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GoalThis study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events.MethodsWe conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency.Principal findingsThere were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages.Practical applicationsOverall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.

BackgroundCommunity health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship.ObjectiveWe examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth.Research designThis was a cohort study.ParticipantsElectronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020.MethodsMultivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020.ResultsMMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P

BACKGROUND AND OBJECTIVES: The United States has an under-performing healthcare system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the Lean management system based on the Shingo principles originally developed by Toyota in Japan. Our objective is to examine the association between hospital use of the Lean management system and evidence-based or recommended quality improvement care management processes. METHODS: A cross sectional analysis of data from 223 hospitals that responded to both the 2017 National Survey of Healthcare Organizations and Systems (NSHOS) and the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals (NSL) was conducted. RESULTS: Controlling for hospital organizational and market characteristics, the number of years doing Lean was positively associated with use of electronic health record-based decision support, use of quality-focused information management, use of evidence-based guidelines, and support for care transitions at the p

Background Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied. Objective To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care. Methods From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated. Results The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable. Conclusions GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.

No research has considered a range of physician practice capabilities for managing patient care when examining practice-level influences on quality of care, utilization, and spending. Using data from the 2017 National Survey of Healthcare Organizations and Systems linked to 2017 Medicare fee-for-service claims data from attributed beneficiaries, we examined the association of practice-level capabilities with process measures of quality, utilization, and spending. In propensity score-weighted mixed-effects regression analyses, physician practice locations with "robust" capabilities had lower total spending compared to locations with "mixed" or "limited" capabilities. Quality and utilization, however, did not differ by practice-level capabilities. Physician practice locations with robust capabilities spend less on Medicare fee-for-service beneficiaries but deliver quality of care that is comparable to the quality delivered in locations with low or mixed capabilities. Reforms beyond those targeting practice capabilities, including multipayer alignment and payment reform, may be needed to support larger performance advantages for practices with robust capabilities.

ObjectiveTo assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.Data sourcesMultiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.Study designCross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.Data collection/extraction methods1604580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414209 beneficiaries were considered clinically complex (frailty or 2+chronic conditions).Principal findingsFinancial integration and clinical integration were weakly correlated (correlation coefficient=0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).ConclusionsHigher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

Health systems continue to grow in size. Financial integration-the ownership of hospitals or physician practices-often has anticompetitive effects that contribute to the higher prices for health care seen in the US. To determine whether the potential harms of financial integration are counterbalanced by improvements in quality, we surveyed nationally representative samples of hospitals (n = 739) and physician practices (n = 2,189), stratified according to whether they were independent or were owned by complex systems, simple systems, or medical groups. The surveys included nine scales measuring the level of adoption of diverse, quality-focused care delivery and payment reforms. Scores varied widely across hospitals and practices, but little of this variation was explained by ownership status. Quality scores favored financially integrated systems for four of nine hospital measures and one of nine practice measures, but in no case favored complex systems. Greater financial integration was generally not associated with better quality.

PURPOSE Despite the importance of training in ambulatory care settings for residents to acquire important competencies, little is known about the organizational and environmental factors influencing the relative amount of time primary care residents train in ambulatory care during residency. The authors examined factors associated with postgraduate year 1 (PGY-1) residents' ambulatory care training time in Accreditation Council for Graduate Medical Education (ACGME)-accredited primary care programs. METHOD U.S.-accredited family medicine (FM) and internal medicine (IM) programs' 2016-2017 National Graduate Medical Education (GME) Census data from 895 programs within 550 sponsoring institutions (representing 13,077 PGY-1s) were linked to the 2016 Centers for Medicare and Medicaid Services Cost Reports and 2015-2016 Area Health Resource File. Multilevel regression models examined the association of GME program characteristics, sponsoring institution characteristics, geography, and environmental factors with PGY-1 residents' percentage of time spent in ambulatory care. RESULTS PGY-1 mean (standard deviation, SD) percent time spent in ambulatory care was 25.4% (SD, 0.4) for both FM and IM programs. In adjusted analyses (% increase [standard error, SE]), larger faculty size (0.03% [SE, 0.01], P < .001), sponsoring institution's receipt of Teaching Health Center (THC) funding (6.6% (SE, 2.7), P < .01), and accreditation warnings (4.8% [SE, 2.5], P < .05) were associated with a greater proportion of PGY-1 time spent in ambulatory care. Programs caring for higher proportions of Medicare beneficiaries spent relatively less time in ambulatory care (< 0.5% [SE, 0.2], P < .01). CONCLUSIONS Ambulatory care time for PGY-1s varies among ACGME-accredited primary care residency programs due to the complex context and factors primary care GME programs operate under. Larger ACGME-accredited FM and IM programs and those receiving federal THC GME funding had relatively more PGY-1 time spent in ambulatory care settings. These findings inform policies to increase resident exposure in ambulatory care, potentially improving learning, competency achievement, and primary care access.

Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients' values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012-15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.

BACKGROUND: Health care systems can support dissemination of innovations, such as social risk screening in physician practices, but to date, no studies have examined the association of health system characteristics and practice-level adoption of social risk screening. PURPOSE: The aim of the study was to examine the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices. METHODOLOGY: Secondary analyses of the 2018 National Survey of Healthcare Organizations and Systems were conducted. Multilevel linear regression models examined physician practice and system characteristics associated with practice adoption of screening for five social risks (food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs), accounting for clustering of practices within systems using random effects. RESULTS: System-owned practices screened for an average of 1.7 of the five social risks assessed. The intraclass correlation indicated 16% of practice variation in social risk screening was attributable to differences between their health systems owners, with 84% attributable to differences between individual practices. Practices owned by systems with multiple hospitals screened for an additional 0.44 social risks (p = .046) relative to practices of systems without hospitals. Practice characteristics associated with social risk screening included health information technology capacity (β = 0.20, p = .005), innovation culture (β = 0.26, p < .001), and patient engagement strategies (β = 0.57, p < .001). CONCLUSIONS: Health care system capabilities account for less variation in physician practice adoption of social risk screening compared to practice-level capabilities. PRACTICE IMPLICATIONS: Efforts to expand social risk screening among system-owned physician practices should focus on supporting practice capabilities, including enhancing health information technology, promoting an innovative organizational culture, and advancing patient engagement strategies.

Background Community health centers (CHCs) pivoted to remote chronic care services during the COVID-19 pandemic. While care continuity is associated with improved care quality and patients’ experiences, telehealth’s impact on these relationships is unclear. Objective We aimed to examine the association among care continuity, telehealth use, and quality of diabetes or hypertension care in CHCs before and during the COVID-19 pandemic. Methods We collected electronic health record data from a cohort of 20,792 patients with diabetes or hypertension with ≥2 visits per year from March to December 2019 and 2020 among 166 California CHCs in the OCHIN Accelerating Data Value Across a National Community Health Center Network Collaborative. Logistic regression models estimated the association between care continuity (modified, modified continuity index [MMCI]) and telehealth adoption and blood pressure or hemoglobin A1c (HbA1c) testing. Generalized linear regression models for 2019 and 2020 estimated the association between MMCI and blood pressure or HbA1c, exploring telehealth as a mediator. Results Patients experienced reduced care continuity (2019: MMCI=0.71, SD 0.28; 2020: MMCI=0.63, SD 0.36; P Conclusions Care continuity facilitates telehealth use and enables resilient performance on process measures. Elucidating how care continuity influences telehealth adoption may provide insights about implementing patient-centered innovations.

To identify potential orderings of primary care practice adoption of patient engagement strategies overall and separately for interpersonally and technologically oriented strategies.We analyzed physician practice survey data (n = 71) on the adoption of 12 patient engagement strategies.Mokken scale analysis was used to assess latent traits among the patient engagement strategies.Three groupings of patient engagement strategies were analyzed: (1) all 12 patient engagement strategies, (2) six interpersonally oriented strategies, and (3) six technologically oriented strategies.We did not find scalability among all 12 patient engagement strategies, however, separately analyzing the subgroups of six interpersonally and six technologically oriented strategies demonstrated scalability (Loevinger's H coefficient of scalability [range]: interpersonal strategies, H = 0.54 [0.49-0.60], technological strategies, H = 0.42 [0.31, 0.54]). Ordered patterns emerged in the adoption of strategies for both interpersonal and technological types.Common pathways of practice adoption of patient engagement strategies were identified. Implementing interpersonally intensive patient engagement strategies may require different physician practice capabilities than technological strategies. Rather than simultaneously adopting multiple patient engagement strategies, gradual and purposeful practice adoption may improve the impact of these strategies and support sustainability.

Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare. Background Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare. Methods The original HISI survey was sent over a secure organizational email system to the over 26,000 employees of the Hospital District of Helsinki and Uusimaa in March 2020. The data were randomly split with one part used to carry out an exploratory factor analysis (EFA), and the other for testing the resulting model using confirmatory factor analysis (CFA). Results A total of 6073 employees responded to the LHISI survey, for an overall response rate of 23%. The results indicated that the 43 items used in the original LHISI can be reduced to 25 items, and these items measure a five-dimensional model of the progress of Lean implementation: leadership, commitment, standard work, communication, and daily management system. In comparison with a single-factor model, the fit measures for the 5-factor model were better: smaller X-2, larger comparative fit index (CFI), smaller root mean square error of approximation (RMSEA), and smaller standardized root mean square residual (SRMR). Conclusions The 25 item LHISI is valid and feasible to use in the context of Finnish healthcare. The LHISI allows the organization to self-monitor the progress of its Lean implementation and provides the leadership with actionable knowledge to guide the path towards Lean maturity across the organization. Our findings encourage further studies on the adoption and validation of the LHISI in healthcare organizations worldwide.

Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low.This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption.Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression.A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs.Health system and physician practice adoption of PROs for depression, pain, and disability.Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p0.05) and depression (p0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs.Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

Background Health-care organizations around the world are striving to achieve transformational performance improvement, often through adopting process improvement methodologies such as lean management. Indeed, lean management has been implemented in hospitals in many countries. But despite a shared methodology and the potential benefit of benchmarking lean implementation and its effects on hospital performance, cross-national lean benchmarking is rare. Health-care organizations in different countries operate in very different contexts, including different health-care system models, and these differences may be perceived as limiting the ability of improvers to benchmark lean implementation and related organizational performance. However, no empirical research is available on the international relevance and applicability of lean implementation and hospital performance measures. To begin understanding the opportunities and limitations related to cross-national benchmarking of lean in hospitals, we conducted a cross-national case study of the relevance and applicability of measures of lean implementation in hospitals and hospital performance. Methods We report an exploratory case study of the relevance of lean implementation measures and the applicability of hospital performance measures using quantitative comparisons of data from Hospital District of Helsinki and Uusimaa (HUS) Helsinki University Hospital in Finland and a sample of 75 large academic hospitals in the USA. Results The relevance of lean-related measures was high across the two countries: almost 90% of the items developed for a US survey were relevant and available from HUS. A majority of the US-based measures for financial performance (66.7%), service provision/utilization (100.0%) and service provision/care processes (60.0%) were available from HUS. Differences in patient satisfaction measures prevented comparisons between HUS and the USA. Of 18 clinical outcome measures, only four (22%) were not comparable. Clinical outcome measures were less affected by the differences in health-care system models than measures related to service provision and financial performance. Conclusions Lean implementation measures are highly relevant in health-care organizations operating in the USA and Finland, as is the applicability of a variety of performance improvement measures. Cross-national benchmarking in lean healthcare is feasible, but a careful assessment of contextual factors, including the health-care system model, and their impact on the applicability and relevance of chosen benchmarking measures is necessary. The differences between the US and Finnish health-care system models is most clearly reflected in financial performance measures and care process measures.

Background The Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive care, for example, through quality metrics linked to disease prevention. However, little is known about how ACOs deliver preventive care services. Objective To understand how Medicare ACOs provide preventive care services to their attributed patients. Design Mixed-methods study using survey data reporting Medicare ACO capabilities in patient care management and interviews with high-performing ACOs. Participants ACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. Main Measures Survey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews followed a semi-structured interview guide and explored the mechanisms used, and motivations of, ACOs to deliver preventive care services. Key Results Medicare ACOs that reported being comprehensively engaged in the planning and management of patient care - including conducting reminders for preventive care services - had more beneficiaries and had a history of collaboration experience, but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients’ preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets. Conclusions ACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.

BACKGROUND Teamwork is a central aspect of integrated care delivery and increasingly critical to primary care practices of accountable care organizations. Although the importance of leadership facilitation in implementing organizational change is well documented, less is known about the extent to which strong leadership facilitation can positively influence relational coordination among primary care team members. PURPOSE The aim of this study was to examine the association of leadership facilitation of change and relational coordination among primary care teams of accountable care organization-affiliated practices and explore the role of team participation and solidarity culture as mediators of the relationship between leadership facilitation and relational coordination among team members. METHODOLOGY/APPROACH Survey responses of primary care clinicians and staff (n = 764) were analyzed. Multilevel linear regression estimated the relationships among leadership facilitation, team participation, group solidarity, and relational coordination controlling for age, time, occupation, gender, team tenure, and team size. Models included practice site random effects to account for the clustering of respondents within practices. RESULTS Leadership facilitation (β = 0.19, p < .001) and team participation (β = 0.18, p < .001) were positively associated with relational coordination, but solidarity culture was not associated. The association of leadership facilitation and relational coordination was only partially mediated (9%) by team participation. CONCLUSIONS Leadership facilitation of change is positively associated with relational coordination of primary care team members. The relationship is only partially explained by better team participation, indicating that leadership facilitation has a strong direct effect on relational coordination. Greater solidarity was not associated with better relational coordination and may not contribute to better team task coordination. PRACTICE IMPLICATIONS Leadership facilitation of change may have a positive and direct impact on high relational coordination among primary care team members.

Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.

Author(s): Harrison, Michael I; Shortell, Stephen M | Abstract: IntroductionOrganizations and systems that deliver health care may better adapt to rapid change in their environments by acting as learning organizations and learning health systems (LHSs). Despite widespread recognition that multilevel forces shape capacity for learning within care delivery organizations, there is no agreed-on, comprehensive, multilevel framework to inform LHS research and practice.MethodsWe develop such a framework, which can enhance both research on LHSs and practical steps toward their development. We draw on existing frameworks and research within organization and implementation science and synthesize contributions from three influential frameworks: the Consolidated Framework for Implementation Research, the social-ecological framework, and the organizational change framework. These frameworks come, respectively, from the fields of implementation science, public health, and organization science.ResultsOur proposed integrative framework includes both intraorganizational levels (individual, team, mid-management, organization) and the operating and general environments in which delivery organizations operate. We stress the importance of examining interactions among influential factors both within and across system levels and focus on the effects of leadership, incentives, and culture. Additionally, we indicate that organizational learning depends substantially on internal and cross-level alignment of these factors. We illustrate the contribution of our multilevel perspective by applying it to the analysis of three diverse implementation initiatives that aimed at specific care improvements and enduring system learning.ConclusionsThe framework and perspective developed here can help investigators and practitioners broadly scan and then investigate forces influencing improvement and learning and may point to otherwise unnoticed interactions among influential factors. The framework can also be used as a planning tool by managers and practitioners.

Objective Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments. Data sources The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS). Study design Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems. Data collection Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms. Principal findings Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system. Conclusions The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.

Health care systems continue to grow in size. Financial integration—the ownership of hospitals or physician practices—often has anticompetitive effects that contribute to the higher prices for health care seen in the US. To determine whether the potential harms of financial integration are counterbalanced by improvements in quality, we surveyed nationally representative samples of hospitals (n = 739) and physician practices (n = 2,189), stratified according to whether they were independent or were owned by complex systems, simple systems, or medical groups. The surveys included nine scales measuring the level of adoption of diverse, quality-focused care delivery and payment reforms. Scores varied widely across hospitals and practices, but little of this variation was explained by ownership status. Quality scores favored financially integrated systems for four of nine hospital and one of nine practice measures, but in no case favored complex systems. Greater financial integration was generally not associated with better quality.

BackgroundShared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed.ObjectiveWe examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship.DesignPatient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics.Participants1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate).ResultsPAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (β = 0.35; p

The Centers for Medicare and Medicaid Services’ (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices ( N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p < .001), SIM Round 2 (4.7 vs. 7.0 capabilities, p < .001), and non-SIM (4.2 vs. 6.3 capabilities, p < .001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends.

IMPORTANCE: It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES: Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES: The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017‐2018 (response rates = 47 percent and 48 percent). STUDY DESIGN: Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS: ACO‐affiliated practices feed back clinician‐level information and use it for quality improvement and compensation on more performance domains than non‐ACO‐affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION: ACO‐affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.

Accountable care organizations (ACOs) are a prominent payment and delivery model, often described and promoted as provider-driven organizations. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We use data from the National Survey of ACOs (N=276) to understand the prevalence of non-provider management partners’ involvement in ACOs, the services these partners provide, and the structure of ACOs with such partners. We find that 37% of ACOs reported having a management partner, and two-thirds of these reported that the partner shared financial risk or reward. Among ACOs with partners, ACOs reported that 94% provided data services, 66% care coordination, 68% education, and 84% administrative services; half received all four services from their partner. ACOs with partners were smaller and more primary care focused than other ACOs. Performance and cost and quality was similar between ACOs with and without partners. Our findings suggest that management partners play a central role in many ACOs, perhaps providing smaller or physician-run ACOs with capital and expertise perceived as necessary to launch an ACO. However, further research is needed to understand the nature of these relationships including both positive aspects (e.g. enabling participation) and negative aspects (e.g. value extracted compared to delivered).

Objective To examine the relationship of physician versus hospital ownership of small- and medium-sized practices with spending and utilization of care. Data Source/Study Setting/Data Collection Survey data for 1,045 primary care-based practices of 1–19 physicians linked to Medicare claims data for 2008 for 282,372 beneficiaries attributed to the 3,010 physicians in these practices. Study Design We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending). Principal Findings Beneficiaries linked to hospital-owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician-owned practices. Conclusions Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care.

BackgroundThe growing movement toward more accountable care delivery and the increasing number of people with chronic illnesses underscores the need for primary care practices to engage patients in their own care.ObjectiveFor adult primary care practices seeing patients with diabetes and/or cardiovascular disease, we examined the relationship between selected practice characteristics, patient engagement, and patient-reported outcomes of care.DesignCross-sectional multilevel observational study of 16 randomly selected practices in two large accountable care organizations (ACOs).ParticipantsPatients with diabetes and/or cardiovascular disease (CVD) who met study eligibility criteria (n = 4368) and received care in 2014 were randomly selected to complete a patient activation and PRO survey (51% response rate; n = 2176). Primary care team members of the 16 practices completed surveys that assessed practice culture, relational coordination, and teamwork (86% response rate; n = 411).Main measuresPatient-reported outcomes included depression (PHQ-4), physical functioning (PROMIS SF12a), and social functioning (PROMIS SF8a), the Patient Assessment of Chronic Illness Care instrument (PACIC-11), and the Patient Activation Measure instrument (PAM-13). Patient-level covariates included patient age, gender, education, insurance coverage, limited English language proficiency, blood pressure, HbA1c, LDL-cholesterol, and disease comorbidity burden. For each of the 16 practices, patient-centered culture and the degree of relational coordination among team members were measured using a clinician and staff survey. The implementation of shared decision-making activities in each practice was assessed using an operational leader survey.Key resultsHaving a patient-centered culture was positively associated with fewer depression symptoms (odds ratio [OR] = 1.51; confidence interval [CI] 1.04, 2.19) and better physical function scores (OR = 1.85; CI 1.25, 2.73). Patient activation was positively associated with fewer depression symptoms (OR = 2.26; CI 1.79, 2.86), better physical health (OR = 2.56; CI 2.00, 3.27), and better social health functioning (OR = 4.12; CI 3.21, 5.29). Patient activation (PAM-13) mediated the positive association between patients' experience of chronic illness care and each of the three patient-reported outcome measures-fewer depression symptoms, better physical health, and better social health. Relational coordination and shared decision-making activities reported by practices were not significantly associated with higher patient-reported outcome scores.ConclusionsDiabetic and CVD patients who received care from ACO-affiliated practices with more developed patient-centered cultures reported lower PHQ-4 depression symptom scores and better physical functioning. Diabetic and CVD patients who were more highly activated to participate in their care reported lower PHQ-4 scores and better physical and social outcomes of care.

Accountable care organizations (ACOs) are intended, in part, to improve health care quality. However, little is known about how ACOs may affect disparities or how providers serving disadvantaged patients perform under Medicare ACO contracts. We analyzed racial and ethnic disparities in health care outcomes among ACOs to investigate the association between the share of an ACO's patients who are members of racial or ethnic minority groups and the ACO's performance on quality measures. Using data from Medicare and a national survey of ACOs, we found that having a higher proportion of minority patients was associated with worse scores on twenty-five of thirty-three Medicare quality performance measures, two disease composite measures, and an overall quality composite measure. However, ACOs serving a high share of minority patients were similar to other ACOs in most observable characteristics and capabilities, including provider composition, services, and clinical capabilities. Our findings suggest that ACOs with a high share of minority patients may struggle with quality performance under ACO contracts, especially during their early years of participation-maintaining or potentially exacerbating current inequities. Policy makers must consider how to refine ACO programs to encourage the participation of providers that serve minority patients and to reward performance appropriately.

Policy Points: For accountable care organizations (ACOs) to be successful they need to change the behavior of their physicians. To stimulate this change, a broad range of motivators are being used, including ways to see a greater impact on patients (social purpose) and opportunities to be a more effective physician (mastery), in addition to personal financial incentives. From our analysis of case studies, it does not appear that the full range of motivators is being deployed by ACOs, which suggests an opportunity to develop more sophisticated and wider-ranging portfolios of motivators for greater impact. Context There are approximately 800 accountable care organizations (ACOs) in the United States. In order to achieve the ACO goals of reduced cost, improved outcomes of care, and better population health, it is critical to change how physicians within ACOs deliver care. While knowledge of ACO development and evolution is growing, relatively little is known about the motivational drivers that are being used to effect change among participating physicians. Methods We synthesized 9 well-established and empirically tested theories of motivation into an overarching framework of 6 motivator domains. This framework was then used to explore the types of motivators that leaders use to stimulate change within 4 case study ACOs. We explored the organizational characteristics, strategies, and motivators for changing physicians’ behaviors through in-depth interviews and document review. Findings The case study ACOs more strongly emphasized nonfinancial motivators for changing physician behavior than financial incentives. These motivators included mastery and social purpose, which were used frequently across all case study sites. Overall, the ACO case studies illustrated variability across all motivational domains. While there was evidence of changing motivators as a result of the ACO, the case study ACOs found it difficult to comprehensively change the use of motivators, in part due to dispersed managerial attention and the complexity and diversity of programs and contracts that fragmented efforts to improve. Conclusions Motivating behavior change within ACOs goes beyond financial incentives. ACOs are using a broad range of motivators, including creating ways to make a greater impact on patients and opportunities to be a more effective physician. Overall, it does not appear that ACOs are deploying the full range of available motivators. This suggests an opportunity to develop more sophisticated and wider-ranging portfolios of motivators to drive behavior change.

Policy Points Accountable care organizations (ACOs) have incentives to promote the adoption of patient engagement strategies such as shared decision making and self-management support programs to improve patient outcomes and contain health care costs. High adoption of patient engagement strategies among ACO-affiliated practices did not improve patient-reported outcomes (PROs) of physical, emotional, and social function among adult patients with diabetes and/or cardiovascular disease over a one-year time frame, likely because implementing these strategies requires extensive clinician and staff training, workflow redesign, and patient participation over time. A dominant focus on improving clinical measures to meet external requirements may crowd out time needed for care team members to address other outcomes that matter to patients, including PROs. Payers and policy-makers should explicitly incentivize the collection and use of PROs when contracting with ACOs. Context Adult primary care practices of accountable care organizations (ACOs) are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient-reported outcomes (PROs) and how relational coordination among team members aids implementation. Methods We used a mixed-methods cohort study design integrating administrative and clinical data with two data collection waves (2014-2015 and 2016-2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n = 103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross-lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies. Findings There were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation. Conclusions Adult patients with diabetes and/or CVD of ACO-affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one-year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.

Background: In the World Health Report 2000, Spain ranked 7th out of 191 countries regarding health systems performance. According to WHO’s world health statistics, in 2015 life expectancy at birth in Spain was 82.8, the third highest in the world. The Spanish state is made up of the central state and 17 decentralized autonomous communities, responsible for payment with public funds as well as healthcare budgeting, and organization of the delivery of services. The right to health protection for all citizens, the right of universal access to health care, and a strong primary care are common elements in all the regions. Added to this, in the last years, the Strategy of Care for People with Chronic Diseases, has represented the strategic framework to drive the development of integrated initiatives in most of the regions in Spain. These three regions were selected as being within the most advanced in the implementation of new innovative integrated care initiatives. Objectives: To explore, identify, describe and analyze the main innovative integrated care initiatives implemented in the three regions that could be translated to the United States. To develop several case studies about integrated care initiatives with tangible results. Format: Moderator: Stephen Shortell (University of California, Berkeley). Keynote Speaker: Roberto Nuno (Deusto University Basque Country) Nuria Mas (IESE -Navarra University Catalonia), Ana Miquel (Rey Juan Carlos University Madrid) Further Insights and US applications: Stephen Shortell and Richard Scheffler (University of California, Berkeley). Timings: 1. Background, Methodology objectives (S. Shortell) 2. Introduction to the Spanish Health System.Data of Cost and Population Health in Spain and in the three regions 3. Initiatives from Basque Country: Innovation relative to Chronic patients, Social and Healthcare Integration, Mental health integration, Budget integration, Local Area coordination across sectors. 4. Initiatives from Catalonia: Integration of Electronic Health Record, Stratification of population, personalized care plans, integration of the emergency medical services, social and healthcare integration, cross sectorial meetings 5. Initiatives from Madrid: Strategy of care for patients with Chronic Conditions, Stratification of the population, The integrated pathways, the Palliative Care plan, The evaluation of the implementation process and the impact in a territory 6. Conclusions and main lessons learned applicable to the US Target Audience: Professionals and leaders from the rest of Spanish Regions and other countries interested in the integrated care initiatives that are taken place in Spain. Learnings to take away: The key success elements that could be Applicable to the US: Overall framework and learning for area-based integration continuum in Spain; Local area care pathways; Personalized care plans for complex, chronic patients; Territorial meetings and agreements/plans for integrated actions among healthcare, social care, schools; Palliative care program; Public payment of private contractor such as Madrid from more than one source to create integration; the basic benefit package all Regional health systems must provide; certain roles such as negotiating drug prices for all of Spain; The definition in Spain of educational requirements of professionals. Leadership and aggressive Change Management are considered relevant factor for Integration Success

Shared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed.We examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship.Patient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics.1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate).PAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (β = 0.35; p 0.0001) was stronger than the path from baseline CollaboRATE to follow-up PAM (β = 0.04; p = 0.001).The relationship between patient activation and patients' experiences of the SDM process is bidirectional, but dominated by baseline patient activation. Rather than promoting the use of SDM for all patients, healthcare organizations should prioritize interventions to promote patient activation and engage patients with relatively high activation in SDM interventions.

INTRODUCTION: The adoption of advanced health information technology (HIT) capabilities, such as predictive analytic functions and patient access to records, remains variable among healthcare systems across the US. This study is the first to identify characteristics that may drive this variability among health systems. METHODS: Responses from the 2017/18 National Survey of Healthcare Organizations and Systems (NSHOS) were used to assess the extent to which health care system organizational structure, electronic health record (EHR) standardization, and resource allocation practices were associated with use of five advanced HIT capabilities. Of 732 systems surveyed, 446 responded (60.9%), 425 met sample inclusion criteria and 389 reported consistent EHR use. Multivariate linear regression with control variables estimated the relationships. RESULTS: Adoption of advanced HIT capabilities is low and variable, with a mean of 2.4 capabilities adopted and only 8.4% of systems reporting widespread adoption of all five capabilities. In adjusted analyses, EHR standardization (β= 0.76, p =0.001) was the strongest predictor of the number of advanced capabilities adopted, and ownership and management of medical groups (β= 0.32, p =0.04) was also a significant predictor. DISCUSSION: EHR standardization across organizations within a health care system appears to drive adoption of advanced HIT features. CONCLUSION: Health systems that standardize their EHRs and that own and manage hospitals and medical groups have higher rates of advanced health information technology capabilities features. System leaders looking to increase the use of advanced HIT capabilities should consider ways to better standardize their EHRs across organizations.

Policy Points The rate of adoption of chronic care management processes (CMPs) by physician organizations has been fairly slow in spite of demonstrated effectiveness of CMPs in improving outcomes of chronic care. Exnovation (ie, removal of innovations) by physician organizations largely explains the slow population-level increases in practice use of CMPs over time. Expanded health information technology functions may aid practices in retaining CMPs. Low provider reimbursement by Medicaid programs, however, may contribute to disinvestment in CMPs by physician organizations. Context Exnovation is the process of removal of innovations that are not effective in improving organizational performance, are too disruptive to routine operations, or do not fit well with the existing organizational strategy, incentives, structure, and/or culture. Exnovation may contribute to the low overall adoption of care management processes (CMPs) by US physician organizations over time. Methods Three national surveys of US physician organizations, which included common questions about organizational characteristics, use of CMPs, and health information technology (HIT) capabilities for practices of all sizes, and Truven Health Insurance Coverage Estimates were integrated to assess organizational and market influences on the exnovation of CMPs in a longitudinal cohort of 1,048 physician organizations. CMPs included 5 strategies for each of 4 chronic conditions (diabetes, asthma, congestive heart failure, and depression): registry use, nurse care management, patient reminders for preventive and care management services to prevent exacerbations of chronic illness, use of nonphysician clinicians to provide patient education, and quality of care feedback to physicians. Findings Over one-third (34.1%) of physician organizations exnovated CMPs on net. Quality of care data feedback to physicians and patient reminders for recommended preventive and chronic care were discontinued by over one-third of exnovators, while nurse care management and registries were largely retained. Greater proportions of baseline Medicaid practice revenue (incidence rate ratio [IRR] = 1.44, p < 0.001) and increasing proportions of revenue from Medicaid (IRR = 1.02, p < 0.05) were associated with greater CMP exnovation by physician organizations on net. Practices with greater expansion of HIT functionality exnovated fewer CMPs (IRR = 0.91, p < 0.001) compared to practices with less expansion of HIT functionality. Conclusions Exnovation of CMPs is an important reason why the population-level adoption of CMPs by physician organizations has remained low. Expanded HIT functions and changes to Medicaid reimbursement and incentives may aid the retention of CMPs by physician organizations.

Background The accountable care organization (ACO) is a new type of health care organization incentivized to improve quality of care, improve population health, and reduce the cost of care. An ACO's success in meeting these objectives depends greatly upon its ability to improve patient care management. Numerous studies have found relational coordination to be positively associated with key measures of organizational performance in health care organizations, including quality and efficiency. Purpose The purpose of this paper is twofold: (a) identify the extent to which ACO leaders are aware of the dimensions of relational coordination, and (b) identify the ways these leaders believe the dimensions influenced care management practices in their organization. Methodology/approach We performed content analysis of interviews with managerial and clinical leaders from a diverse group of 11 ACOs to assess awareness of relational coordination and identify the ways that dimensions of relational coordination were perceived to influence development of care management practices. Findings ACO leaders mentioned four relational coordination dimensions: shared goals, frequency of communication, timeliness of communication, and problem solving communication. Three dimensions - shared knowledge of team members' tasks, mutual respect, and accuracy of communication - were not mentioned. Our analysis identified numerous ways leaders believed the four mentioned dimensions contributed to the development of care management, including contributions to standardization of care, patient engagement, coordination of care, and care planning. Discussion We propose two hypotheses for future research on relational coordination and care management. Practice implications If relational coordination is to have a beneficial influence on ACO performance, organizational leaders must become more aware of relational coordination and its various dimensions and become cognizant of relational coordination's influence on care management in their ACO. We suggest a number of means by which ACO leaders could become more aware of relational coordination and its potential effects.

Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered.

Background: Diabetes is a major contributor to global death and disability. Text-messaging interventions hold promise for improving diabetes outcomes through better knowledge and self-management. Objective: The aim of this study was to examine the implementation and impact of a diabetes text-messaging program targeted primarily for low-income Latino patients receiving care at 2 federally qualified health centers (FQHCs). Methods: A mixed-methods, quasi-experimental research design was employed for this pilot study. A total of 50 Spanish or English-speaking adult patients with diabetes attending 2 FQHC sites in Los Angeles from September 2015 to February 2016 were enrolled in a 12-week, bidirectional text-messaging program. A comparison group (n=160) was constructed from unexposed, eligible patients. Demographic data and pre/post clinical indicators were compared for both the groups. Propensity score weighting was used to reduce selection bias, and over-time differences in clinical outcomes between groups were estimated using individual fixed-effects regression models. Population-averaged linear models were estimated to assess differential effects of patient engagement on each clinical indicator among the intervention participants. A sample of intervention patients (n=11) and all implementing staff (n=8) were interviewed about their experiences with the program. Qualitative data were transcribed, translated, and analyzed to identify common themes. Results: The intervention group had a mean glycated hemoglobin (HbA1c) reduction of 0.4 points at follow-up, relative to the comparison group (P=.06). Patients who were more highly engaged with the program (response rate ≥median of 64.5%) experienced a 2.2 point reduction in HbA1c, relative to patients who were less engaged, controlling for demographic characteristics (P

To assess whether the characteristics and capabilities of individual practices intending to join the early Medicare accountable care organization (ACO) programs differed from those of practices not intending to join.Data from a 2012-2013 national survey of 1398 physician practices were linked to 2012 Medicare beneficiary claims data to examine differences between practices intending to join a Medicare ACO and practices not intending to join a Medicare ACO.Differences were examined with regard to patient sociodemographic characteristics and disease burden, practice characteristics and capabilities, and cost and quality measures. Logistic regression was used to examine the differences.Practices intending to join were more likely to have better care management capabilities (odds ratio [OR], 1.72; P.003), health information technology functionality (OR, 1.87; P.001), and use of quality improvement methods (OR, 1.52; P.04). They were also more likely to have had prior pay-for-performance experience (OR, 1.59; P.02) and less likely to be physician-owned (OR, 0.51; P.001). However, the practices with the greater capabilities still used half or less of them.Physician practices that intended to join the early ACO programs had greater capabilities and experience to manage risk than those practices that decided not to join. The early ACO programs thus attracted the more capable physician practices, but those practices still fell short of implementing key recommended behaviors. The findings have implications for future physician practice selection into ACOs.

BACKGROUND Primary care teams face daily time pressures both during patient encounters and outside of appointments. OBJECTIVES We theorize 2 types of time pressure, and test hypotheses about organizational determinants and patient consequences of time pressure. RESEARCH DESIGN Cross-sectional, observational analysis of data from concurrent surveys of care team members and their patients. SUBJECTS Patients (n=1291 respondents, 73.5% response rate) with diabetes and/or coronary artery disease established with practice teams (n=353 respondents, 84% response rate) at 16 primary care sites, randomly selected from 2 Accountable Care Organizations. MEASURES AND ANALYSIS We measured team member perceptions of 2 potentially distinct time pressure constructs: (1) encounter-level, from 7 questions about likelihood that time pressure results in missing patient management opportunities; and (2) practice-level, using practice atmosphere rating from calm to chaotic. The Patient Assessment of Chronic Illness Care (PACIC-11) instrument measured patient-reported experience. Multivariate logistic regression models examined organizational predictors of each time pressure type, and hierarchical models examined time pressure predictors of patient-reported experiences. RESULTS Encounter-level and practice-level time pressure measures were not correlated, nor predicted by the same organizational variables, supporting the hypothesis of two distinct time pressure constructs. More encounter-level time pressure was most strongly associated with less health information technology capability (odds ratio, 0.33; P

Objective To examine the extent to which physician-to-system ownership transitions are associated with declines in practice-reported patient responsiveness (PRPR). Data Sources A longitudinal cohort of practices (n = 897) from the National Survey of Large Physician Organizations/National Survey of Small- and Medium-Sized Physician Organizations (2006/08) and the National Survey of All-Size Physician Organizations (2012/13). Study Design Multivariable regression estimated the effect of ownership on changes in PRPR, controlling for practice size, specialty composition, other practice, and market characteristics. Data Collection/Extraction Methods Data were collected from three nationally representative surveys of physician organizations consisting of 40-minute interviews with the medical director, president, or chief executive officer. Principal Findings Nine percent of organizations transitioned to system ownership. Compared to practices that were continuously physician-owned, practices that switched to system ownership did not have significantly lower PRPR at baseline but continuously system-owned practices did. Transitions to system ownership were associated with increased PRPR compared to continuously physician ownership. Increased practice size and changes in specialty composition, however, were associated with diminished PRPR. Conclusions Practices can maintain or improve strategies to address patient concerns when transferring ownership to systems with careful attention to the impact of increased size and changes in specialty composition.

BACKGROUND:Accountable care organizations (ACOs) have increased their use of patient activation and engagement strategies, but it is unknown whether they achieve better outcomes for patients with comorbid chronic physical and mental health conditions. OBJECTIVES:To assess the extent to which practices with patient-centered cultures, greater shared decision-making strategies, and better coordination among team members have better patient-reported outcomes (PROs) for patients with diabetes and/or cardiovascular and comorbid mental health diagnoses. RESEARCH DESIGN:Sixteen practices randomly selected from top and bottom quartiles of a 39-item patient activation/engagement implementation survey of primary care team members (n=411) to assess patient-centered culture, shared decision-making, and relational coordination among team members. These data were linked to survey data on patient engagement and on emotional, physical, and social patient-reported health outcomes. SUBJECTS:Adult patients (n=606) with diabetes, cardiovascular, and comorbid mental health conditions who had at least 1 visit at participating primary care practices of 2 ACOs. MEASURES:Depression/anxiety, physical functioning, social functioning; patient-centered culture, patient activation/engagement implementation, relational coordination. RESULTS:Patients receiving care from practices with high patient-centered cultures reported better physical functioning (0.025) and borderline better emotional functioning (0.059) compared with less patient-centered practices. More activated patients reported better PROs, with higher activation levels partially mediating the relationship of patient-centered culture and better PROs. CONCLUSIONS:ACO patients with comorbid physical and mental health diagnoses report better physical functioning when practices have patient-centered cultures. More activated/engaged patients report better patient emotional, physical, and social health outcomes.

OBJECTIVE:To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). DATA SOURCES:Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N=204); SK&A Office Based Physicians Database from QuintilesIMS. STUDY DESIGN:We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. PRINCIPAL FINDINGS:There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. CONCLUSIONS:ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.