Manasi A. Tirodkar

Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change

PURPOSE We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Support and Strategies for Change Among Small Patient-Centered Medical Home Practices

PURPOSE We aimed to determine the motivations and barriers facing small practices that seek to adopt the patient-centered medical home (PCMH) model, as well as the type of help and strategies they use. METHODS We surveyed lead physicians at practices with fewer than 5 physicians, stratified by state and level of National Committee for Quality Assurance PCMH recognition, using a Web-based survey with telephone, fax, and mail follow-up. The response rate was 59%, yielding a total sample of 249 practices from 23 states. RESULTS Improving quality and patient experience were the strongest motivations for PCMH implementation; time and resources were the biggest barriers. Most practices participated in demonstration projects or received financial rewards for PCMH, and most received training or other kinds of help. Practices found training and help related to completing the PCMH application to be the most useful. Training for patients was both less common and less valued. The most commonly used strategies for practice transformation were staff training, systematizing processes of care, and quality measurement/goal setting. The least commonly endorsed strategy was involving patients in quality improvement. Practices with a higher level of PCMH recognition were more likely to have electronic health records, to report barriers, and to use measurement-based quality improvement strategies. CONCLUSIONS To spread the adoption of the PCMH model among small practices, financial support, practical training, and other help are likely to continue to be important. Few practices involved patients in their implementation, so it would be helpful to test the impact of greater patient involvement in the PCMH.

Patient-centered medical homes in the United States.

The concept of a medical home is receiving increased attention as a potential means to improve care and reduce costs. This study describes the characteristics and capabilities of practices that have achieved recognition of National Committee for Quality Assurance as a “patient-centered medical home” (PCMH). Both small and large practices demonstrate capabilities related to the goals of PCMH of accessible, coordinated, and patient-centered care; however, practices affiliated with larger organizations achieve higher levels of PCMH recognition compared with unaffiliated small practices. Efforts to support practices to implement medical home capabilities are needed, particularly in the use of data for population management and patient self-management.

South Asian American Perspectives on Overweight, Obesity, and the Relationship Between Weight and Health

Introduction Compared with other racial groups, South Asian adults develop type 2 diabetes and cardiovascular disease at a lower body mass index (BMI). Perceptions of weight and the effect of weight on health can influence weight-loss attempts but are not well described in this population. The objective of this study was to examine perceptions of weight appropriateness and the effect of weight on health among South Asian Americans. Methods We recruited 75 South Asian American adults from a single metropolitan area in the Midwestern United States. During individual, face-to-face interviews, we asked participants what they think about their weight and how weight affects their health. We measured their weight and height and calculated BMI. Each interview was audiotaped, transcribed verbatim, and translated into English. We conducted analyses using NVivo software. A second investigator coded 20% of interviews to verify coding consensus. Results Sixty-seven percent of participants were overweight or obese; 40% of overweight participants and 12% of obese participants perceived themselves to be normal weight or underweight. Forty-eight percent of overweight and 82% of obese participants believed their weight affected their health. Participants commonly cited physical problems as being associated with their weight, but few connected their weight with risk for chronic diseases. Conclusion South Asian Americans may underestimate their weight status and the effect of their weight on their risk for chronic diseases. Interventions to promote weight loss among South Asian Americans should focus on modifying perceptions of normal weight and personalizing the relationship between overweight and chronic diseases.

Lessons From Early Implementation of a Patient-Centered Care Model in Oncology

PURPOSE Oncology practices may serve as the primary health provider for patients with cancer and the so-called neighbor during periods of transition and survivorship. New standards for patient-centered oncology practice articulate expectations for the primary health provider and neighbor roles. We report the implementation experiences of five oncology practices participating in a pilot of these standards. METHODS For each practice, auditors reviewed workflows and documentation supporting the progress of the practice in meeting the oncology medical home standards. We also observed clinical encounters and practice workflow and interviewed clinicians, staff, and patients. RESULTS Referral coordination and care management were the most demonstrated functions. The least commonly demonstrated functions related to tracking and coordination of tests and medications, as well as quality measurement and improvement. Some opportunities for structural and process improvement included improving the use of health information technology, care coordination, quality improvement, telephone triage, symptom management, patient education, financial counseling, and care team communication. Making patient-centered care a priority and motivation to change were cited as facilitators for transformation. CONCLUSION The pilot oncology practices had many structures and processes in common, many of which were established during the early intervention period of this pilot. However, there was little standardization within and across practices in the way these processes were established and documented. Establishing structures for care coordination, quality improvement, and quality measurement should be priorities for practices considering transformation to a patient-centered model of care.

Biological Models of Health

The objective of this chapter is to review indigenous medicine systems of South Asia and their influence on the health of immigrant South Asians. First, there is a brief review of the medical history of South Asia and an in-depth description of Ayurveda, Siddha, and Unani. Second, we consider how these systems influence explanatory models of health and behavior in South Asian migrant populations, in operation with Western biomedical approaches. We end with a discussion of how these different medicine systems and their interoperability may be relevant when treating South Asian patients.

Health Quality Measures Addressing Disparities in Culturally and Linguistically Appropriate Services: What are Current Gaps?

Abstract:Purpose. Disparities in health care persist among many at-risk groups. This study examines the current state of health quality measures addressing disparities and culturally and linguistically appropriate services (CLAS), and identifies important gaps in existing measures and their implementation. Methods. We searched key quality reporting databases and websites to identify measures and structural program requirements addressing disparities or CLAS. We also conducted a dozen semi-structured interviews to obtain expert perspectives. Results. Twenty-four measures and eight private or public-sector programs with relevant structural requirements were identified. Half the measures focused on language needs. Few measures were used in national reporting programs and adoption of requirements has been limited. Barriers to implementation included lack of data among health plans, lack of health workforce training, and challenges in defining cultural competence. Conclusions. Future efforts should seek to enhance implementation of existing quality measures addressing disparities and CLAS, and address barriers to their adoption.

Connecting specialty practices with primary care.

47 Background: Public and private payers are beginning to adopt alternative payment structures that call for greater attention to patient-centered care and quality improvement activities (CMMI 2015; MACRA 2015). The National Committee for Quality Assurance (NCQA) developed standards for Patient-Centered Specialty Practice based on American College of Physicians principles. The report describes achievement on the standards among an initial cohort of recognized physicians. METHODS We analyzed practice characteristics and determined how practices performed on each of the 21 elements in the PCSP program by showing the percent of practices scoring less than 50% of points, or 100% of points (i.e. full credit) for each element. RESULTS One third of the 91 practices recognized in the first year of the program are Oncology/Hematology. Overall, about half of recognized practices have more than 5 clinicians and half are physician-owned (52%). Most specialty practices achieved full credit on having key clinical data in structured fields and using electronic prescribing. More than 75% of practices also achieved full credit for providing culturally and linguistically appropriate services, providing information about specialist visits back to primary care and providing patients/families information about the role of the specialist and coordination of care. Tracking of referrals to secondary specialists was most challenging, with only 6% of practices earning full credit. Only 34% of practices received full credit for coordinating care transitions from hospitals and other facilities; most practices did not even receive half credit. Measuring and improving performance was also challenging for all practices. Compared to other specialties, oncology/hematology practices were less likely to achieve full credit on the following elements: electronic access, measure patient/family experience, patient information, and care planning and support self-care. However, they performed better on documenting clinical data than other specialty practices. CONCLUSIONS Specialty care practices have started to implement the patient-centered care model. Research to identify which components of the model have the greatest impact on outcomes is needed.

Patient surveys for cancer populations: Initial experiences with Cancer CAHPS.

281 Background: Patient experiences are an important component of quality, but information on how well oncology providers meet the specific needs of patients with cancer is limited. This study reports on the patient experiences among patients undergoing drug therapy treatment for cancer in diverse outpatient settings. METHODS We assessed patient experiences using a modified version of the CAHPS Survey for Cancer Caredeveloped by the American Institutes for Research.The survey has five composites and an overall rating of providers. We used claims data from an insurance plan in Southeastern Pennsylvania to identify all patients who had a paid claim for drug therapy treatment at 26 practices from January 1 through July 31, 2014. The survey was sent to 2,302 patients who met this criteria and 701 patients returned a completed survey for a response rate of 31%. We calculated scores of 0-100 on the composites after adjusting for age, education, self-rating of mental health and response tendency (a measure of level of optimism/pessimism). RESULTS In general, cancer patients rated their providers highly on patient experience, particularly on access and communication. However, cancer patients rated their providers lower on shared decision-making and helping patients manage their symptoms and care at home. The scaled, adjusted scores on the five composites were: Access (score=91; 95% CI=90-92); Affective communication (score=90; 95% CI=88-91); Exchanging information/keeping patients up to date (score=89; 95% CI=88-90); Shared decision-making (score=78; 95% CI=76-80); Enabling patient self-management (score=69; 95% CI=67-71). We encountered several challenges in fielding the survey related to attributing patients to specific practice sites, identifying patients who had died, and concerns raised by patients/family respondents about the length or content of the survey. CONCLUSIONS Our findings suggest the need for strong efforts to engage cancer patients in decision-making and provide supportive care. Methodology for sampling patients using claims data needs to be more accurate and the survey could be edited for length and comprehension.