Debora Goetz Goldberg

Elements of the patient-centered medical home in family practices in Virginia.

PURPOSE The patient-centered medical home (PCMH) is a widely accepted theory of a practice model to improve quality of care, patient satisfaction, and access to primary care services. This study explores existing elements of the PCMH and characteristics of family practices in Virginia. METHOD We developed and administered a survey questionnaire to capture information on practice characteristics and PCMH elements. We randomly sampled 700 family medicine offices in Virginia from a population of practices derived from the Virginia Board of Medicine Practitioner Information Database. We used a mixed-mode survey, allowing practices in the sample to respond by mail or Internet or at a regional family medicine conference. RESULTS The survey resulted in a response rate of 56%, with 342 office locations participating in the study. Most practices reported continuity-of-care processes (87%) and clinical guidelines (77%). Fewer reported use of patient surveys (48%), electronic medical record for internal coordination (38%), community linkages for care (31%), and clinical performance measurement (28%). A small number reported patient registries for multiple diseases (19%). Very few practices exhibited all elements outlined in the PCMH model (1%). Practice size (number of physicians) is significantly related to PCMH model alignment. CONCLUSIONS Most family practices in Virginia exhibit some elements of the PCMH model. Full implementation of the PCMH model is low. Baseline information on practice characteristics, prevalence of PCMH, and challenges of small practices should be considered in guiding efforts, evaluating progress, and developing policies for care model reform.

Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs) ☆

OBJECTIVE(S) This study examines the on-site availability of long-acting reversible contraception (LARC) methods, defined here as intrauterine devices and contraceptive implants, at Federally Qualified Health Centers (FQHCs). We also describe factors associated with on-site availability and specific challenges and barriers to providing on-site access to LARC as reported by FQHCs. STUDY DESIGN An original survey of 423 FQHC organizations was fielded in 2011. RESULTS Over two thirds of FQHCs offer on-site availability of intrauterine devices yet only 36% of FQHCs report that they offer on-site contraceptive implants. Larger FQHCs and FQHCs receiving Title X Family Planning program funding are more likely to provide on-site access to LARC methods. Other organizational and patient characteristics are associated with the on-site availability of LARC methods, though this relationship varies by the type of method. The most commonly reported barriers to providing on-site access to LARC methods are related to the cost of stocking or supplying the drug and/or device, the perceived lack of staffing and training, and the unique needs of special populations. CONCLUSION Our findings indicate that patients seeking care in small FQHC organizations, FQHCs with limited dedicated family planning funding and FQHCs located in rural areas may have fewer choices and limited access to LARC methods on-site. IMPLICATIONS Despite the presumed widespread coverage of contraceptives for women as a result of provisions in the Affordable Care Act, there is a limited understanding of how FQHCs may redesign their practices to provide on-site availability of LARC methods. This study sheds light on the current state of practice and challenges related to providing LARC methods in FQHC settings.

Scope of family planning services available in Federally Qualified Health Centers

OBJECTIVES Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age; however, only limited knowledge exists on the scope of family planning care they provide and the mechanisms for delivery of these essential reproductive health services, including family planning. In this paper, we report on the scope of services provided at FQHCs including on-site provision, prescription only and referral options for the range of contraceptive methods. STUDY DESIGN An original survey of 423 FQHC organizations was fielded in 2011. RESULTS Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. A large majority (87%) of FQHCs report that their largest primary care site prescribes oral contraceptives plus one additional method category of contraception, with oral contraception and injectables being the most commonly available methods. Substantial variation is seen among other methods such as intrauterine devices (IUDs), contraceptive implants, the patch, vaginal ring and barrier methods. For all method categories, Title-X-funded sites are more likely to provide the method, though, even in these sites, IUDs and implants are much less likely to be provided than other methods. CONCLUSION There is clearly wide variability in the delivery of family planning services at FQHCs in terms of methods available, level of counseling, and provision of services on-site or through prescription or referral. Barriers to provision likely include cost to patients and/or additional training to providers for some methods, such as IUDs and implants, but these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives. IMPLICATIONS With the expansion of contraceptive coverage under private insurance as part of preventive health services for women, along with expanded coverage for the currently uninsured, and the growth of FQHCs as the source of care for women of reproductive age, it is critical that women seeking family planning services at FQHCs have access to a wide range of contraceptive options. Our study both highlights the essential role of FQHCs in providing family planning services and also identifies remaining gaps in the provision of contraception in FQHC settings.

Team-Based Care: A Critical Element of Primary Care Practice Transformation

The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study.

The relationship between organizational culture and practice systems in primary care.

The patient-centered medical home is an approach to comprehensive primary care relying on well-developed systems. Research has shown that for practices to meet patient-centered medical home requirements, care models may need to be redesigned. However, there is a dearth of information about what factors are important to achieve this goal. Self-report surveys from 293 staff across 42 practices in Minnesota showed variation in use of systems and dimensions of organizational culture. Organizational cultures that emphasize collegiality and quality but not autonomy were significantly related to the use of clinician reminders, clinical quality evaluation and improvement, and clinical information systems.

Medical Home Infrastructure: Effect of the Environment and Practice Characteristics on Adoption in Virginia:

This study examined whether environmental factors and practice characteristics influence the existence of patient-centered medical home elements in family practices in Virginia. The study used multiple secondary data sets to measure the external environment and a survey of family practices to enumerate and describe medical home elements and practice environment. Results show a positive association between organizational slack, organizational relationships, and stakeholder expectations on the existence of medical home elements. A negative association was found between competition and medical home elements. Medicare and managed care penetration were not associated with medical home elements. The ability or willingness, or both, of family practices to innovate along the patient-centered medical home model is constrained by important institutional and resource dependencies, and policy makers should take these constraints into account if there is to be widespread adoption of a medical home approach to fee-for-service practices.

Primary care in the United States: practice‐based innovations and factors that influence adoption

PURPOSE This study aims to explore the use of specific innovations in primary care practices. The research seeks to examine whether a relationship exists between environmental factors and organizational characteristics and the level of innovation in primary care practices in Virginia. DESIGN/METHODOLOGY/APPROACH The study utilized multiple secondary data sets and an organizational survey of primary care practices to define the external environment and the level of innovation. Institutional theory was used to explain the connection between innovations in primary care practices and institutional forces within the environment. Resource dependency theory was used to explain motivators for change based on a dependence on scarce financial, human, and information resources. FINDINGS Results show a positive association between organizational size, organizational relationships, and stakeholder expectations on the level of innovation. A negative association was found between competition and the level of innovation. No relationship was found between degree of Medicare and managed care penetration and innovation, nor between knowledge of, and difficulty complying with, payer organization requirements and innovation. ORIGINALITY/VALUE Primary care physician practices exist in a market-driven environment characterized by high pressure from regulatory sources, decreasing reimbursement levels, increasing rate of change in technologies, and increasing patient and community expectations. This study contributes new information on the relationship between organizational characteristics, the external environment and specific innovations in primary care practices. Information on the contributing factors to innovation in primary care is important for improving delivery of health care services and the ability of these practices to survive.

The Role of Primary Care Practices in Advancing Population Health.

Improving population health requires the contribution of many entities including state and local governments, hospitals, community organizations, health centers, and private practices. Primary care practices have the potential to play a key role in improving population health. While sporadic, primary care practices engage in a spectrum of practice- and community-based population health activities. Community-based activities are largely driven by altruistic motivations of physicians and staff. Patient and disease registries and access to comprehensive patient data are critical to improving population health. Guidance is needed for practices to engage in population health initiatives and appropriate incentives to motivate practices to address population health issues.

Hospital Culture of Transitions in Care: Survey Development.

Understanding hospital culture is important to effectively manage patient flow. The purpose of this study was to develop a survey instrument that can assess a hospitals culture related to in-hospital transitions in care. Key transition themes were identified using a multidisciplinary team of experts from 3 health care systems. Candidate items were rigorously evaluated using a modified Delphi technique. Findings indicate 8 themes associated with hospital culture-mediating transitions. Forty-four items reflect the themes.

Collaboration Across the Safety Net in the Era of Health Reform Opportunities or Obstacles

While implementation of the Patient Protection and Affordable Care Act brings significant opportunities for safety net providers (SNP), local systems vary in how well they adapt to the rapidly evolving environment. Collaboration may enhance SNP capacity to leverage opportunities in the health reform era. Our study examines key opportunities and challenges SNPs face under health reform and how providers use collaboration as a strategy to adapt to the new environment. A qualitative study of 78 executives at safety net organizations identified six priorities that pose both opportunities and challenges for SNP, and around which collaboration is used as a strategy to achieve common goals: Medicaid expansion, outreach and enrollment, capacity and access, health system transformation, health insurance exchanges, and reductions in government funding. Three types of collaborations emerged: policy and advocacy, community action, and practice-based. Types of collaborations and stakeholders involved appeared to vary by priority.