Abstract: Publication date: March 2019Source: Healthcare, Volume 7, Issue 1Author(s): Leah Tuzzio, Eric B. Larson, David A. Chambers, Gloria D. Coronado, Lesley H. Curtis, Wendy J. Weber, Douglas F. Zatzick, Catherine M. Meyers The National Institutes of Health (NIH) Health Care Systems (HCS) Research Collaboratory hosted a workshop to explore challenges and strategies for the dissemination, implementation, and sustainability of findings from pragmatic clinical trials (PCTs) embedded in HCS. PCTs are designed to assess the impact of interventions delivered in usual or real-world conditions and leverage existing infrastructure to answer important clinical questions. The goal of the workshop was to discuss strategies for conducting impactful future PCTs that bridge the gap between evidence, practice, and policy. This paper summarizes presentations about how to design and conduct PCTs embedded in HCS and use dissemination and implementation strategies during the planning and conduct of projects, emphasizing the ever-changing world of care delivery and the need for pragmatic trial operations to adapt at various levels of operation.
Abstract: Publication date: March 2019Source: Healthcare, Volume 7, Issue 1Author(s): Dori A. Cross, Paige Nong, Christy Harris-Lemak, Genna R. Cohen, Ariel Linden, Julia Adler-Milstein BackgroundImproving primary care for patients with chronic illness is critical to advancing healthcare quality and value. Yet, little is known about what strategies are successful in helping primary care practices deliver high-quality care for this population under value-based payment models.MethodsDouble-blind interviews in 14 primary care practices in the state of Michigan, stratified based on whether they did (n = 7) or did not (n = 7) demonstrate improvement in primary care outcomes for patients with at least one reported chronic disease between 2010 and 2013. All practices participate in a statewide pay-for-performance program run by a large commercial payer. Using an implementation science framework to identify leverage points for effecting organizational change, we sought to identify, describe and compare strategies among improving and non-improving practices across three domains: (1) organizational learning opportunities, (2) approaches to motivating staff, and (3) acquisition and use of resources.ResultsWe identified 10 strategies; 6 were “differentiating” – that is, more prevalent among improving practices. These differentiating strategies included: (1) participation in learning collaboratives, (2) accessing payer tools to monitor quality performance, (3) framing pay-for-performance as a practice transformation opportunity, (4) reinvesting earned incentive money in equitable, practice-centric improvement, (5) employing a care manager, and (6) using available technical support from local hospitals and provider organizations to support performance improvement. Implementation of these strategies varied based on organizational context and relative strengths.ConclusionsPractices that succeeded in improving care for chronic disease patients pursued a mix of strategies that helped meet immediate care delivery needs while also creating new adaptive structures and processes to better respond to changing pressures and demands. These findings help inform payers and primary care practices seeking evidence-based strategies to foster a stronger delivery system for patients with significant healthcare needs.
Abstract: Publication date: March 2019Source: Healthcare, Volume 7, Issue 1Author(s): Jill D. Nault Connors, Bonnie L. Binkley, J. Carolyn Graff, Satya Surbhi, James E. Bailey •Program theory of change must account for the lived experiences of medically and socially complex patients in order to affect dysfunctional patterns of acute care utilization.•Mental and emotional health, access to self-management resources, and patient-provider communication are key issues of importance to super-utilizing patients.•Transformation of didactic, patient education sessions to interactive, self-management support group sessions achieved success in improving patient engagement.•Lack of collaboration and compliance-oriented healthcare culture are primary threats to successful implementation of innovative healthcare delivery programs.•Linkage and navigation roles of healthcare staff are important in improving patient access to existing community resources, but further health system investments are required to effectively integrate community-based and social services into care delivery.•Peer support interventions are underutilized but hold great promise for addressing behavioral health needs of medically and socially complex patients.
Abstract: Publication date: March 2019Source: Healthcare, Volume 7, Issue 1Author(s): Kathryn Zager, Yhenneko J. Taylor Emergency department visits for non-urgent reasons contribute to overcrowding and higher healthcare costs. Routing patients to lower cost care settings may improve outcomes. The Discharge to Medical Home model is a new care delivery model that routes low-acuity, ambulatory, emergency department (ED) patients to an adjacent primary care clinic, which provides the opportunity for patients to establish a medical home. During clinic hours, walk-in patients presenting to the ED are screened and, if appropriate, scheduled for a same-day appointment with a primary care provider. Over the first year of operation, the model reached 38% of all ED encounters and over 90% of daytime ED encounters. Over a third (36%) of daytime ED patients were discharged to primary care. Future steps include examining primary care follow up after initial discharge and examining models to best leverage the capacity of the primary care clinic to care for both walk-in and established patients.
Abstract: Publication date: March 2019Source: Healthcare, Volume 7, Issue 1Author(s): Timothy J. Judson, Matthew J. Press, Allan S. Detsky Hospitals are increasingly shifting toward value-based reimbursement and focusing on cost consciousness and patient experience. These concepts are crucial to high-quality, affordable healthcare. However, physicians are not well-trained in factoring cost and patient experience into clinical decisions. The addition of these ideas may create the opportunity for patient harm by depriving patients of necessary care. We discuss ways for physicians to mitigate this risk by engaging in online high value care curricula, using a “5-Question High Value Care Time Out,” getting mentorship from master clinicians and using clinical decision support tools.
Abstract: Publication date: March 2019Source: Healthcare, Volume 7, Issue 1Author(s): Helena C. Lyson, Sara Ackerman, Courtney Lyles, Dean Schillinger, Pamela Williams, Gato Gourley, Reena Gupta, Margaret Handley, Urmimala Sarkar BackgroundTeam-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.MethodsWe 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.ResultsSalient 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.ConclusionsTeam-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.
Abstract: Publication date: Available online 13 February 2019Source: HealthcareAuthor(s): Jarrod Basto, Rani Chahal, Bernhard Riedel BackgroundValue-based healthcare is strongly advocated to reduce the spiralling rise in healthcare expenditure. Operating room efficiency is an important focus of value-based healthcare delivery due to high costs and associated hospital revenue derived from procedural streams of care. A parallel induction design, utilising induction rooms for anesthetising patients, may improve operating room efficiency and optimise revenue. We used time-driven activity-based costing (TDABC) to model personnel costs for a high-turnover operating list to assess value of parallel induction redesign.MethodsWe prospectively captured activity data from high-turnover surgery allocated to induction of anesthesia within the operating room (serial design) or within induction rooms prior to completion of preceding surgery (parallel design). Personnel costs were constructed using TDABC following assignment of a case-mix that integrated our activity data. This was contrasted against procedural revenue to assess value of projected case throughput.ResultsUnder a parallel induction design, projected operating list duration was reduced by 55 min at marginal increase (1.6%) in personnel costs as assessed by TDABC. This could facilitate an additional short duration surgical case (e.g. Wide Local Excision, with potential additional revenue of $2818 per day and $0.73 M per annum per operating room.ConclusionsParallel induction design reduces non-operative time at minimal increase in personnel costs for all-day, high turnover surgery. An additional short duration surgical case is likely feasible under this model and represents a value investment with minimal requirement for additional personnel resources.ImplicationsA parallel induction design, within the constraints of finite healthcare funding, may help alleviate some of the global increase in demand for surgical capacity that accompanies an expanding and aging population.
Abstract: Publication date: Available online 11 February 2019Source: HealthcareAuthor(s): Miriam C. Tepper, Ekta Taneja, Kristin M. King •Individuals with serious mental illness (SMI) experience significant health disparities and die much younger than the general population. Interventions to address this disparity have targeted nutrition, physical fitness, and smoking cessation, but have not yet resulted in significant improvements in health outcomes for this population.•The patient-centered care plan, used by providers and patients during outpatient visits, is a potential tool for engaging patients in their own care. We undertook a quality improvement initiative to boost the use of care plans.•Care plan completion increased substantially over the time period of the initiative. Interviews with patient-provider dyads indicated that patients found care plan conversations helpful for articulating and working toward their goals. Providers generally found them useful for refocusing the treatment, though some found the workflow cumbersome.•Improving health outcomes among those with SMI will likely require improving patient activation; the patient-centered care plan might be a useful tool for addressing patient activation.
Abstract: Publication date: Available online 11 February 2019Source: HealthcareAuthor(s): Karleen F. Giannitrapani, Hector Rodriguez, Alexis K. Huynh, Alison B. Hamilton, Linda Kim, Susan E. Stockdale, Jack Needleman, Elizabeth M. Yano, Lisa V. Rubenstein BackgroundThe Veterans Health Administration (VA) primary care is organized as a Patient Centered Medical Home (PCMH) that is based on continuity management of patient panels by interdisciplinary “teamlets” consisting of primary care providers, nurses, and clerical associates. While the teamlets are envisioned as interdisciplinary in this model, teamlet members may continue to report separately to middle management supervisors within their respective disciplines. Little is known about the role of middle managers in medical home implementation; therefore, the study purpose is to examine and characterize teamlet members’ perceptions of middle managers’ role in primary care operations and teamlet functioning in an outpatient setting.MethodsThis study applied a formal qualitative data collection method and analysis based on semi-structured interviews of 79 frontline interdisciplinary staff (primary care providers, nurses, and clerical associates) in VA Patient Aligned Care Teams (PACT) teamlets. Interviews were analyzed using a method of constant comparison.ResultsTeamlet members recognize that their supervising middle managers are essential to daily functioning of PACT teamlets in terms of clarifying roles and responsibilities, setting expectations, providing coverage strategies, supporting conflict resolution, and facilitating teamlet-initiated innovation. Teamlet members identified challenges when middle manager involvement was lacking.ConclusionWithin a multilevel system, frontline interdisciplinary staff continue to perceive the need for leadership by middle managers from their own professional disciplines for solving interdisciplinary problems, setting role-specific schedules and expectations, and fostering innovation. As such, greater focus on the structure and training of middle managers for participation in PCMH models is needed.
Abstract: Publication date: Available online 30 January 2019Source: HealthcareAuthor(s): Association of Rural Surgeons of India - Lancet Commission on Global Surgery (ARSI-LCoGS) Consensus Committee In India, 90% of the rural population is estimated to lack access to safe, affordable, and timely surgical care. Surgical care in these settings is often characterized by limited resources. Provision of rural surgical care often requires novel approaches as compared to those in higher income urban sectors, specifically in areas of infrastructure, workforce, and blood. This consensus statement draws upon the wealth of experience held by India's rural surgeons to identify key problems and lay forth actionable solutions in the areas of surgical infrastructure, workforce, and blood supply.
Abstract: Publication date: Available online 4 January 2019Source: HealthcareAuthor(s): Adrienne Faerber, Alice Andrews, Ano Lobb, Eric Wadsworth, Katherine Milligan, Robert Shumsky, Elliott Fisher, Tim Lahey Health care delivery science focuses on ways to improve health and health care services provided to individuals and populations. Health care professionals must be trained in health care delivery science in order to diagnose and treat the sources of health care system dysfunction and achieve better outcomes while controlling costs. The ideal model for health care delivery science training has not been fully defined, but doing so is critical especially for frontline mid-career health care professionals whose original clinical training omitted these concepts. To better prepare leaders to address the complex challenges of health care, we created a novel hybrid residential/online 18-month master's degree in health care delivery science. Key strengths of the program are the curriculum, pedagogy, teaching team and close-knit cohort. Here, we discuss the program design rationale and six years of evaluation data of a novel master of health care delivery science program. Novel online education in health care delivery science can empower inter-professional leaders in multiple leadership positions throughout health care to improve the United States health care system.
Abstract: Publication date: Available online 26 December 2018Source: HealthcareAuthor(s): Michael L. Millenson, David B. Muhlestein, Emily M. O’Donnell, Daniel A. Northam Jones, R. Sterling Haring, Thomas Merrill, Joel S. Weissman Although there is a widespread belief that ACOs must be patient-centered to be successful, evidence to guide them in achieving that goal has been lacking. This case report examines four ACO innovators in patient-centered care that together represent urban, suburban and rural populations with a broad range of economic, racial, ethnic and geographic diversity. Seven patient-centeredness strategies emerged: transform primary care practices into patient-centered medical homes; move upstream to address social and economic issues; use both high-tech and high-touch to identify and engage high-risk patients; practice a whole-person orientation; optimize patient-reported measures; treat patients like valued customers; and incorporate patient voices into governance and operations. Exemplars prioritized direct care interventions perceived as central to financial and clinical success, and organizational maturity played a role. Activities that decreased the traditional system's authority, such as incorporating patient voices, were less popular. Local practice factors were important, and a mixture of mission and margin energized front-line staff in implementing patient-centered care as “the right thing to do.” Unresolved questions remain that are related to the impact of individual and multiple interventions and how successful interventions can be disseminated widely. In order for patient-centeredness innovations to enable transformation, providers, payers and policymakers alike must consciously adopt strategies that nurture it.
Abstract: Publication date: December 2018Source: Healthcare, Volume 6, Issue 4Author(s): Marcela Colom, Kirsten Austad, Neftali Sacuj, Karen Larson, Peter Rohloff The utilization of existing social networks is increasingly being recognized as a powerful strategy for delivering healthcare services to underserved populations in low- and middle-income countries. In Guatemala, multiple barriers prevent access to healthcare services for rural and indigenous populations, and strategies for delivering healthcare in more efficient ways are needed. The case study we describe here is a unique collaboration between a microfinance institution (Friendship Bridge) and a primary care organization (Wuqu' Kawoq Maya Health Alliance) to scale up healthcare through an existing lending-borrowing social network. The program provides primary care services to female clients of Friendship Bridge in rural areas of Guatemala, with nurses working as frontline primary care providers, providing door-to-door healthcare services. Over the first 22 months of the project, we have reached over 3500 of Friendship Bridge's clients, with overall high acceptance of services. All clinical documentation and program monitoring and evaluation are done through audit trails within an electronical medical record system, which improves efficiency and lowers the associated time and resources costs. We utilize quality improvement methodologies to aid in decision making and programmatic adjustments scale up. These strategies have allowed us to expand services rapidly under challenging geographic and logistical constraints, while concurrently iteratively improving staff training and supervision, clinical care, and client engagement processes.
Abstract: Publication date: December 2018Source: Healthcare, Volume 6, Issue 4Author(s): Josh Durfee, Tracy Johnson, Holly Batal, Jeremy Long, Deborah Rinehart, Rachel Everhart, Carlos Irwin Oronce, Ivor Douglas, Kimberly Moore, Adam Atherly BackgroundInterventions designed to improve care and reduce costs for patients with the highest rates of hospital utilization (super-utilizers) continue to proliferate, despite conflicting evidence of cost savings.MethodsWe evaluated a practice transformation intervention that implemented team-based care and risk-stratification to match specific primary care resources based on need. This included an intensive outpatient clinic for super-utilizers. We used multivariate regression and a difference-in-differences approach to compare changes in mortality, utilization, and charges between the intervention group and a historical control. Sensitivity analyses tested the robustness of findings and revealed the inherent challenges associated with quasi-experimental designs.ResultsObserved charges for the intervention group were significantly lower than expected charges as derived by the trend of the historical control (p
Abstract: Publication date: December 2018Source: Healthcare, Volume 6, Issue 4Author(s): Christopher Moriates, Vineet M. Arora Medical training is increasingly focused on the need to improve healthcare delivery. To succeed in this endeavor, teaching hospitals should align their educational and clinical operations. This article discusses recent innovations and emerging strategies in medical training across three key components for achieving alignment: (1) bridging educational and clinical priorities; (2) developing curricula to support alignment; (3) and fostering resident-led programs that lead to systems change. Understanding the current landscape of educational and operational innovations across clinical learning environments can help health system leaders and medical educators work together to implement cohesive programs that achieve all of these key components.
Abstract: Publication date: December 2018Source: Healthcare, Volume 6, Issue 4Author(s): Elise Fields, Smriti Neogi, Pamela J. Schoettker, Jennifer Lail BackgroundAn improvement team from the Complex Care Center at our large pediatric medical center participated in a 60-day initiative to use Lean methodologies to standardize their processes, eliminate waste and improve the timely and reliable provision of durable medical equipment and supplies.MethodsThe team used value stream mapping to identify processes needing improvement. Improvement activities addressed the initial processing of a request, provider signature on the form, returning the form to the sender, and uploading the completed documents to the electronic medical record. Data on lead time (time between receiving a request and sending the completed request to the Health Information Management department) and process time (amount of time the staff worked on the request) were collected via manual pre- and post-time studies.ResultsFollowing implementation of interventions, the median lead time for processing durable medical equipment and supply requests decreased from 50 days to 3 days (p < 0.0001). Median processing time decreased from 14 min to 9 min (p < 0.0001). The decrease in processing time realized annual cost savings of approximately $11,000.ConclusionsCollaborative leadership and multidisciplinary training in Lean methods allowed the CCC staff to incorporate common sense, standardize practices, and adapt their work environment to improve the timely and reliable provision of equipment and supplies that are essential for their patients.ImplicationsThe application of Lean methodologies to processing requests for DME and supplies could also result in a natural spread to other paperwork and requests, thus avoiding delays and potential risk for clinical instability or deterioration.
Abstract: Publication date: Available online 26 November 2018Source: HealthcareAuthor(s): Nakul Raykar, John Meara, Atul Gawande, Paul Farmer, Nobhojit Roy
Abstract: Publication date: Available online 23 August 2018Source: HealthcareAuthor(s): Madeleine Ballard, Ryan Schwarz To harness the potential of community health workers (CHWs) to extend health services to poor and marginalized populations and avoid the pitfalls of the post-Alma-Ata period, there is an urgent need to better understand how CHW programs can be optimized. Understanding that several operational questions are unresolved by current academic evidence, this viewpoint considers the role of practitioner expertise in optimizing community health systems and highlights findings from a recently published report that captures implementation experience from 15 countries. The viewpoint considers applications of the report’s suggested community health design principles and implications for implementers, philanthropists, policymakers, and academic researchers.
Abstract: Publication date: Available online 14 August 2018Source: HealthcareAuthor(s): Colleen A. Hughes Driscoll, Samuel Gurmu, Ahad Azeem, Dina El Metwally Implementation Lessons 1. Mobile telephony use in the hospital setting is complex and sub-optimal implementation of mobile communication technology can create inefficiencies in clinical workflow 2. Objective measurement of mobile technology’s impact on clinical communication workflow is necessary to identify and remediate associated inefficiencies in real-time 3. Functionality between mobile applications and devices should be evaluated when implementing technology, particularly when an application is non-native to a device 4. Continual collaboration between front-line clinicians and technical teams allows for early identification of adverse impacts from, and optimization of, mobile communication technology implementation.
Abstract: Publication date: Available online 30 June 2018Source: HealthcareAuthor(s): Richard A. Helmers, C. Michel Harper The multi-campus Academic Health Center (AHC) of the future will need to be system-based and committed to clinical integration to continue to meet institutional goals and serve the needs of its patients. The key tactics we describe to accomplish this are:-the creation of a central governance body and a single strategic and operational plan-the subsequent development of specialty councils and independent multidisciplinary practices (IMP)-the creation of enterprise-wide specialty departments
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