Melinda M. Davis

Understanding the context of health for persons with multiple chronic conditions: moving from what is the matter to what matters.

PURPOSE An isolated focus on 1 disease at a time is insufficient to generate the scientific evidence needed to improve the health of persons living with more than 1 chronic condition. This article explores how to bring context into research efforts to improve the health of persons living with multiple chronic conditions (MCC). METHODS Forty-five experts, including persons with MCC, family and friend caregivers, researchers, policy makers, funders, and clinicians met to critically consider 4 aspects of incorporating context into research on MCC: key contextual factors, needed research, essential research methods for understanding important contextual factors, and necessary partnerships for catalyzing collaborative action in conducting and applying research. RESULTS Key contextual factors involve complementary perspectives across multiple levels: public policy, community, health care systems, family, and person, as well as the cellular and molecular levels where most research currently is focused. Needed research involves moving from a disease focus toward a person-driven, goal-directed research agenda. Relevant research methods are participatory, flexible, multilevel, quantitative and qualitative, conducive to longitudinal dynamic measurement from diverse data sources, sufficiently detailed to consider what works for whom in which situation, and generative of ongoing communities of learning, living and practice. Important partnerships for collaborative action include cooperation among members of the research enterprise, health care providers, community-based support, persons with MCC and their family and friend caregivers, policy makers, and payers, including government, public health, philanthropic organizations, and the business community. CONCLUSION Consistent attention to contextual factors is needed to enhance health research for persons with MCC. Rigorous, integrated, participatory, multimethod approaches to generate new knowledge and diverse partnerships can be used to increase the relevance of research to make health care more sustainable, safe, equitable and effective, to reduce suffering, and to improve quality of life.

Photovoice Engages Rural Youth in Childhood Obesity Prevention

Photovoice is a participatory action research methodology that involves the use of photography and enables people to document, reflect upon, and communicate community needs to policymakers for the purpose of promoting social change. We describe how Photovoice was used to engage rural youth in childhood obesity prevention research and obtain their perspectives of community assets and barriers that influenced childrens physical activity and diets in their county. The photographs and stories produced by the youth garnered public interest and were beneficial in raising community awareness of community conditions that may contribute to childhood obesity and the need for environmental change. Utilization of the method also provided a beneficial leadership experience for the youth participants.

“Did I Do as Best as the System Would Let Me?” Healthcare Professional Views on Hospital to Home Care Transitions

ABSTRACTBACKGROUNDPatients are vulnerable to poor quality, fragmented care as they transition from hospital to home. Few studies examine the discharge process from the perspectives of multiple healthcare professionals.OBJECTIVETo understand care transitions from the perspective of diverse healthcare professionals, and identify recommendations for process improvement.DESIGNCross sectional qualitative study.PARTICIPANTS AND SETTINGClinicians, care teams, and administrators from the inpatient general medicine services at one urban, academic hospital; two outpatient primary care clinics; and one Medicaid managed care plan.APPROACHWe conducted 13 focus groups and two in-depth interviews with participants prior to initiating a hospital-funded, multi-component transitional care intervention for uninsured and low-income publicly insured patients, the Care Transitions Innovation (C-TraIn). We used thematic analysis to identify emergent themes and a cross-case comparative analysis to describe variation by participant role and setting.KEY RESULTSPoor transitional care reflected healthcare system fragmentation, limiting the ability of healthcare professionals to provide optimal patient care. Lack of standardized processes, poor multidisciplinary communication within the hospital, and fragmented communication across settings led to chaotic, unsystematic transitions, poor patient outcomes, and feelings of futility and dissatisfaction among providers. Patients with complex psychosocial needs were especially vulnerable during care transitions. Recommended changes to improve transitional care included improving hospital multidisciplinary hospital rounds, clarifying accountability as patients move across settings, standardizing discharge processes, and providing additional medical staff training.CONCLUSIONSHospital to home care transitions are critical junctures that can impact health outcomes, experience of care, and costs. Transitional care quality improvement initiatives must address system fragmentation, reduce communication barriers within and between settings, and ensure adequate professional training.

Integrating Behavioral and Physical Health Care in the Real World: Early Lessons from Advancing Care Together

Background: More than 20 years ago the Institute of Medicine advocated for integration of physical and behavioral health care. Today, practices are integrating care in response to recent policy initiatives. However, few studies describe how integration is accomplished in real-world practices without the financial or research support available for most randomized controlled trials. Methods: To study how practices integrate care, we are conducting a cross-case comparative, mixed-methods study of 11 practices participating in Advancing Care Together (ACT). Using a grounded theory approach, we analyzed multiple sources of data (eg, documents, practice surveys, field notes from observation visits, semistructured interviews, online diaries) collected from each ACT innovator. Results: Integration requires making changes in organization and interpersonal relationships. During early integration efforts, challenges related to workflow and access, leadership and culture change, and tracking and using data to evaluate patient- and practice-level improvement emerged for ACT innovators. We describe the strategies innovators are developing to address these challenges. Conclusion: Integrating care is a fundamental and difficult change for practices and health care professionals. Research identifying common challenges that manifest in early efforts can help others attempting integration and inform state, local, and federal policies aimed at achieving wide-spread implementation.

Linking practice-based research networks and Clinical and Translational Science Awards: new opportunities for community engagement by academic health centers.

Purpose Practice-based research networks (PBRNs) are a part of many National Institutes of Health (NIH)-funded Clinical and Translational Science Award (CTSA) sites. PBRNs, groups of primary care practices committed to collaborating on practice-relevant research, are unfamiliar to many CTSA leaders. Conversely, the CTSAs, as new research structures designed to transform clinical research, are unfamiliar to many PBRN directors. This study examined the extent to which these programs have congruent goals and expectations, and whether their engagement is likely to be mutually beneficial. Method The authors sent a Web-based survey to 38 CTSA community engagement directors and a similar survey to 114 PBRN directors during the fall of 2008. Results A total of 66% (25/38) CTSA community engagement directors and 61% (69/114) PBRN directors responded. Two thirds of responding CTSAs reported working with PBRNs, and over half of responding PBRNs reported a CTSA affiliation. Both groups indicated this relationship was important. CTSAs looked to PBRNs for access to patients and expertise in engaging communities and clinical practices. PBRNs reported seeking stable infrastructure support and greater collaboration and visibility in the academic research community. PBRN infrastructure support from CTSAs was highly variable. Both groups perceived considerable promise for building sustainable relationships and a bidirectional flow of information and research opportunities. Conclusions With fewer than three years of experience, the PBRN/CTSA relationship remains in the discovery phase; the participants are still negotiating expectations. If these collaborations prove mutually beneficial, they may advance the community engagement goals of many academic health centers.

Perceived Barriers, Resources, and Training Needs of Rural Primary Care Providers Relevant to the Management of Childhood Obesity

PURPOSE To explore the perceived barriers, resources, and training needs of rural primary care providers in relation to implementing the American Medical Association Expert Committee recommendations for assessment, treatment, and prevention of childhood obesity. METHODS In-depth interviews were conducted with 13 rural primary care providers in Oregon. Transcribed interviews were thematically coded. RESULTS Barriers to addressing childhood obesity fell into 5 categories: barriers related to the practice (time constraints, lack of reimbursement, few opportunities to detect obesity), the clinician (limited knowledge), the family/patient (family lifestyle and lack of parent motivation to change, low family income and lack of health insurance, sensitivity of the issue), the community (lack of pediatric subspecialists and multidisciplinary/tertiary care services, few community resources), and the broader sociocultural environment (sociocultural influences, high prevalence of childhood obesity). There were very few clinic and community resources to assist clinicians in addressing weight issues. Clinicians had received little previous training relevant to childhood obesity, and they expressed an interest in several topics. CONCLUSIONS Rural primary care providers face extensive barriers in relation to implementing recommended practices for assessment, treatment, and prevention of childhood obesity. Particularly problematic is the lack of local and regional resources. Employing nurses to provide case management and behavior counseling, group visits, and telehealth and other technological communications are strategies that could improve the management of childhood obesity in rural primary care settings.

Perceptions of Shared Decision Making and Decision Aids Among Rural Primary Care Clinicians

Background Shared decision making (SDM) and decision aids (DAs) increase patients’ involvement in health care decisions and enhance satisfaction with their choices. Studies of SDM and DAs have primarily occurred in academic centers and large health systems, but most primary care is delivered in smaller practices, and over 20% of Americans live in rural areas, where poverty, disease prevalence, and limited access to care may increase the need for SDM and DAs. Objective To explore perceptions and practices of rural primary care clinicians regarding SDM and DAs. Design Cross-sectional survey. Setting and Participants Primary care clinicians affiliated with the Oregon Rural Practice-based Research Network. Results Surveys were returned by 181 of 231 eligible participants (78%); 174 could be analyzed. Two-thirds of participants were physicians, 84% practiced family medicine, and 55% were male. Sixty-five percent of respondents were unfamiliar with the term shared decision making, but following definition, 97% reported that they found the approach useful for conditions with multiple treatment options. Over 90% of clinicians perceived helping patients make decisions regarding chronic pain and health behavior change as moderate/hard in difficulty. Although 69% of respondents preferred that patients play an equal role in making decisions, they estimate that this happens only 35% of the time. Time was reported as the largest barrier to engaging in SDM (63%). Respondents were receptive to using DAs to facilitate SDM in print- (95%) or web-based formats (72%), and topic preference varied by clinician specialty and decision difficulty. Conclusions Rural clinicians recognized the value of SDM and were receptive to using DAs in multiple formats. Integration of DAs to facilitate SDM in routine patient care may require addressing practice operation and reimbursement.

Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations

BackgroundIn healthcare change interventions, on-the-ground learning about the implementation process is often lost because of a primary focus on outcome improvements. This paper describes the Learning Evaluation, a methodological approach that blends quality improvement and implementation research methods to study healthcare innovations.MethodsLearning Evaluation is an approach to multi-organization assessment. Qualitative and quantitative data are collected to conduct real-time assessment of implementation processes while also assessing changes in context, facilitating quality improvement using run charts and audit and feedback, and generating transportable lessons. Five principles are the foundation of this approach: (1) gather data to describe changes made by healthcare organizations and how changes are implemented; (2) collect process and outcome data relevant to healthcare organizations and to the research team; (3) assess multi-level contextual factors that affect implementation, process, outcome, and transportability; (4) assist healthcare organizations in using data for continuous quality improvement; and (5) operationalize common measurement strategies to generate transportable results.ResultsLearning Evaluation principles are applied across organizations by the following: (1) establishing a detailed understanding of the baseline implementation plan; (2) identifying target populations and tracking relevant process measures; (3) collecting and analyzing real-time quantitative and qualitative data on important contextual factors; (4) synthesizing data and emerging findings and sharing with stakeholders on an ongoing basis; and (5) harmonizing and fostering learning from process and outcome data. Application to a multi-site program focused on primary care and behavioral health integration shows the feasibility and utility of Learning Evaluation for generating real-time insights into evolving implementation processes.ConclusionsLearning Evaluation generates systematic and rigorous cross-organizational findings about implementing healthcare innovations while also enhancing organizational capacity and accelerating translation of findings by facilitating continuous learning within individual sites. Researchers evaluating change initiatives and healthcare organizations implementing improvement initiatives may benefit from a Learning Evaluation approach.

Characteristics and lessons learned from practice-based research networks (PBRNs) in the United States.

Practice-based research networks (PBRNs) are organizations that involve practicing clinicians in asking and answering clinically relevant research questions. This review explores the origins, characteristics, funding, and lessons learned through practice-based research in the United States. Primary care PBRNs emerged in the USA in the 1970s. Early studies explored the etiology of common problems encountered in primary care practices (eg, headache, miscarriage), demonstrating the gap between research conducted in controlled specialty settings and real-world practices. Over time, national initiatives and an evolving funding climate have shaped PBRN development, contributing to larger networks, a push for shared electronic health records, and the use of a broad range of research methodologies (eg, observational studies, pragmatic randomized controlled trials, continuous quality improvement, participatory methods). Today, there are over 160 active networks registered with the Agency for Healthcare Research and Quality’s PBRN Resource Center that engage primary care clinicians, pharmacists, dentists, and other health care professionals in research and quality-improvement initiatives. PBRNs provide an important laboratory for encouraging collaborative research partnerships between academicians and practices or communities to improve population health, conduct comparative effectiveness and patient-centered outcomes research, and study health policy reform. PBRNs continue to face critical challenges that include: (1) adapting to a changing landscape; (2) recruiting and retaining membership; (3) securing infrastructure support; (4) straddling two worlds (academia and community) and managing expectations; and (5) preparing for workforce transitions.

Unmet Dental Needs in Rural Primary Care: A Clinic-, Community-, and Practice-based Research Network Collaborative

Background: Oral health is an essential component of general health and well-being, yet barriers to the access of dental care and unmet needs are pronounced, particularly in rural areas. Despite associations with systemic health, few studies have assessed unmet dental needs across the lifespan as they present in primary care. This study describes the prevalence of oral health conditions and unmet dental needs among patients presenting for routine care in a rural Oregon family medicine practice. Methods: Eight primary care clinicians were trained to conduct basic oral health screenings for 7 dental conditions associated with International Statistical Classification of Diseases and Related Health Problems 9—Clinical Modification codes. During the 6-week study period, patients older than 12 months of age who presented to the practice for a regularly scheduled appointment received the screening and completed a brief dental access survey. Results: Of 1655 eligible patients, 40.7% (n = 674) received the screening and 66.9% (n = 1108) completed the survey. Half of the patients who were screened (46.0%, n = 310) had oral health conditions detected, including partial edentulism (24.5%), dental caries (12.9%), complete edentulism (9.9%), and cracked teeth (8.9%). Twenty-eight percent of the patients reported experiencing unmet dental needs. Patients with dental insurance were significantly more likely to report better oral and general health outcomes as compared with those who had no insurance or health insurance only. Conclusions: Oral health diseases and unmet dental needs presented substantially in patients with ages ranging across the lifespan from one rural primary care practice. Primary care settings may present opportune environments for reaching patients who are unable to obtain regular dental care.