Jane N. Bolin

Medical homes: "where you stand on definitions depends on where you sit".

The medical home is a potentially transformative strategy to address issues of access, quality, and efficiency in the delivery of health care in the United States. While numerous organizations support a physician-driven definition, it is by no means the universally accepted definition. Several professional groups, payers, and researchers have offered differing, or nuanced, definitions of medical homes. This lack of consensus has contributed to uncertainty among providers about the medical home. We conducted a systematic review of the literature on the medical home and identified 29 professional, government, and academic sources offering definitions. While consensus appears to exist around a core of selected features, the medical home means different things to different people. The variation in definitions can be partly explained by the obligation of organizations to their members and whether the focus is on the patient or provider. Differences in definitions have implications at both the policy and practice levels.

Rural Healthy People 2010, 2020, and beyond: the need goes on.

Rural Healthy People 2010 represented the first effort to specifically include small and rural communities in the Healthy People movement to improve the health of Americans. Rural Healthy People 2010 set rural-specific health priority areas, documented what is known about health in rural areas, identified rural best practice programs/interventions, and promoted rural health services research and researchers. Over the last decade Rural Healthy People 2010 has provided policy makers, rural providers, and rural communities with a valuable resource for planning and policy making. Sustaining the Rural Healthy People project in collaboration with the broader Healthy People 2020 effort will provide an important infrastructure for improving rural health.

Organizational technologies for transforming care: measures and strategies for pursuit of IOM quality aims.

Progress on the Institute of Medicines (IOMs) 6 aims to bridge the “quality chasm” requires both measurement and the concerting of multiple organizational technologies. The basic thesis of this article is that rapid progress on the IOMs multiple aims calls for transformative change within and among healthcare organizations. The promise of a number of types of transformative approaches is closely linked to their ability to simultaneously build upon several organizational technologies: clinical, social, information, and administrative technologies. To encourage and advance such efforts, this article identifies illustrative measures of attainment of the IOMs 6 aims or targeted areas for improvement that reflect the contributions of the 4 organizational technologies. It discusses examples of relationships between the IOM aims and the organizational technologies considered. Finally, the article offers illustrations of the interplay of these organizational technologies and IOM aims—across an array of organizational innovations with transformative potential. Included among such innovations are information technology in the form of electronic medical records, computer-based physician order entry, and patient health records; organization-wide patient-centered cultural change such as Studers Hardwiring Excellence; Six Sigma and Toyota Production Management/LEAN; major clinical technology change, for example, minimally invasive cardiac surgery and broader treatment innovations such as disease management.

Management of chronic pain among older patients: Inside primary care in the US

Under‐treatment of pain is a worldwide problem. We examine how often pain was addressed and the factors that influence how much time was spent on treating pain.

Factors Associated With Successful Completion of the Chronic Disease Self-Management Program by Adults With Type 2 Diabetes

This study examines factors associated with completion (attendance ≥4 of 6 sessions) of the Chronic Disease Self-Management Program (CDSMP) by adults with type 2 diabetes. Patients with glycated hemoglobin ≥ 7.5 within 6 months were enrolled and completed self-report measures on demographics, health status, and self-care (n = 146). Significant differences in completion status were found for several self-care factors including healthful eating plan, spacing carbohydrates, frequent exercise, and general health. Completion was not influenced by race/ethnicity or socioeconomics. Results suggest better attention to exercise and nutrition at the start of CDSMP may be associated with completion, regardless of demographic subgroup.

Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: A survival analysis model

OBJECTIVE This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization. METHODS Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization. RESULTS Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm. CONCLUSION CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM. PRACTICE IMPLICATIONS Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.

Urban and rural differences in end-of-life pain and treatment status on admission to a nursing facility

Individuals receiving end-of-life (EOL) care may have needs that are unrecognized or treated inappropriately. Yet, very little is known about differences in pain and special-care needs of EOL patients admitted to rural nursing facilities compared with urban nursing facilities, and whether the differing payer mix in urban and rural facilities affects the treatment ordered on admission. We examine a nationally representative sample of 6,084 EOL patients upon admission to nursing homes to examine differences in diseases, pain assessments, and treatment orders. We found that rural EOL residents have higher rates of congestive heart failure, cancer, renal failure, and emphysema than urban EOL residents and are significantly more likely to report frequent pain, however, they are less likely to receive treatments such as IV medications, dialysis, and wound care.

Patient-centered medical homes: will health care reform provide new options for rural communities and providers?

Many are calling for the expansion of the patient-centered medical home model into rural and underserved populations as a transformative strategy to address issues of access, efficiency, quality, and sustainability in the delivery of health care. Patient-centered medical homes have been touted as a promising cost-saving model for comprehensive management of persons with chronic diseases and disabilities, but it is unclear how rural practitioners in medically underserved areas will implement the patient-centered medical home. This article examines how the Patient Protection & Affordable Care Act of 2010 will enhance rural providers’ ability to provide patient-centered care and services contemplated under the Act in a comprehensive, coordinated, cost-effective way despite leaner budgets and health workforce shortages.

Predictors of Colorectal Cancer Screening: Does Rurality Play a Role?

PURPOSE The purpose of this study was to explore the associations between sociodemographic factors such as residence, health care access, and colorectal cancer (CRC) screening among residents of Texas. METHODS Using the 2012 Behavioral Risk Factor Surveillance Survey, we performed logistic regression analyses to determine predictors of CRC screening among Texas residents, including rural versus urban differences. Our outcomes of interest were previous (1) CRC screening using any CRC test, (2) fecal occult blood test (FOBT), or (3) endoscopy, as well as up-to-date screening using (4) any CRC test, (5) FOBT, or (6) endoscopy. The independent variable of interest was rural versus urban residence; we controlled for other sociodemographic and health care access variables such as lack of health insurance. RESULTS Multivariate analysis showed that individuals who were residents of a rural/non-Metropolitan Statistical Area (MSA) location (OR = 0.70, 95% CI = 0.51-0.97) or a suburban county (OR = 0.61, 95% CI = 0.39-0.95) were less likely to report ever having any CRC screening compared to residents of a center city of an MSA. Residents of a rural/non-MSA location were less likely (OR = 0.49, 95% CI = 0.28-0.87) than residents of a center city of an MSA to be up-to-date using FOBT. There was decreased likelihood of ever being screened for CRC among the uninsured (OR = 0.43, 95% CI = 0.31-0.59). CONCLUSIONS Effective development and implementation of strategies to improve screening rates should aim at improving access to health care, taking into account demographic characteristics such as rural versus urban residence.

Strategies for Incorporating Professional Ethics Education in Graduate Medical Programs

Medicine and ethics have an historic and rich relationship dating back to the fourth century and the work of Greek physician Hippocrates, and later the work of Galen, who cautioned and instructed young physicians to be concerned and conscientious (Osler 1913). The classic admonishment popularly attributed to Galen “primum non nocere,” or “First, do no harm,” is still timely. The separate treatises on medicine and ethics, set down by these two scholars more than 2,000 years ago, are as relevant in today’s complex world of medicine, with its myriad laws, regulations, and “best practices,” as they were in ancient Greece. Goold and Stern (2006) are correct in making a strong scientific case for uniform medical ethics classroom instruction within medical residency programs. I would, however, take their proposals further and advocate that medical ethics training be included throughout all formal medical school training, and incorporate this feature of professional medical accountability into lifelong ethics continuing medical education requirements. Although professional ethics instruction cannot “make” someone ethical, what ethics training can do is to provide a foundation for principled, legal behavior characterized by sensitivity to unfolding ethical and moral dilemmas within the medical profession. It seems axiomatic that if medical students and residents are not instructed in medical ethics and health laws, they will be unlikely to learn their duties and obligations to the patient and to their profession. In my current professional life I teach Health Law and Ethics in a school of public health: the Texas A&M Health Sciences Center School of Rural Public Health. Often enrolled in my courses are medical students and residents who express surprise at the kinds of unethical conduct and legal problems that trap and entangle physicians. To get an idea of the magnitude of illegal and fraudulent (unethical) conduct occurring in healthcare, one need only to look at the Office of the Inspector General list of excluded and sanctioned providers. As of February 2006, more than 36,000 health providers have been excluded from participating in Medicare or Medicaid for fraudulent or other illegal conduct involving healthcare. Of these, 4,898 (7%) were physicians (MDs or DOs) who had engaged in behavior considered fraudulent or abusive.1 Considering that ethical and legal problems often result in suspension or loss of medical li-