Rebecca A. Malouin

Evaluation of patient centered medical home practice transformation initiatives.

Background:The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. Methods:Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. Results:A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Conclusions:Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.

Clinician perceptions of factors influencing referrals to a smoking cessation program

BackgroundReferral of patients to smoking cessation telephone counseling (i.e., quitline) is an underutilized resource by primary care physicians. Previously, we conducted a randomized trial to determine the effectiveness of benchmarked feedback on clinician referrals to a quitline. Subsequently, we sought to understand the successful practices used by the high-referring clinicians, and the perceptions of the barriers of referring patients to a quitline among both high and non-referring clinicians in the trial.MethodsWe conducted a qualitative sub-study with subjects from the randomized trial, comparing high- and non-referring clinicians. Structured interviews were conducted and two investigators employed a thematic analysis of the transcribed data. Themes and included categories were organized into a thematic framework to represent the main response sets.ResultsAs compared to non-referring clinicians, high-referring clinicians more often reported use of the quitline as a primary source of referral, an appreciation of the quitline as an additional resource, reduced barriers to use of the quitline referral process, and a greater personal motivation related to tobacco cessation. Time and competing demands were critical barriers to initiating smoking cessation treatment with patients for all clinicians. Clinicians reported that having one referral source, a referral coordinator, and reimbursement for tobacco counseling (as a billable code) would aid referral.ConclusionFurther research is needed to test the effectiveness of new approaches in improving the connection of patients with smoking cessation resources.Trial Registration NumberClinicaltrials.gov NCT00529256

Impact of the 340B Pharmacy Program on Services and Supports for Persons Served by Hemophilia Treatment Centers in the United States

Purpose Hemophilia Treatment Centers (HTCs) provide integrated and comprehensive services to individuals affected with rare bleeding disorders, such as hemophilia and Von Willebrand disease. Through the 340 Drug Pricing Program, HTCs may use pharmacy income to support clinical staff and patient services. The objective of this study was to describe the impact of the 340B program funding on services and support provided by HTCs to persons affected by rare bleeding disorders. Description Federally designated comprehensive HTCs with established 340B programs were invited to participate in a mailed survey in 2014. Participants were requested to report on 340B program-funded staff and services in the calendar year 2013. Assessment The 31 of 37 HTCs responding served over 10,000 individuals, or one-third of the national HTC patient population. The majority of responding HTCs reported that 340B program income supported over 90% of staff such as nurses, social workers, and physical therapists. Conclusion The results from this survey of 31 centers with established programs demonstrates the HTCs’ reliance on 340B program support for vital comprehensive services, that are otherwise non-reimbursable, and highlights the importance of the 340B program in sustaining the high quality of care and in increasing access for a geographically dispersed, medically vulnerable population.

Care Managers and Knowledge Shift in Primary Care Patient-Centered Medical Home Transformation

Primary care practices across the United States are implementing a new model of care, the patient-centered medical home (PCMH), in an effort to improve care to patients and, consequently, control health care costs. The addition of care managers is a key aspect of PCMH implementation with important implications for the production and reproduction of authoritative knowledge in primary care. Redistribution of patient interaction from the primary care provider to a range of other health care providers in this model of care is a significant means by which primary care approaches to the prevention and management of chronic diseases such as diabetes are being transformed. Based on a study of a health insurance company-sponsored primary care transformation project in Michigan, we explore the perceptions of care management from the perspective of providers and practice staff to examine these shifts in knowledge and their broader implications for primary care. This research demonstrates how the diffusion of clinica...

Physician and Staff Acceptance of Care Managers in Primary Care Offices

Introduction: Embedded care managers are increasingly implemented as part of the care team within primary care practices, yet previous studies have indicated variability in acceptance by physicians and staff. This study assesses the acceptability of care managers among staff and physicians within the Michigan Primary Care Transformation (MiPCT) demonstration. Methods: Care manager acceptance was measured using a web-based survey distributed to practices participating in the MiPCT demonstration. Results: Both physicians and staff reported high levels of care manager acceptance. Longer length of care manager employment at the practice, higher care manager FTE dedicated to care management, and care manager employed by practice were all significantly associated with care manager acceptance. Discussion: The MiPCT demonstration found high care manager acceptance across all care team members. The high level of acceptance may be due to the structures and processes developed by MiPCT to support implementation of care managers and the length of the intervention period. Conclusion: The MiPCT demonstration confirms that following three years of implementation, embedded care managers are acceptable to both physicians and staff within primary care practices. Importantly, embeddedness, or the amount of time care managers are located within practices, is associated with increased acceptance.