Judith Schaefer

Development and validation of the patient assessment of chronic illness care (PACIC)

Rationale:There is a need for a brief, validated patient self-report instrument to assess the extent to which patients with chronic illness receive care that aligns with the Chronic Care Model—measuring care that is patient-centered, proactive, planned and includes collaborative goal setting; problem-solving and follow-up support. Sample:A total of 283 adults reporting one or more chronic illness from a large integrated health care delivery system were studied. Methods:Participants completed the 20-item Patient Assessment of Chronic Illness Care (PACIC) as well as measures of demographic factors, a patient activation scale, and subscales from a primary care assessment instrument so that we could evaluate measurement performance, construct, and concurrent validity of the PACIC. Results:The PACIC consists of 5 scales and an overall summary score, each having good internal consistency for brief scales. As predicted, the PACIC was only slightly correlated with age and gender, and unrelated to education. Contrary to prediction, it was only slightly correlated (r = 0.13) with number of chronic conditions. The PACIC demonstrated moderate test-retest reliability (r = 0.58 during the course of 3 months) and was correlated moderately, as predicted (r = 0.32–0.60, median = 0.50, P < 0.001) to measures of primary care and patient activation. Discussion:The PACIC appears to be a practical instrument that is reliable and has face, construct, and concurrent validity. The resulting questionnaire is in the public domain, and recommendations for its use in research and quality improvement are outlined.

Twelve evidence-based principles for implementing self-management support in primary care.

BACKGROUND Recommendations to improve self-management support and health outcomes for people with chronic conditions in primary care settings are provided on the basis of expert opinion supported by evidence for practices and processes. Practices and processes that could improve self-management support in primary care were identified through a nominal group process. In a targeted search strategy, reviews and meta-analyses were then identifed using terms from a wide range of chronic conditions and behavioral risk factors in combination with Self-Care, Self-Management, and Primary Care. On the basis of these reviews, evidence-based principles for self-management support were developed. FINDINGS The evidence is organized within the framework of the Chronic Care Model. Evidence-based principles in 12 areas were associated with improved patient self-management and/or health outcomes: (1) brief targeted assessment, (2) evidence-based information to guide shared decision-making, (3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, (5) collaborative problem solving, (6) self-management support by diverse providers, (7) self-management interventions delivered by diverse formats, (8) patient self-efficacy, (9) active followup, (10) guideline-based case management for selected patients, (11) linkages to evidence-based community programs, and (12) multifaceted interventions. A framework is provided for implementing these principles in three phases of the primary care visit: enhanced previsit assessment, a focused clinical encounter, and expanded postvisit options. CONCLUSIONS There is a growing evidence base for how self-management support for chronic conditions can be integrated into routine health care.

A conceptual model of the role of complexity in the care of patients with multiple chronic conditions.

Background:Effective healthcare for people with multiple chronic conditions (MCC) is a US priority, but the inherent complexity makes both research and delivery of care particularly challenging. As part of AHRQ Multiple Chronic Conditions Research Network (MCCRN) efforts, the Network developed a conceptual model to guide research in this area. Objective:To synthesize methodological and topical issues relevant to MCC patient care into a framework that can improve the delivery of care and advance future research about caring for patients with MCC. Methods:The Network synthesized essential constructs for MCC research identified from roundtable discussion, input from expert advisors, and previously published models. Results:The AHRQ MCCRN conceptual model defines complexity as the gap between patient needs and healthcare services, taking into account both the multiple considerations that affect the needs of MCC patients, as well as the contextual factors that influence service delivery. The model reframes processes and outcomes to include not only clinical care quality and experience, but also patient health, well being, and quality of life. The single-condition paradigm for treating needs one-by-one falls apart and highlights the need for care systems to address dynamic patient needs. Conclusions:Defining complexity in terms of the misalignment between patient needs and services offers new insights in how to research and develop solutions to patient care needs.

Case management and the chronic care model: a multidisciplinary role.

The core functions of case management, assessment, planning, linking, monitoring, advocacy, and outreach assume a new perspective in the context of systems that have adopted the Chronic Care Model. This article considers case management through the experience of three systems that have implemented the Chronic Care Model. A movement toward condition neutral case management, focused on care that is more wholly patient centric, is also examined.

Qualitative study of an intervention for depression among patients with diabetes: how can we optimize patient-professional interaction?

OBJECTIVES To describe the communication between the depression care specialist (DCS) nurses and patients with both depression and diabetes in an intervention study. Our aims were to inform both the quantitative findings of the present trial and the design of future primary care intervention studies. METHODS Qualitative content analysis of consultations between DCS nurses and patients in nine primary care clinics. RESULTS Patients experienced a wide range of physical, social and psychological problems. The DCS nurses employed a range of interventions in addition to the problem-solving and case-management skills that formed the basis of this intervention. CONCLUSIONS Patients sometimes posed difficulties in being unable to understand the treatment, unprepared to engage with a new treatment and unready (or even unable) to acquire new skills. To optimize the interaction between patient and professional in the case management of depression and diabetes, training should provide guidance in the use of different models of care (medical and psychological), help case managers to identify and negotiate problem scenarios and combine an active model of therapy such as problem-solving treatment for primary care (PST-PC) with elements from motivational interviewing, ensure effective engagement in treatment, and specifically explore how interaction between depression and diabetes might result in adverse outcomes.

Assessing Progress toward Becoming a Patient-Centered Medical Home: An Assessment Tool for Practice Transformation

Objective. To describe the properties of the Patient-Centered Medical Home Assessment (PCMH-A) as a tool to stimulate and monitor progress among primary care practices interested in transforming to patient-centered medical homes (PCMHs). Study Setting. Sixty-five safety net practices from five states participating in a national demonstration program for PCMH transformation. Study Design. Longitudinal analyses of PCMH-A scores were performed. Scores were reviewed for agreement and sites were categorized over time into one of five categories by external facilitators. Comparisons to key activity completion rates and NCQA PCMH recognition status were completed. Data Collection/Extraction Methods. Multidisciplinary teams at each practice completed the 33-item self-assessment tool every 6 months between March 2010 and September 2012. Principal Findings. Mean overall PCMH-A scores increased (7.2, March 2010, to 9.1, September 2012; [p < .01]). Increases were statistically significant for each of the change concepts (p < .05). Facilitators agreed with scores 82% of the time. NCQA-recognized sites had higher PCMH-A scores than sites that were not yet recognized. Sites that completed more transformation activities and progressed over defined tiers reported higher PCMH-A scores. Scores improved most in areas where technical assistance was provided. Conclusions. The PCMH-A was sensitive to change over time and provided an accurate reflection of practice transformation.

A review of instruments to measure interprofessional team-based primary care

ABSTRACT Interprofessional team-based care is increasingly regarded as an important feature of delivery systems redesigned to provide more efficient and higher quality care, including primary care. Measurement of the functioning of such teams might enable improvement of team effectiveness and could facilitate research on team-based primary care. Our aims were to develop a conceptual framework of high-functioning primary care teams to identify and review instruments that measure the constructs identified in the framework, and to create a searchable, web-based atlas of such instruments (available at: http://primarycaremeasures.ahrq.gov/team-based-care/). Our conceptual framework was developed from existing frameworks, the teamwork literature, and expert input. The framework is based on an Input-Mediator-Output model and includes 12 constructs to which we mapped both instruments as a whole, and individual instrument items. Instruments were also reviewed for relevance to measuring team-based care, and characterized. Instruments were identified from peer-reviewed and grey literature, measure databases, and expert input. From nearly 200 instruments initially identified, we found 48 to be relevant to measuring team-based primary care. The majority of instruments were surveys (n = 44), and the remainder (n = 4) were observational checklists. Most instruments had been developed/tested in healthcare settings (n = 30) and addressed multiple constructs, most commonly communication (n = 42), heedful interrelating (n = 42), respectful interactions (n = 40), and shared explicit goals (n = 37). The majority of instruments had some reliability testing (n = 39) and over half included validity testing (n = 29). Currently available instruments offer promise to researchers and practitioners to assess teams’ performance, but additional work is needed to adapt these instruments for primary care settings.

Development of a facilitation curriculum to support primary care transformation: the "coach medical home" curriculum.

Background:In an effort to improve patient care, retain high-quality primary care providers, and control costs, primary care practices across the United States are transforming to patient-centered medical homes. This is no small task. Practice facilitation, also called “coaching,” is increasingly being used to support system change; however, there is limited guidance for these programs. Objective:To develop an evidence-based curriculum to help practice coaches guide broad-scale transformation efforts in primary care. Methods:We gathered evidence about effective practice transformation coaching from 25 published programs and 8 expert interviews. Given limited published information, we drew extensively on our experience as leaders and coaches in the Safety Net Medical Home Initiative. Using these data, and with input from a User Group, we identified 6 curricular topics and created learning objectives and curricular content related to these topics. Results:The Coach Medical Home curriculum guides coaches in the following areas: getting started with a practice; recognition and payment; sequencing changes; measurement; learning communities; and sustainability and spread. Conclusions:Coach Medical Home is a publically available web-based curriculum that provides tools, resources, and guidance for practice transformation support programs, including practice facilitators and learning community organizers.

Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices

BackgroundBroad consensus exists about the value and principles of primary care; however, little is known about the workforce configurations required to deliver it.ObjectiveThe aim of this study was to explore the team configurations and associated costs required to deliver high-quality, comprehensive primary care.MethodsWe used a mixed-method and consensus-building process to develop staffing models based on data from 73 exemplary practices, findings from 8 site visits, and input from an expert panel. We first defined high-quality, comprehensive primary care and explicated the specific functions needed to deliver it. We translated the functions into full-time-equivalent staffing requirements for a practice serving a panel of 10,000 adults and then revised the models to reflect the divergent needs of practices serving older adults, patients with higher social needs, and a rural community. Finally, we estimated the labor and overhead costs associated with each model.ResultsA primary care practice needs a mix of 37 team members, including 8 primary care providers (PCPs), at a cost of

PS1-38: Catalyzing Innovation at the Front Lines of Health Care

45 per patient per month (PPPM), to provide comprehensive primary care to a panel of 10,000 actively managed adults. A practice requires a team of 52 staff (including 12 PCPs) at