Search

Shared medical appointments (SMAs) are an evidence-based approach to diabetes care in primary care settings, yet practices can struggle to ensure participation, especially among racial and ethnic minority and low-income patients. We conducted a multimethod evaluation of reach and attendance in the Invested in Diabetes study of the comparative effectiveness of two SMA delivery models (standardized and patient-driven) in two practice settings (federally qualified health centers [FQHCs] and clinics serving more commercially insured patients). Through this study, 22 practices reached 6.2% of patients with diabetes through SMAs over 3 years, with good attendance for both practice types and both SMA delivery models. FQHCs were especially successful at enrolling underserved populations and improved attendance with virtual SMAs. [ABSTRACT FROM AUTHOR]

Background: Self-management is essential for good outcomes in type 2 diabetes and patients often benefit from self-management education. Shared medical appointments (SMAs) can increase self-efficacy for self management but are difficult for some primary care practices to implement. Understanding how practices adapt processes and delivery of SMAs for patients with type 2 diabetes may provide helpful strategies for other practices interested in implementing SMAs. Methods: The Invested in Diabetes study was a pragmatic cluster-randomized, comparative effectiveness trial designed to compare two different models of diabetes SMAs delivered in primary care. We used a multi-method approach guided by the FRAME to assess practices' experience with implementation, including any planned and unplanned adaptations. Data sources included interviews, practice observations and field notes from practice facilitator check-ins. Results: Several findings were identified from the data: 1) Modifications and adaptations are common in implementation of SMAs, 2) while most adaptations were fidelity-consistent supporting the core components of the intervention conditions as designed, some were not, 3) Adaptations were perceived to be necessary to help SMAs meet patient and practice needs and overcome implementation challenges, and 4) Content changes in the sessions were often planned and enacted to better address the contextual circumstances such as patient needs and culture. Discussion: Implementing SMAs in primary care can be challenging and adaptations of both implementation processes and content and delivery of SMAS for patients with type 2 diabetes were common in the Invested in Diabetes study. Recognizing the need for adaptations based on practice context prior to implementation may help improve fit and success with SMAs, but care needs to be given to ensure that adaptations do not weaken the impact of the intervention. Practices may be able to assess what might need to adapted for them to be successful prior to implementation but likely will continue to adapt after implementation. Conclusion: Adaptations were common in the Invested in Diabetes study. Practices may benefit from understanding common challenges in implementing SMAs and adapting processes and delivery based on their own context. Trial registration: This trial is registered on clinicaltrials.gov under Trial number NCT03590041, posted 18/07/2018. [ABSTRACT FROM AUTHOR]

Objectives: It is important to understand the unique perspectives and values that motivate patients and clinicians in rural primary care settings to participate in clinical care activities. Our objective was to explore perspectives, preferences, and values related to primary care that could influence implementation of evidence-based programs. Methods: Qualitative study utilizing semi-structured interviews and using immersion/crystallization and thematic analysis. Participants were primary care practice members (clinicians, clinical staff, and administrators) and their patients in rural Colorado. Results: Twenty-six practice members and 23 patients across 9 practices participated. There were 4 emergent themes that were consistent across practice members and some patients. Patient perspectives are located in parenthesis. They included: (1) Focus on quality patient care, patient satisfaction, and continuity of care (patients appreciated quality and compassionate care), (2) Importance of prevention and wellness (patients appreciated help with preventing health problems), (3) Clinician willingness and ability to meet patient preferences for care (patients described comfort with local care), and (4) Passion for serving underserved, uninsured, or vulnerable populations (patients described their vulnerabilities). There were differences in how the perspectives were operationalized by practice member role, illustrating the importance of different ways of addressing these values. Conclusions: Successful implementation requires consideration of context, and much of context is understanding what is important to those involved in the primary care experience. This study sheds light on salient values of rural primary care practice members and their patients, which may inform interventions designed with and for this setting. [ABSTRACT FROM AUTHOR]

Purpose: Evidence supports treatment for opioid use disorder (OUD) with buprenorphine in primary care practices (PCPs). Barriers that slow implementation of this treatment include inadequately trained staff. This study aimed to increase the number of rural PCPs providing OUD treatment with buprenorphine. This evaluation describes the impact of a practice team training on the implementation and delivery of OUD treatment with buprenorphine in PCPs of rural Colorado.Methods: Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) was a multilevel implementation study that included a practice-focused intervention to improve awareness, adoption, and use of buprenorphine treatment for OUD. Participating PCP teams received the IT MATTTRs Practice Team Training and support. Practices' implementation of treatment components was assessed before and after training. Practice-reported and population-level data from the Prescription Drug Monitoring Program were obtained to describe changes in delivery of treatment after training.Results: Forty-two practices received team training. Practices reported an average of 4.7 treatment-related components in place at baseline compared with 13.0 at 12-month follow-up (F[2,56] = 31.17, P <.001). The proportion of participating practices providing or referring patients for treatment increased from 18.8% to 74.4%. The increase in number of people with a prescription for buprenorphine was significantly greater in the study region over a 4-year period compared with the rest of the state (Wald χ2 = 15.73, P <.001).Conclusions: The IT MATTTRs training for PCP teams in OUD treatment with buprenorphine addressed elements beyond clinician waiver training to make implementation feasible and effectively increased implementation and delivery of this treatment in rural Colorado. [ABSTRACT FROM AUTHOR]

Background: The real world implementation of chronic care management model varies greatly. One aspect of this variation is the delivery mode. Two contrasting strategies include provider-delivered care management (PDCM) and health plan-delivered care management (HPDCM).Objective: We aimed to compare the effectiveness of PDCM vs. HPDCM on improving clinical outcomes for patients with chronic diseases.Design: We used a quasi-experimental two-group pre-post design using the difference-in-differences method.Patients: Commercially insured patients, with any of the five chronic diseases-congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or asthma, who were outreached to and engaged in either PDCM or HPDCM were included in the study.Main Measures: Outreached patients were those who received an attempted or actual contact for enrollment in care management; and engaged patients were those who had one or more care management sessions/encounters with a care manager. Effectiveness measures included blood pressure, low density lipoprotein (LDL), weight loss, and hemoglobin A1c (for diabetic patients only). Primary endpoints were evaluated in the first year of follow-up.Key Results: A total of 4,000 patients were clustered in 165 practices (31 in PDCM and 134 in HPDCM). The PDCM approach demonstrated a statistically significant improvement in the proportion of outreached patients whose LDL was under control: the proportion of patients with LDL < 100 mg/dL increased by 3 % for the PDCM group (95 % CI: 1 % to 6 %) and 1 % for the HPDCM group (95 % CI: -2 % to 5 %). However, the 2 % difference in these improvements was not statistically significant (95 % CI: -2 % to 6 %). The HPDCM approach showed 3 % [95 % CI: 2 % to 6 %] improvement in overall diabetes care among outreached patients and significant reduction in obesity rates compared to PDCM (4 %, 95 % CI: 0.3 % to 8 %).Conclusions: Both care management delivery modes may be viable options for improving care for patients with chronic diseases. In this commercially insured population, neither PDCM nor HPDCM resulted in substantial improvement in patients' clinical indicators in the first year. Different care management strategies within the provider-delivered programs need further investigation. [ABSTRACT FROM AUTHOR]

Background: Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care.Objective: To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge.Design: Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus).Data: medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization).Analysis: pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis.Participants: Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys.Measurements: We measured secondary prevention behaviors, physical functioning, and quality of life.Results: QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months.Conclusions: Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization. [ABSTRACT FROM AUTHOR]

Care management is becoming increasingly offered in the U.S. as a means of helping patients better manage their chronic diseases and possibly avoid worsening or exacerbations of their conditions, which can result in potentially avoidable and costly healthcare services. Since care management can be provided using different intervention methods and by different entities, we sought to compare different models of care management delivery on their long-term medical savings. Specifically, we compare health plan provided care management to provider delivered care management. Evaluation of the effectiveness of care management programs can be challenging because it can take time for patients to make recommended changes and then demonstrate healthcare savings associated with those changes. In this study, we modeled the unknown form of the time-varying program effects using a spline-based technique in the Bayesian framework, where the number and locations of knots were treated unknown and learned via reversible jump Markov chain Monte Carlo. We also addressed additional modeling challenges from features seen in our healthcare cost data such as highly right-skewed outcomes with non-constant variances and extra zeros. To provide a more robust analysis, we incorporated a follow-up period of up to 4 years that is longer than the most of the published studies on care management. The results of this work demonstrate that cost savings do accrue with specific models of care management. In particular, the embedded model of care management was significantly more effective than the health plan provided care management in controlling medical costs after 2 years of engagement, and the savings increased over time. This information should help policy makers and employer groups achieve a better understanding of the potential value of care management. [ABSTRACT FROM AUTHOR]

Background: Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice.Methods: Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework.Results: Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively.Conclusions: Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning. [ABSTRACT FROM AUTHOR]

The article presents a study which evaluates the impact of comparative feedback compared to general reminders on practice-based referrals to a tobacco cessation quit line and estimated costs for project quit responses. With a group-randomized clinical trial, it was found out that comparative feedback on clinician referrals to quit-line service had a modest impact with limited increased costs.

Background: Primary care practices able to create linkages with community resources may be more successful at helping patients to make and sustain health behavior changes. Methods: Health behavior-change interventions in eight practice-based research networks were examined. Data were collected July 2005–October 2007. A comparative analysis of the data was conducted to identify and understand strategies used for linking primary care practices with community resources. Results: Intervention practices developed three strategies to initiate and/or implement linkages with community resources: pre-identified resource options, referral guides, and people external to the practice who offered support and connection to resources. To initiate linkages, practices required the capacity to identify patients, make referrals, and know area resources. Linkage implementation could still be defeated if resources were not available, accessible, affordable, and perceived as valuable. Linkages were facilitated by boundary-spanning strategies that compensated for the lack of infrastructure between practices and resources, and by brokering strategies that identified interested community partners and aided mutually beneficial connections with them. Linkages were stronger when they incorporated practice or resource abilities to motivate the patient, such as brief counseling or postreferral outreach. Further, data suggested that sustaining linkages requires continuous attention and ongoing communication between practices and resources. Conclusions: Creating linkages between primary care practices and community resources has the potential to benefit both patients and clinicians and to lessen the burden on the U.S. healthcare system resulting from poor health behaviors. Infrastructure support and communication systems must be developed to foster sustainable linkages between practices and local resources. [Copyright &y& Elsevier]