Holly Mead

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.

The role of self-efficacy in cardiovascular disease self-management: a review of effective programs

Correspondence: Hannah Katch The George washington University, Department of Health Policy, washington DC, USA Tel +1 202 994 3367 email hannah.katch@gwumc.edu Research objective: To conduct a comprehensive, systematic review of disease self-management programs for patients with cardiovascular disease (CVD), looking specifically at those with self-efficacy as a key component to the effectiveness of such programs on CVD management and outcomes. Study design: We conducted a review of effective strategies promoting patient involvement and engagement in the self-management of CVD. To narrow the scope of the review, we defined strategies that were empirically tested and showed a measurable and positive impact on outcomes that reflect improved self-management (eg, medication adherence or patient’s perceived management skills) and/or improved clinical outcomes (eg, lower blood pressure or reduced hospitalization). Results: We identified five disease management programs focusing on self-efficacy that had been rigorously evaluated by multiple studies in varying patient populations. Each of these programs were shown to be effective in increasing patients’ engagement and involvement in the management of their disease, by demonstrating improvement in self-efficacy while developing patients’ self-management skills. They also were shown to improve clinical outcomes for patients, such as lower blood pressure and reduced hospitalizations. Conclusion: The studies that we reviewed demonstrate the importance of including selfefficacy as a key component in CVD self-management programs. These programs should be multidisciplinary in approach, should be tailored to the needs of the patients, and should have a theoretical foundation of behavior change. More research is needed to investigate the causal link between self-efficacy, self-management and clinical outcomes.

Race/Ethnicity and patient confidence to self-manage cardiovascular disease.

Background:Minority populations bear a disproportionate burden of chronic disease, due to higher disease prevalence and greater morbidity and mortality. Recent research has shown that several factors, including confidence to self-manage care, are associated with better health behaviors and outcomes among those with chronic disease. Objective:To examine the association between minority status and confidence to self-manage cardiovascular disease (CVD). Study Sample:Survey respondents admitted to 10 hospitals participating in the “Expecting Success” program, with a diagnosis of CVD, during January–September 2006 (n = 1107). Results:Minority race/ethnicity was substantially associated with lower confidence to self-manage CVD, with 36.5% of Hispanic patients, 30.7% of Black patients, and 16.0% of white patients reporting low confidence (P < 0.001). However, in multivariate analysis controlling for socioeconomic status and clinical severity, minority status was not predictive of low confidence. Conclusions:Although there is an association between race/ethnicity and confidence to self-manage care, that relationship is explained by the association of race/ethnicity with socioeconomic status and clinical severity.

Challenges in Language Services: Identifying and Responding to Patients’ Needs

Objective Identify characteristics of hospital-based language services (LS), and describe practices of identifying patients with limited English proficiency (LEP) and interpreter training. Participants Seventy-one hospitals applied to participate in a national initiative. Applicants were non-federal, acute care hospitals with substantial LEP populations, at least 10,000 discharges, and in-person interpreters. Methods Descriptive statistics were generated on language, collection of language data, LEP volume and service utilization, staffing and training requirements and organizational structure. The relationship between admissions and encounters was analyzed. Results Ninety percent of hospitals collect primary language data. Spanish is the most common language (93% of hospitals). We found no statistically significant correlation between admissions and encounters. Eighty-four percent require training. Eighty-nine percent have a designated LS department but no clear organizational home. Conclusions Hospital-based LS programs are facing challenges identifying patients with language needs, staffing and training a workforce, and creating an organizational identity. Need is not associated with utilization, suggesting that LS are not reaching patients.

Underserved patients' perspectives on patient-centered primary care: does the patient-centered medical home model meet their needs?

The patient-centered medical home (PCMH) has gained significant interest as a delivery system model that can improve health care quality while reducing costs. This study uses focus groups to investigate underserved, chronically ill patients’ preferences for care and develops a patient-centered framework of priorities. Seven major priorities were identified: (a) communication and partnership, (b) affordable care, (c) coordinated care, (d) personal responsibility, (e) accessible care, (f) education and support resources, and (g) the essential role of nonphysician providers in supporting their care. Using the framework, we analyzed the PCMH joint principals as developed by U.S. medical societies to identify where the PCMH model could be improved to better meet the needs of these patients. Four of the seven patient priorities were identified as not present in or supported by current PCMH joint principles. The study discusses how the PCMH model can better address the needs of low-income, disadvantaged patients.

A quality improvement framework for equity in cardiovascular care: Results of a national collaborative

&NA; Disparities in the quality of cardiovascular care provided to minorities have been well documented, but less is known about the use of quality improvement methods to eliminate these disparities. Measurement is also often impeded by a lack of reliable patient demographic data. The objective of this study was to assess the ability of hospitals with large minority populations to measure and improve the care rendered to Black and Hispanic patients. The Expecting Success: Excellence in Cardiac Care project utilized the standardized collection of self‐reported patient race, ethnicity, and language data to generate stratified performance measures for cardiac care coupled with evidence‐based practice tools in a national competitively selected sample of 10 hospitals with high cardiac volumes and largely minority patient populations. Main outcomes included changes in nationally recognized measures of acute myocardial infarction and heart failure quality of care and 2 composite measures, stratified by patient demographic characteristics. Quality improved significantly at 7 of the 10 hospitals as gauged by composite measures (p < .05), and improvements exceeded those observed nationally for all hospitals. Three of 10 hospitals found racial or ethnic disparities which were eliminated in the course of the project. Clinicians and institutions were able to join the standardized collection of self‐reported patient demographic data to evidence‐based measures and quality improvement tools to improve the care of minorities and eliminate disparities in care. This framework may be replicable to ensure equity in other clinical areas.

Improving cardiovascular care through outpatient cardiac rehabilitation: an analysis of payment models that would improve quality and promote use.

Background:Much attention has been paid to improving the care of patients with cardiovascular disease by focusing attention on delivery system redesign and payment reforms that encompass the healthcare spectrum, from an acute episode to maintenance of care. However, 1 area of cardiovascular disease care that has received little attention in the advancement of quality is cardiac rehabilitation (CR), a comprehensive secondary prevention program that is significantly underused despite evidence-based guidelines that recommending its use. Purpose:The purpose of this article was to analyze the applicability of 2 payment and reimbursement models–pay-for-performance and bundled payments for episodes of care — that can promote the use of CR. Conclusions:We conclude that a payment model combining elements of both pay-for-performance and episodes of care would increase the use of CR, which would both improve quality and increase efficiency in cardiac care. Specific elements would need to be clearly defined, however, including: (a) how an episode is defined, (b) how to hold providers accountable for the care they provider, (c) how to encourage participation among CR providers, and (d) how to determine an equitable distribution of payment. Clinical Implications:Demonstrations testing new payment models must be implemented to generate empirical evidence that a melded pay-for-performance and episode-based care payment model will improve quality and efficiency.

Medical Respite and Linkages to Outpatient Health Care Providers among Individuals Experiencing Homelessness

ABSTRACT Medical respite programs provide nursing care and case management to individuals experiencing homelessness following hospitalization for an acute medical problem. One goal of these programs is to link clients to outpatient providers to decrease their reliance on hospital services. Through qualitative interviews with staff members (n = 8) and clients (n = 14) at a medical respite program, we explored processes of, and challenges associated with, linking clients to outpatient care. Six themes were identified, which offer insight about important considerations when linking clients to outpatient providers and highlight the value of medical respite programs for this population.

Provider Perspective on Integrative Medicine for Pediatric Sickle Cell Disease-related Pain:

Objective Integrative medicine (IM) approaches are sometimes used to manage sickle cell disease (SCD)— related pain. The purpose of this research is to (1) understand provider perspective towards the use of IM for pain in children with SCD at a large urban childrens hospital and (2) provide recommendations on how to better promote IM for children and adolescents with SCD. Methods After approval from the institutional review board, a qualitative case study approach was used with criterion-type purposeful sampling to select providers from the division of hematology to adequately inform the study. Semistructured interviews were completed using audiotape to facilitate transcription. NVivo 10 analytic software (QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to organize data into themes to answer the study questions. Results Ten provider interviews were completed. Attitudes were generally positive, and most providers felt that IM is generally helpful. All providers reported that they do not optimally use integrative therapies for children with SCD. The barriers uncovered focused on lack of process for integration of IM, specifically that IM resources seem transient and based on short-term funding. Provider attitude towards CAM is generally positive, but provider comfort level is highly variable. No providers are completely comfortable with their knowledge base about IM, and increased knowledge is desired. Conclusions Creation of protocols and processes to incorporate IM into management plans for patients with SCD could help to promote its use. Education of providers about utility and efficacy of IM for SCD-related pain and about existing resources would aid in promotion of IM for children with SCD.