Andrew Ellner

Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI).

BackgroundMore than three decades after the 1978 Declaration of Alma-Ata enshrined the goal of ‘health for all’, high-quality primary care services remain undelivered to the great majority of the world’s poor. This failure to effectively reach the most vulnerable populations has been, in part, a failure to develop and implement appropriate and effective primary care delivery models. This paper examines a root cause of these failures, namely that the inability to achieve clear and practical consensus around the scope and aims of primary care may be contributing to ongoing operational inertia. The present work also examines integrated models of care as a strategy to move beyond conceptual dissonance in primary care and toward implementation. Finally, this paper examines the strengths and weaknesses of a particular model, the World Health Organization’s Integrated Management of Adolescent and Adult Illness (IMAI), and its potential as a guidepost toward improving the quality of primary care delivery in poor settings.DiscussionIntegration and integrated care may be an important approach in establishing a new paradigm of primary care delivery, though overall, current evidence is mixed. However, a number of successful specific examples illustrate the potential for clinical and service integration to positively impact patient care in primary care settings. One example deserving of further examination is the IMAI, developed by the World Health Organization as an operational model that integrates discrete vertical interventions into a comprehensive delivery system encompassing triage and screening, basic acute and chronic disease care, basic prevention and treatment services, and follow-up and referral guidelines. IMAI is an integrated model delivered at a single point-of-care using a standard approach to each patient based on the universal patient history and physical examination. The evidence base on IMAI is currently weak, but whether or not IMAI itself ultimately proves useful in advancing primary care delivery, it is these principles that should serve as the basis for developing a standard of integrated primary care delivery for adults and adolescents that can serve as the foundation for ongoing quality improvement.SummaryAs integrated primary care is the standard of care in the developed world, so too must we move toward implementing integrated models of primary care delivery in poorer settings. Models such as IMAI are an important first step in this evolution. A robust and sustained commitment to innovation, research and quality improvement will be required if integrated primary care delivery is to become a reality in developing world.

Health Systems Innovation at Academic Health Centers: Leading in a New Era of Health Care Delivery.

Challenged by demands to reduce costs and improve service delivery, the U.S. health care system requires transformational change. Health systems innovation is defined broadly as novel ideas, products, services, and processes—including new ways to promote healthy behaviors and better integrate health services with public health and other social services—which achieve better health outcomes and/or patient experience at equal or lower cost. Academic health centers (AHCs) have an opportunity to focus their considerable influence and expertise on health systems innovation to create new approaches to service delivery and to nurture leaders of transformation. AHCs have traditionally used their promotions criteria to signal their values; creating a health systems innovator promotion track could be a critical step towards creating opportunities for innovators in academic medicine. In this Perspective, the authors review publicly available promotions materials at top-ranked medical schools and find that while criteria for advancement increasingly recognize systems innovation, there is a lack of specificity on metrics beyond the traditional yardstick of peer-reviewed publications. In addition to new promotions pathways and alternative evidence for the impact of scholarship, other approaches to fostering health systems innovation at AHCs include more robust funding for career development in health systems innovation, new curricula to enable trainees to develop skills in health systems innovation, and new ways for innovators to disseminate their work. AHCs that foster health systems innovation could meet a critical need to contribute both to the sustainability of our health care system and to AHCs’ continued leadership role within it.

The Harvard Medical School Academic Innovations Collaborative: Transforming Primary Care Practice and Education

PROBLEM Academic medical centers (AMCs) need new approaches to delivering higher-quality care at lower costs, and engaging trainees in the work of high-functioning primary care practices. APPROACH In 2012, the Harvard Medical School Center for Primary Care, in partnership with with local AMCs, established an Academic Innovations Collaborative (AIC) with the goal of transforming primary care education and practice. This novel two-year learning collaborative consisted of hospital- and community-based primary care teaching practices, committed to building highly functional teams, managing populations, and engaging patients. The AIC built on models developed by Qualis Health and the Institute for Healthcare Improvement, optimized for the local AMC context. Foundational elements included leadership engagement and development, application of rapid-cycle process improvement, and the creation of teams to care for defined patient populations. Nineteen practices across six AMCs participated, with nearly 260,000 patients and 450 resident learners. The collaborative offered three 1.5-day learning sessions each year featuring shared learning, practice coaches, and improvement measures, along with monthly data reporting, webinars, and site visits. OUTCOMES Validated self-reports by transformation teams showed that practices made substantial improvement across all areas of change. Important factors for success included leadership development, practice-level resources, and engaging patients and trainees. NEXT STEPS The AIC model shows promise as a path for AMCs to catalyze health system transformation through primary care improvement. In addition to further evaluating the impact of practice transformation, expansion will require support from AMCs and payers, and the application of similar approaches on a broader scale.

The Coming Primary Care Revolution

The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.

Strengthening of primary-care delivery in the developing world: IMAI and the need for integrated models of care

Vasan, A; Ellner, A; Lawn, SD; Gupta, N; Anatole, M; Drobac, P; Nicholson, T; Gove, S; Seung, K; Mabey, D; +1 more... Farmer, P; (2013) Strengthening of primary-care delivery in the developing world: IMAI and the need for integrated models of care. The Lancet Global health, 1 (6). e321-3. ISSN 2214-109X DOI: https://doi.org/10.1016/S2214-109X(13)70102-5 Downloaded from: http://researchonline.lshtm.ac.uk/1878113/ DOI: https://doi.org/10.1016/S2214-109X(13)70102-5

Closing the Feedback Loop: A 12-month Evaluation of ASTA, a Self-Tracking Application for ASHAs

Accredited Social Health Activists (ASHAs) have been shown to have a positive impact on health outcomes of the households they visit, particularly in maternal and neonatal health. As the first line of the public health system in many countries, they are a critical link to the broader public health infrastructure for community members. Yet they do this all with minimal training and limited support infrastructure. To a pregnant woman, an ASHA is a trusted ally in navigating the health system---information gathered is returned by appropriate advice and counseling. To the health system, the ASHA is a key channel of valuable householdlevel information for the public health system, yet she generally receives minimal guidance in return. In this paper we present ASTA---the ASHA Self-Tracking Application---a system that provides ASHAs with timely, on-demand information regarding their own performance compared to their peers. Using ASTA, ASHAs access comparative performance data through both a web-based and voice-based interface on demand. We evaluated ASTA through a 12-month deployment with 142 ASHAs in Uttar Pradesh, India, assessing the impact of providing feedback on ASHA performance. We find that ASHAs with access to the ASTA system made significantly more client visits, with average monthly visits 21.5% higher than ASHAs who had access to a control system. In addition, higher ASHA performance was correlated with increased usage of ASTA. However, the performance improvement was front-loaded, with the impact of the system decreasing toward the end of the study period. Taken together, our findings provide promising evidence that studying and incorporating tools like ASTA could be cost effective and impactful for ASHA programs.

Decision-making strategies: ignored to the detriment of healthcare training and delivery?

Context: People do not always make health-related decisions which reflect their best interest – best interest being defined as the decision they would make if they carefully considered the options and fully understood the information available. A substantial literature has developed in behavioral economics and social psychology that seeks to elucidate the patterns in individual decision-making. While this is particularly relevant to healthcare, the insights from these fields have only been applied in a limited way. To address the health challenges of the twenty-first century, healthcare providers and healthcare systems designers need to more fully understand how individuals are making decisions. Methods: We provide an overview of the theories of behavioral economics and social psychology that relate to how individuals make health-related decisions. The concentration on health-related decisions leads to a focus on three topics: (1) mental shortcuts and motivated reasoning; (2) implications of time; and (3) implications of affect. The first topic is relevant because health-related decisions are often made in a hurry without a full appreciation of the implications and the deliberation they warrant. The second topic is included because the link between a decision and its health-related outcomes can involve a significant time lag. The final topic is included because health and affect are so often linked. Findings: The literature reviewed has implications for healthcare training and delivery. Selection for medical training must consider the skills necessary to understand and adapt to how patients make decisions. Training on the insights garnered from behavioral economics and social psychology would better prepare healthcare providers to effectively support their clients to lead healthy lives. Healthcare delivery should be structured to respond to the way in which decisions are made. Conclusions: These patterns in decision-making call into question basic assumptions our healthcare system makes about the best way to treat patients and deliver care. This literature has implications for the way we train physicians and deliver care.

A population management system for improving colorectal cancer screening in a primary care setting

RATIONALE Provision of colorectal cancer (CRC) screening in primary care is suboptimal; failure to observe screening guidelines poses unnecessary risks to patients and doctors. AIMS AND OBJECTIVES Implement a population management system for CRC screening; evaluate impact on compliance with evidence-based guidelines. METHODS DESIGN A quasi-experimental, prospective quality improvement study design using pre-post-analyses with concurrent controls. SETTING Six suites within an academic primary care practice. PARTICIPANTS 5320 adults eligible for CRC screening treated by 70 doctors. INTERVENTION In three intervention suites, doctors reviewed real-time rosters of patients due for CRC screening and chose practice delegate outreach or default reminder letter. Delegates tracked overdue patients, made outreach calls, facilitated test ordering, obtained records and documented patient deferral, exclusion or decline. In three control suites, doctors followed usual preventive care practices. MAIN OUTCOME MEASURES CRC screening compliance (including documented decline, deferral or exclusion) and CRC screening completion rates over 5 months. RESULTS At baseline, there was no significant difference in CRC screening compliance (I: 80.4% and C: 79.6%, P = 0.439) and CRC screening completion rates (I: 78.3% and C: 77.3%, P = 0.398) between intervention and control groups. Post-intervention, compliance rates (I: 88.1% and C: 80.5%, P < 0.01) and completion rates (I: 81.0% and C: 78.1%, P < 0.05) were significantly higher in the intervention group. CONCLUSIONS A population management system using closed-loop communication may improve CRC screening compliance and completion rates within academic primary care practices. Team-based care using well-designed IT systems can enable sharing of patient care responsibilities and improve patient outcomes.

Primary Care Collaboration to Improve Diagnosis and Screening for Colorectal Cancer

BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer death, reducible by screening and early diagnosis, yet many patients fail to receive recommended screening. As part of an academic improvement collaborative, 25 primary care practices worked to improve CRC screening and diagnosis. METHODS The project featured triannual learning sessions, monthly conference calls, practice coach support, and monthly reporting. The project phases included literature review and interviews with national leaders/organizations, development of driver diagrams to identify key factors and change ideas, project launch and practice team planning, and a practice improvement phase. RESULTS The project activities included (1) inventory of barriers and best practices, (2) driver diagram to drive improvements, (3) list of changes to try, (4) compilation of lessons learned, and (5) five key changes to optimize screening and follow-up. Practices leveraged prior transformation efforts to track patients for screening and follow-up during and between office visits. By mapping processes, testing changes, and collecting data, sites targeted opportunities to improve quality, safety, efficiency, and patient and care team experience. Successful change interventions centered around partnering with gastroenterology, engaging leadership, leveraging registries and health information technology, promoting alternative screening options, and partnering with and supporting patients. Several practices achieved improvement in screening rates, while others demonstrated no change from baseline during the 10-month testing and implementation phase (July 2014-April 2015). CONCLUSION The collaborative effectively engaged teams in a broad set of process improvements with key lessons learned related to barriers, information technology challenges, outreach challenges/strategies, and importance of stakeholder and patient engagement.

A model for training medical student innovators: the Harvard Medical School Center for Primary Care Abundance Agents of Change program

Background In 2013, the Harvard Medical School Center for Primary Care established the Abundance Agents of Change (AoC) program to promote interprofessional learning and innovation, increase partnership between 15 academic and community health centers (CHCs) in Bostons most under-served communities, and increase medical student interest in primary care careers. Methods The AoC is modeled in the form of a ‘grants challenge’, offering