Peter G. Harper

Challenges of Change: A Qualitative Study of Chronic Care Model Implementation

PURPOSE The Chronic Care Model (CCM) provides a conceptual framework for transforming health care for patients with chronic conditions; however, little is known about how to best design and implement its specifics. One large health care organization that tried to implement the CCM in primary care provided an opportunity to study these issues. METHODS We conducted a qualitative, comparative case study of 5 of 18 group clinics 18 to 23 months after the implementation began. Built on knowledge of the clinics from a previous study of advanced access implementation, data included in-depth interviews with organizational leaders and varied clinic personnel, observation of clinic care processes, and review of written materials. RESULTS Relatively small and highly variable care process changes were made during the study period. The change process underwent several marked shifts in strategy when initial efforts failed to achieve much and bore little resemblance to the change process used in the previously successful large-scale implementation of advanced access scheduling. Many barriers were identified, including too many competing priorities, a lack of specificity and agreement about the care process changes desired, and little engagement of physicians. CONCLUSION These findings highlight specific organizational challenges with health care transformation in the absence of a blueprint more specific than the CCM. Effective models of organizational change and detailed examples of proven, feasible care changes still need to be demonstrated if we are to transform care as called for by the Institute of Medicine.

The Family Education Diabetes Series (FEDS): community-based participatory research with a midwestern American Indian community

Indigenous people around the globe tend to struggle with poorer health and well-being than their non-indigenous counterparts. One area that this is especially evident is in the epidemic of diabetes in North Americas American Indians (AIs) - who evidence higher prevalence rates and concomitant disease-related complications than any other racial/ethnic group. As researchers and AI communities work together to transcend conventional top-down, service-delivery approaches to care, community-based participatory research is beginning to show promise as a way to partner contemporary biomedical knowledge with the lived-experience, wisdom, and customs of Indigenous people. This study describes the Family Education Diabetes Series (FEDS) as an example of such effort, and highlights pilot findings assessing its value and impact across key diabetes-relevant variables. Following 36 intervention participants across baseline, 3-month, and 6-month time periods, data show significant improvements in weight, blood pressure, and metabolic control (A1c). Strengths and limitations of this investigation are presented, along with suggestions about how to further advance and empirically test the work across other Indigenous communities.

Transforming Medical Care: Case Study of an Exemplary, Small Medical Group

PURPOSE Most published descriptions of organizations providing or improving quality of care concern large medical groups or systems; however, 90% of the medical care in the United States is provided by groups of no more than 20 physicians. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality. METHODS A 15–family physician medical group was identified from comparative public performance scores of 27 medical groups providing most of the primary care in our metropolitan area. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents were reviewed. Four primary care physician researchers and a consultant then reviewed transcriptions, field notes, and materials during semistructured sessions to identify the main attributes of this group and their probable origins. RESULTS This medical group ranked first in a composite measure of preventive services and fourth and sixth, respectively, in composite scores for coronary artery disease and diabetes care. Our analysis identified 12 attributes of this group that seemed to be associated with its good care quality, with patient-centeredness being the foundational attribute for most of the others. Historical factors important to most of these attributes included small size, physician ownership, and a high value on practice consistency among the clinicians in the group. CONCLUSIONS The identified 12 attributes of this medical group seem to be associated with its superior care quality, and most of them might be replicable by other small groups if they choose to work toward that end.

The safety of trivalent influenza vaccine among healthy children 6 to 24 months of age

OBJECTIVE. The objective of this study was to assess the safety of routine trivalent influenza vaccine (TIV) administration among healthy children 6 through 23 months of age, after the Advisory Committee on Immunization Practices recommendation. METHODS. The study was a retrospective case-control study of children receiving TIV in the first 2 seasons after the Advisory Committee on Immunization Practices recommendation. We assessed outcomes in the 42 days after vaccination in a population of 13383 children. Each case subject was matched, according to age and gender, with 3 control subjects. Hazard ratios were calculated with conditional logistic regression analysis. RESULTS. We found no statistically significantly elevated hazard ratios for the first TIV dose. An elevated risk of pharyngitis was found for children receiving a second TIV dose. No elevated risk of seizure was found. CONCLUSION. These results, for a population of healthy children, showed no medically significant adverse events related to TIV among children 6 to 23 months of age.

Students Against Nicotine and Tobacco Addiction (S.A.N.T.A.): Community-Based Participatory Research in a High-Risk Young Adult Population

Students Against Nicotine and Tobacco Addiction (S.A.N.T.A.) is a community-based participatory research project involving an active collaboration between University health providers and Job Corps students, administrators, teachers, counselors, and staff. In this article, we describe the project, its evolution, and key strategies that have employed over the course of the initiative and its ongoing efforts.

Syndromic Surveillance for Measleslike Illnesses in a Managed Care Setting

Surveillance for measles must be enhanced to support the objective of measles elimination in the United States. Many conditions produce febrile rash illnesses that are clinically similar to measles; investigations of measleslike illnesses (MLIs) should occur regardless of the incidence of measles. Few data exist regarding the incidence of MLI in the United States, and it is unknown how providers evaluate patients with such conditions. We searched databases at a large managed care organization to obtain complete ascertainment of MLI during 1994-1998. Among 6000000 patient encounters, 68 records were identified that met the study case definition. The incidence of MLI was 4.5 cases/100000 persons/year. Measles diagnoses were considered by physicians for 9 patients (13.2%); 2 were laboratory-tested and reported to the state health department and the other 7 were given alternative diagnoses. It was not possible to determine for the remaining MLI patients whether measles was ruled out on clinical grounds or whether the possibility was not considered. Provider education regarding evaluation and reporting of measles is warranted. Databases at health care plans can be used to address public health issues and to establish syndromic surveillance for communicable diseases.

The SANTA project (students against nicotine and tobacco addiction): Using community-based participatory research to reduce smoking in a high-risk young adult population

Students Against Nicotine and Tobacco Addiction (SANTA) is an action research project that engages local medical and mental health providers in partnership with students, teachers, and administrators in the Minneapolis/St Paul Job Corps community to reduce on-campus smoking. In this article, we describe how the initiative has endeavored to better understand the causes of students’ smoking behaviors; changed the campus environment in ways facilitative to stress-management and boredom-reduction; revised the manners in which smoking cessation and support services are conducted; and sustained the project following the discontinuation of its start-up grant. Evaluative efforts across several cohorts of students in time show that smoking rates decrease significantly with prolonged exposure to SANTA interventions.

Health promotion counseling in residency training

This report describes health promotion counseling attitudes and practices in a family medicine residency that attempted to encourage such counseling. A patient “Health Habits Questionnaire” and matching patient education booklets were developed and distributed. Six grand rounds presentations on counseling were given. On three occasions, residency physicians completed questionnaires about counseling. Despite good personal health habits and positive attitudes toward counseling, the residency physicians had only moderate confidence in their counseling ability and infrequently documented counseling. The residents reported significant improvement in their ability to counsel patients about smoking cessation. Overall, the curriculum appeared to have a limited effect on health promotion.

Community-based participatory research to decrease smoking prevalence in a high-risk young adult population: An evaluation of the students against nicotine and tobacco addiction (SANTA) project

Students Against Nicotine and Tobacco Addiction is a community-based participatory research project that engages local medical and mental health providers in partnership with students, teachers, and administrators at the Minnesota-based Job Corps. This intervention contains multiple and synchronous elements designed to allay the stress that students attribute to smoking, including physical activities, nonphysical activities, purposeful modifications to the campuss environment and rules/policies, and on-site smoking cessation education and peer support. The intent of the present investigation was to evaluate (a) the types of stress most predictive of smoking behavior and/or nicotine dependence, (b) which activities students are participating in, and (c) which activities are most predictive of behavior change (or readiness to change). Quantitative data were collected through 5 campus-wide surveys. Response rates for each survey exceeded 85%. Stressors most commonly cited included struggles to find a job, financial problems, family conflict, lack of privacy or freedom, missing family or being homesick, dealing with Job Corps rules, and other-unspecified. The most popular activities in which students took part were physically active ones. However, activities most predictive of beneficent change were nonphysical. Approximately one third of respondents were nicotine dependent at baseline. Nearly half intended to quit within 1 month and 74% intended to quit within 6 months. Interventions perceived as most helpful toward reducing smoking were nonphysical in nature. Future efforts with this and comparable populations should engage youth in advancing such activities within a broader range of activity choices, alongside conventional education and support.