Cindy Brach

Evidence On The Chronic Care Model In The New Millennium

Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCMs effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.

Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model:

This article develops a conceptual model of cultural competencys potential to reduce racial and ethnic health disparities, using the cultural competency and disparities literature to lay the foundation for the model and inform assessments of its validity. The authors identify nine major cultural competency techniques: interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of community health workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations. The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities. The authors conclude that while there is substantial research evidence to suggest that cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.

Development of the Patient Education Materials Assessment Tool (PEMAT): A new measure of understandability and actionability for print and audiovisual patient information

OBJECTIVE To develop a reliable and valid instrument to assess the understandability and actionability of print and audiovisual materials. METHODS We compiled items from existing instruments/guides that the expert panel assessed for face/content validity. We completed four rounds of reliability testing, and produced evidence of construct validity with consumers and readability assessments. RESULTS The experts deemed the PEMAT items face/content valid. Four rounds of reliability testing and refinement were conducted using raters untrained on the PEMAT. Agreement improved across rounds. The final PEMAT showed moderate agreement per Kappa (Average K=0.57) and strong agreement per Gwets AC1 (Average=0.74). Internal consistency was strong (α=0.71; Average Item-Total Correlation=0.62). For construct validation with consumers (n=47), we found significant differences between actionable and poorly-actionable materials in comprehension scores (76% vs. 63%, p<0.05) and ratings (8.9 vs. 7.7, p<0.05). For understandability, there was a significant difference for only one of two topics on consumer numeric scores. For actionability, there were significant positive correlations between PEMAT scores and consumer-testing results, but no relationship for understandability. There were, however, strong, negative correlations between grade-level and both consumer-testing results and PEMAT scores. CONCLUSIONS The PEMAT demonstrated strong internal consistency, reliability, and evidence of construct validity. PRACTICE IMPLICATIONS The PEMAT can help professionals judge the quality of materials (available at: http://www.ahrq.gov/pemat).

Wrestling with Typology: Penetrating the "Black Box" of Managed Care by Focusing on Health Care System Characteristics

The health care system has undergone a fundamental transformation undermining the usefulness of the typology of the health maintenance organization, the independent practice association, the preferred provider organization, and so forth. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain—financial features, structure, care delivery and management policies, and products—and by key roles in the health care system—sponsor, plan, provider intermediary organization, and direct services provider. The matrix is a tool for researchers, administrators, clinicians, data collectors, regulators, and other policy makers. It suggests a new set of players to be studied, emphasizes the relationships among the players, and provides a checklist of independent, control, and interactive variables to be included in analyses.

Toward a Systems Approach to Health Literacy Research

Implementing the Affordable Care Act (ACA) requires a new commitment to “person-centeredness” as a central feature of health care. Person-centered health care means people have both the knowledge required to make decisions about their care and the support of providers and family who respect their needs and preferences (Hurtado, Swift, & Corrigan, 2001). To realize a person-centered health care system, the ACA and the HITECH Act,1 two federal laws, promote new health care service delivery models and health information technologies that emphasize teams and people’s engagement in information seeking, decision-making and self-management. These changes reflect the growing priority of health literacy.

Mental Health Services: Critical Component of Integrated Primary Care and Substance Abuse Treatment

The documented high incidence of mental health disorders among individuals in substance abuse treatment argues for the importance of studying the provision of mental health services to this population. This survey documents how the Linkage Programs assembled an array of mental health services based on the assessed health care needs of clients. Specialty and nonspecialty personnel addressed the extensive mental health needs of ethnically diverse, multiproblem clients with substance abuse problems. The innovative use of nonconventional providers, however, did not eliminate the shortfall between the number of clients with mental health problems and the number who were referred to and received mental health services; nor did it enable all Linkage Programs to address the mental health needs of the most severely ill clients. There is a continuing need to forge relationships between mental health providers and integrated providers of primary care and substance abuse treatment.

Demonstration of the Health Literacy Universal Precautions Toolkit: Lessons for Quality Improvement.

The Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit was developed to help primary care practices assess and make changes to improve communication with and support for patients. Twelve diverse primary care practices implemented assigned tools over a 6-month period. Qualitative results revealed challenges practices experienced during implementation, including competing demands, bureaucratic hurdles, technological challenges, limited quality improvement experience, and limited leadership support. Practices used the Toolkit flexibly and recognized the efficiencies of implementing tools in tandem and in coordination with other quality improvement initiatives. Practices recommended reducing Toolkit density and making specific refinements.

Improving the Effectiveness of Medication Review: Guidance from the Health Literacy Universal Precautions Toolkit.

Background: Although routine medication reviews in primary care practice are recommended to identify drug therapy problems, it is often difficult to get patients to bring all their medications to office visits. The objective of this study was to determine whether the medication review tool in the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit can help to improve medication reviews in primary care practices. Methods: The toolkits “Brown Bag Medication Review” was implemented in a rural private practice in Missouri and an urban teaching practice in California. Practices recorded outcomes of medication reviews with 45 patients before toolkit implementation and then changed their medication review processes based on guidance in the toolkit. Six months later we conducted interviews with practice staff to identify changes made as a result of implementing the tool, and practices recorded outcomes of medication reviews with 41 additional patients. Data analyses compared differences in whether all medications were brought to visits, the number of medications reviewed, drug therapy problems identified, and changes in medication regimens before and after implementation. Results: Interviews revealed that practices made the changes recommended in the toolkit to encourage patients to bring medications to office visits. Evaluation before and after implementation revealed a 3-fold increase in the percentage of patients who brought all their prescription medications and a 6-fold increase in the number of prescription medications brought to office visits. The percentage of reviews in which drug therapy problems were identified doubled, as did the percentage of medication regimens revised. Conclusions: Use of the Health Literacy Universal Precautions Toolkit can help to identify drug therapy problems.

Management tools for Medicaid and State Children's Health Insurance Program (SCHIP).

Medicaid and the State Childrens Health Insurance Program need analytic tools to manage their programs. Drawing upon extensive discussions with experts in states, this article describes the state of the art in tool use, making several observations: (1) Several states have linked Medicaid/State Childrens Health Insurance Program administrative data to other data (eg, birth and death records) to measure access to care. (2) Several states use managed care encounter data to set payment rates. (3) The analysis of pharmacy claims data appears widespread. The article also describes “lessons learned” regarding building capacity and improving data to support the implementation of management tools.