Martha Quinn

Alliance System and Policy Change: Necessary Ingredients for Improvement in Diabetes Care and Reduction of Disparities

Reducing diabetes inequities requires system and policy changes based on real-life experiences of vulnerable individuals living with the condition. While introducing innovative interventions for African American, Native American, and Latino low-income people, the five community-based sites of the Alliance to Reduce Disparities in Diabetes recognized that policy changes were essential to sustain their efforts. Data regarding change efforts were collected from site leaders and examined against documents provided routinely to the National Program Office at the University of Michigan. A policy expert refined the original lists to include only confirmed policy changes, scope of change (organizational to national), and stage of accomplishment (1, beginning; 2, adoption; 3, implementation; and 4, full maintenance). Changes were again verified through site visits and telephone interviews. In 3 years, Alliance teams achieved 53 system and policy change accomplishments. Efforts were implemented at the organizational (33), citywide (13), state (5), and national (2) levels, and forces helping and hindering success were identified. Three types of changes were deemed especially significant for diabetes control: data sharing across care-providing organizations, embedding community health workers into the clinical care team, and linking clinic services with community assets and resources in support of self-management.

Food & Community: the cross-site evaluation of the W.K. Kellogg Food & Fitness community partnerships

This article describes the collaborative development of the cross-site evaluation of the Food & Fitness initiative. Evaluators and community partners together created a multi-site evaluation to document similarities and unique aspects across the work in the nine participating communities. The evaluation includes measures of partner engagement, resources, processes, and outcomes of achieving systems and policy change, and impact of the work in vulnerable communities. Inherent in and critical to the evaluation is a process for providing feedback to communities and stakeholders. Pioneering ways to assess the process of achieving systems and policy change and the impact of this work on children and families, the Food & Fitness cross-site evaluation is creating a picture of the collective accomplishments of these community partnerships, which are doing innovative work related to equity around food access and the built environment.

Coping with kidney disease - qualitative findings from the Empowering Patients on Choices for Renal Replacement Therapy (EPOCH-RRT) study

BackgroundThe highly burdensome effects of kidney failure and its management impose many life-altering changes on patients. Better understanding of successful coping strategies will inform patients and help health care providers support patients’ needs as they navigate these changes together.MethodsA qualitative, cross-sectional study involving semi-structured telephone interviews including open- and closed-ended questions, with 179 U.S. patients with advanced chronic kidney disease (CKD), either not yet on dialysis ([CKD-ND], n = 65), or on dialysis (hemodialysis [HD], n = 76; or peritoneal dialysis [PD], n = 38) recruited through social media and in-person contacts from June to December 2013. Themes identified through content analysis of interview transcripts were classified based on the Coping Strategies Index (CSI) and compared across groups by demographics, treatment modality, and health status.ResultsOverall, more engagement than disengagement strategies were observed. “Take care of myself and follow doctors’ orders,” “accept it,” and “rely on family and friends” were the common coping themes. Participants often used multiple coping strategies. Various factors such as treatment modality, time since diagnosis, presence of other chronic comorbidities, and self-perceived limitations contributed to types of coping strategies used by CKD patients.ConclusionsThe simultaneous use of coping strategies that span different categories within each of the CSI subscales by CKD patients reflects the complex and reactive response to the variable demands of the disease and its treatment options on their lives. Learning from the lived experience of others could empower patients to more frequently use positive coping strategies depending on their personal context as well as the stage of the disease and associated stressors. Moreover, this understanding can improve the support provided by health care systems and providers to patients to better deal with the many challenges they face in living with kidney disease.

Moving toward and beyond equity: the Food & Fitness approach to increasing opportunities for health in communities

Through creating avenues for authentic civic engagement of individuals living in vulnerable communities, the Food & Fitness community partnerships have actualized innovative ways to change the trajectory of health outcomes in neighborhoods across the United States. Working to increase the availability of healthy, locally grown food and opportunities for physical activity in communities that have suffered from years of disinvestment, the partnerships have moved toward and beyond merely bridging the equity gap.

Survey Instruments to Assess Patient Experiences With Access and Coordination Across Health Care Settings: Available and Needed Measures

Background: Improving access can increase the providers a patient sees, and cause coordination challenges. For initiatives that increase care across health care settings, measuring patient experiences with access and care coordination will be crucial. Objectives: Map existing survey measures of patient experiences with access and care coordination expected to be relevant to patients accessing care across settings. Preliminarily examine whether aspects of access and care coordination important to patients are represented by existing measures. Research Design: Structured literature review of domains and existing survey measures related to access and care coordination across settings. Survey measures, and preliminary themes from semistructured interviews of 10 patients offered VA-purchased Community Care, were mapped to identified domains. Results: We identified 31 existing survey instruments with 279 items representing 6 access and 5 care coordination domains relevant to cross-system care. Domains frequently assessed by existing measures included follow-up coordination, primary care access, cross-setting coordination, and continuity. Preliminary issues identified in interviews, but not commonly assessed by existing measures included: (1) acceptability of distance to care site given patient’s clinical situation; (2) burden on patients to access and coordinate care and billing; (3) provider familiarity with Veteran culture and VA processes. Conclusions: Existing survey instruments assess many aspects of patient experiences with access and care coordination in cross-system care. Systems assessing cross-system care should consider whether patient surveys accurately reflect the level of patients’ concerns with burden to access and coordinate care, and adequately reflect the impact of clinical severity and cultural familiarity on patient preferences.

Program Implementation Approaches to Build and Sustain Health Care Coordination for Type 2 Diabetes

Background: As more people enter the U.S. health care system under the Affordable Care Act (ACA), it is increasingly critical to deliver coordinated, high-quality health care. The ACA supports implementation and sustainability of efficient health care models, given expected limits in available resources. This article highlights implementation strategies to build and sustain care coordination, particularly ones consistent with and reinforced by the ACA. It focuses on disease self-management programs to improve the health of patients with type 2 diabetes, exemplified by grantees of the Alliance to Reduce Disparities in Diabetes. Method: We conducted interviews with grantee program representatives throughout their 5-year programs and conducted a qualitative framework analysis of data to identify key themes related to care coordination. Results: The most promising care coordination strategies that grantee programs described included establishing clinic–community collaborations, embedding community health workers within care management teams, and sharing electronic data. Establishing provider buy-in was crucial for these strategies to be effective. Discussion: This article adds new insights into strategies promoting effective care coordination. The strategies that grantees implemented throughout the program align with ACA requirements, underscoring their relevance to the changing U.S. health care environment and the likelihood of further support for program sustainability.

Focused Ethnography of Diagnosis in Academic Medical Centers

BACKGROUND Approaches of trainees to diagnosis in teaching hospitals are poorly understood. Identifying cognitive and system-based barriers and facilitators to diagnosis may improve diagnosis in these settings. METHODS We conducted a focused ethnography of trainees at 2 academic medical centers to understand the barriers and facilitators to diagnosis. Field notes regarding the diagnostic process (eg, information gathering, integration and interpretation, working diagnosis) and the work system (eg, team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand the viewpoints, problems, and solutions to improve diagnosis. RESULTS Between January 2016 and May 2016, four teaching teams (4 attendings, 4 senior residents, 9 interns, and 12 medical students) were observed for 168 hours. Observations of diagnosis during care led to identification of the following four key themes: (1) diagnosis is a social phenomenon, (2) data necessary to make diagnoses are fragmented, (3) distractions interfere with the diagnostic process, and (4) time pressures impede diagnostic decision-making. These themes suggest that specific interventions tailored to the academic setting such as team-based discussions of diagnostic workups, scheduling diagnostic time-outs during the day, and strategies to “protect” learners from interruptions might prove to be useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multimodal intervention) appear to be necessary. CONCLUSION Diagnosis in teaching hospitals is a unique process that requires improvement. Contextual insights gained from this ethnography may be used to inform future interventions.

The Food & Fitness Community Partnerships: Results From 9 Years of Local Systems and Policy Changes to Increase Equitable Opportunities for Health

The Food & Fitness (F&F) community partnerships, funded by the W.K. Kellogg Foundation from 2007 to 2016, were established to create community-determined change in the conditions that affect health and health equity in neighborhoods. The focus of the work has been to increase access to locally grown good food (food that is healthy, sustainable, fair, and affordable), and safe places for physical activity for children and families in communities with inequities across the United States through changes in policies, community infrastructure, and systems at the local level. This article describes the outcomes related to systems and policy change over 9 years of community change efforts in the F&F partnerships. Characteristics of the F&F communities where the work took place; the change model that emerged from the work; efforts and changes achieved related to community food, school food, and active living/built environment; overall factors in the community that helped or hindered the work of the partnerships; and a depiction of the community-determined process for change employed by the partnerships are described. Local systems and policy change is a long-term process. Community-determined efforts that build capacity for systems change, commitment to long-term funding, and provision of technical assistance tailored to community needs were elements that contributed to success in the F&F work. Achieving intermediate outcomes on the road to policy and systems change created a way to monitor success and make midcourse corrections when needed.

Defining and Measuring Sustainability in the Food & Fitness Initiative

Several frameworks for defining and measuring sustainability in public health have been documented in the literature. For the Food & Fitness Initiative, sustainability was a central aim at the outset and was defined broadly throughout the project. Sustainability included not only funding and resources necessary to support organizational structures but was a core function of how these partnerships were able to focus their work, build capacity, forge lasting relationships, execute the work, and produce systems and policy changes that would endure over time. In this article, we present findings from an online survey assessing partners’ views on 10 distinct dimensions of sustainability and several key themes from a set of key informant interviews with partnership leaders. Of the 10 dimensions, participants reported having the most success in creating (1) community ownership, where initiatives are led by and reflect the needs of community residents; (2) a vision that is shared across partners and developed collaboratively; and (3) leadership that includes a diverse team of skilled, credible people. A key learning in this project was that sustainability needs to be intentional and clearly defined and that evaluations should include multiple and ongoing methods to capture several dimensions of sustainability.

Summarizing 9 Years of the Food & Fitness Initiative

Place matters for health. Health inequities in the United States span from the cradle to the grave, in the form of higher rates of infant mortality, chronic and infectious diseases, disability, and premature mortality among many neighborhoods of color relative to national averages (Kramer & Hogue, 2009; LaVeist, Gaskin, & Trujillo, 2011). We have known for some time that the uneven pattern of opportunities for health across racial/ ethnic groups is not fully explained by differences in family income (Acevedo-Garcia, McArdle, Osypuk, Lefkowitz, & Krimgold, 2007; Pattillo, 2005; Schulz et al., 2012). The physical infrastructure, services, and opportunities available in neighborhoods can either enhance or constrain an individual’s choices benefiting health and well-being. Transforming communities into places of opportunity for everyone’s health requires changing the policies and practices that affect how programs and plans are implemented related to food access and safe places for activity. Changes to systems and structures are needed, and these changes need to be made at the local level and linked with regional, state, and national efforts. Community–driven approaches to health focus on civic engagement and leadership from residents in the many settings that influence how people think about and act with regard to health, including homes, schools, workplaces, places of worship, and other neighborhood settings (Clark et al., 2010; National Research Council, 2003a, 2003b). This work takes time and needs considerable effort and support to create and maintain a vision, prioritize goals, develop capacity, and create changes that will be sustainable. In September 2006, the W.K. Kellogg Foundation (WKKF) began a major, long-term, cultural and social change effort. The Food & Fitness (F&F) community partnerships were established to increase equitable access to locally grown food and safe places for physical activity for children and families across the United States through a focus on creating and changing local