert in which knowledge domain). Team performance was measured as risk-adjusted average number of client hospitalization for the 6 months following each survey. DATA COLLECTION METHODS: Survey data were collected by the authors. Administrative data were collected by the state's administrative agency. PRINCIPAL FINDINGS: Expertise redundancy had a negative effect on performance. TM accuracy had a positive effect on performance, and such effect was stronger when expertise redundancy was higher. No significant effect was found on TM consensus. CONCLUSIONS: Transactive memory could serve as a cognitive coordination mechanism for mitigating the negative effect of complex knowledge structure in ICTs.

Assessing medical home mechanisms: certification, asthma education, and outcomes.

OBJECTIVES: Patient-centered medical homes (PCMHs) represent a widespread model of healthcare transformation. Despite evidence that PCMHs can improve care quality, the mechanisms by which they improve outcomes are relatively unexamined. We aimed to assess the mechanisms linking certification as a Health Care Home (HCH), a statewide PCMH initiative, with asthma care quality and outcomes. We compared direct certification effects versus indirect clinical effects (via improved care process). STUDY DESIGN: This was an observational study using statewide patient-level data on asthma care quality and asthma outcomes. METHODS: This study examined care quality for 296,662 adults and children with asthma in 501 HCH-certified and non-HCH clinics in Minnesota from 2010 to 2013. Using endogenous treatment effects models, we assessed the effects of HCH certification on care process (patient education using asthma action plans [AAPs]) and outcomes (asthma controlled; having no exacerbations) and asthma education's effect on outcomes. We used logistic regression to formally decompose direct (certification) versus indirect (via education/AAPs) effects. RESULTS: Adults' adjusted rates of process and outcomes targets were double for HCH versus non-HCH clinics; children's rates were also significantly higher for HCHs. Tests of the indirect/care process effect showed that rates of meeting outcomes targets were 7 to 9 times higher with education using an AAP. Decomposition indicated that the indirect effect (via education/AAPs) constituted 16% to 35% of the total HCH effect on outcomes. CONCLUSIONS: HCHs were associated with better asthma care and outcomes. Asthma education with AAPs also was associated with better outcomes despite being a minority of HCHs' total effect. These findings suggest that HCHs improve outcomes partially via increased care management activity, but also via other mechanisms (eg, electronic health records, registries).

Public Reporting of Primary Care Clinic Quality: Accounting for Sociodemographic Factors in Risk Adjustment and Performance Comparison.

Performance measurement and public reporting are increasingly being used to compare clinic performance. Intended consequences include quality improvement, value-based payment, and consumer choice. Unintended consequences include reducing access for riskier patients and inappropriately labeling some clinics as poor performers, resulting in tampering with stable care processes. Two analytic steps are used to maximize intended and minimize unintended consequences. First, risk adjustment is used to reduce the impact of factors outside providers' control. Second, performance categorization is used to compare clinic performance using risk-adjusted measures. This paper examines the effects of methodological choices, such as risk adjusting for sociodemographic factors in risk adjustment and accounting for patients clustering by clinics in performance categorization, on clinic performance comparison for diabetes care, vascular care, asthma, and colorectal cancer screening. The population includes all patients with commercial and public insurance served by clinics in Minnesota. Although risk adjusting for sociodemographic factors has a significant effect on quality, it does not explain much of the variation in quality. In contrast, taking into account the nesting of patients within clinics in performance categorization has a substantial effect on performance comparison.

Developing Workforce Capacity in Public Health Informatics: Core Competencies and Curriculum Design.

We describe a master's level public health informatics (PHI) curriculum to support workforce development. Public health decision-making requires intensive information management to organize responses to health threats and develop effective health education and promotion. PHI competencies prepare the public health workforce to design and implement these information systems. The objective for a Master's and Certificate in PHI is to prepare public health informaticians with the competencies to work collaboratively with colleagues in public health and other health professions to design and develop information systems that support population health improvement. The PHI competencies are drawn from computer, information, and organizational sciences. A curriculum is proposed to deliver the competencies and result of a pilot PHI program is presented. Since the public health workforce needs to use information technology effectively to improve population health, it is essential for public health academic institutions to develop and implement PHI workforce training programs.

The evolving role of third parties in the hospital physician relationship.

Hospital-physician relationships (HPRs) are a key concern for both parties. Hospital interest has been driven historically by the desire for the physician's clinical business, the need to combat managed care, and now the threats posed by single specialty hospitals, medical device vendors, and consumerism. Physician interest has been driven by fears of managed care and desires for new sources of revenue. The dyadic relationships between hospitals and physicians are thus motivated and influenced by the role of third parties. This article analyzes the history of HPRs and the succession of third parties. The analysis illustrates that the role of third parties has shifted from a unifying one to one that divides hospitals and physicians. This shift presents both opportunities and problems.

Physicians' perceptions of managed care: a review of the literature.

In this article, the authors review the health services research literature regarding physician attitudes and opinions relating to managed care and how managed care has affected their clinical practice. This literature suggests that physician perceptions of managed care are largely related to the nature of their ties to managed care plans and to their selection of practice setting. There are substantial limitations in study designs and execution, suggesting that many of the published findings should be viewed with caution; the research basis regarding physicians' perceptions of managed care is not as strong as the number of articles published on this subject would suggest. The review concludes with suggestions for the conduct of future research on this topic.

Variation in Medicare's local coverage policies: content analysis of local medical review policies.

OBJECTIVE: To assess variation in the content of Medicare's local medical review policies. STUDY DESIGN: Six case studies to compare differences in coverage policies by diagnosis codes, procedure codes, and indications for use. METHODS: All carrier policies from 48 carrier contracts (n = 5213) posted to the Centers for Medicare & Medicaid Services Web site were downloaded on May 31, 2001. All policies in the data set were coded based on a typology: new technology (NT), extensions of new technology (TE), and utilization management (UM) of widely used procedures. We identified policies addressing the same procedure or technology. We required at least 20 separate policies in each case study to allow meaningful comparisons. We randomly selected 1 case study of a diagnostic and 1 for a treatment modality from each policy type (NT, TE, and UM). RESULTS: Given previous research on local carriers, we expected to find variations among policies in each case study. We found substantial similarity, however, among policies covering the NT and TE types. We found significantly more variation among our UM-type case studies. CONCLUSIONS: Medicare legislation has called for greater coverage policy consistency in Medicare. This analysis on variation in policy content, part of a larger study on variation in Medicare's local coverage process, provides data on policy content differences. Policy reform should reflect the nature of and reasons for policy variation as suggested by the findings of this research.

Physician evaluations of care management practices in Medicaid programs.

OBJECTIVE: To assess differences in care management practices for Medicaid beneficiaries in predominantly commercial and predominantly Medicaid health plans. STUDY DESIGN: Physicians in the networks of 8 managed care plans participating in Medicaid programs were surveyed regarding the availability and usefulness of care management practices and the overall quality of care management. The responses of physicians in plans serving predominantly Medicaid enrollees were contrasted with the responses of physicians in predominantly commercial plans who cared for Medicaid enrollees. METHODS: Logistic regression analysis was used to calculate adjusted odds ratios relating to the availability of care management practices. Multiple regression techniques were used to construct comparisons of adjusted means relating to the usefulness of practices and the overall quality of care management. RESULTS: Physicians in predominantly commercial plans reported greater availability of care management practices. No patterns of differences were noted in ratings of the usefulness of practices if available. Physicians in predominantly commercial plans rated the quality of care management higher than physicians in predominantly Medicaid plans. However, there remains room for substantial improvement for commercial and other Medicaid contracting plans. CONCLUSIONS: Commercial plans add value to Medicaid programs, and efforts to discourage their withdrawal from participation are justified. However, physician evaluations support the potential for better care management in all types of contracting plans.

Physician use of disease management programs.

This paper examines differences in availability, use, and perceived usefulness of disease management programs as reported by generalist and specialist physicians functioning as primary care providers in health plans. Implications of these differences are discussed in terms of the three types of purchasers: private insurers, Medicare, and Medicaid. The design is a cross-sectional mail and telephone mixed-mode survey. The data come from 23 health plans in five states (Florida, New York, Colorado, Pennsylvania, and Washington), including six metropolitan areas: Seattle, New York City, Miami, Pittsburgh, Philadelphia, and Denver. The study participants are 1,244 generalist and specialist physicians who contracted with health plans as primary care providers. They were drawn from a 2001 mail and telephone survey of 2,105 generalist and 1,693 specialist physicians serving commercial, Medicaid, and Medicare patients. Physician responses about use of disease management for their patients in the health plan and how useful they thought it was were regressed on physician, physician organization, and physician-health plan relationship characteristics. While generalist physicians are likely to report having disease management programs available and using them, specialists vary greatly in their response to the disease management programs. In contrast to physicians associated with commercial plans, implementation of disease management programs among physicians associated with Medicaid plans varied across states. Primary care providers trained in generalist areas of practice are more likely than specialists functioning as primary care providers to report that disease management programs are available and to use them. They also find them more useful than do specialists.

Is the system really the solution? Operating costs in hospital systems.

Hospital system formation has recently accelerated. Executives emphasize scale economies that lower operating costs, a claim unsupported in academic research. Do systems achieve lower costs than freestanding facilities, and, if so, which system types? We test hypotheses about the relationship of cost with membership in systems, larger systems, and centralized and local hub-and-spoke systems. We also test whether these relationships have changed over time. Examining 4,000 U.S. hospitals during 1998 to 2010, we find no evidence that system members exhibit lower costs. However, members of smaller systems are lower cost than larger systems, and hospitals in centralized systems are lower cost than everyone else. There is no evidence that the system's spatial configuration is associated with cost, although national system hospitals exhibit higher costs. Finally, these results hold over time. We conclude that while systems in general may not be the solution to lower costs, some types of systems are.

Assessing Diabetes Care Disparities with Ambulatory Care Quality Measures.

OBJECTIVE: To identify and describe racial/ethnic disparities in overall diabetes management. DATA SOURCE/STUDY SETTING: Electronic health record data from calendar year 2010 were obtained from all primary care clinics at one large health system in Minnesota (n = 22,633). STUDY DESIGN: We used multivariate logistic regression to estimate the odds of achieving the following diabetes management goals: A1C <8 percent, LDL cholesterol <100 mg/dl, blood pressure <140/90 mmHg, tobacco-free, and daily aspirin. PRINCIPAL FINDINGS: Blacks and American Indians have higher odds of not achieving all goals compared to whites. Disparities in specific goals were also found. CONCLUSIONS: Although this health system has above-average diabetes care quality, significant disparities by race/ethnicity were identified. This underscores the importance of stratifying quality measures to improve care and outcomes for all.

How are health plans supporting physician practice? The physician perspective.

IPA-model HMOs are now the dominant organizational structures for delivering "managed care" in the United States. Are they taking advantage of opportunities to support physician practices in ways that arguably could improve care? In this paper we report the findings from a survey of generalist and specialist physicians in nineteen health plans. Not surprisingly, we found that generalists are much more likely than specialists are to be the target of health plans' efforts to support care delivery. However, our survey data indicate that these opportunities generally are not being fully exploited; also, efforts that plans do make to provide information to support care often are not seen as useful by physicians.

Assessing the influence of incentives on physicians and medical groups.

This article describes issues that should be considered in the development of a theory or theories about incentives from which testable hypotheses could be derived. Economic, psychological, and organizational theories are described, and issues that should be considered in hypothesis generation are presented. Psychological factors influencing incentives include decision framing, regret, heuristics, and reinforcements. Organizational factors influencing incentives include bundling of services or people, matching of incentive structure with work organization, and the incompletely contained hierarchical nesting of incentives. Finally, the dynamics of incentive change are considered, with a focus on describing the conditions under which physicians and physician organizations respond to incentive changes.