Renée H. Lawrence

Long-term impact of preventive proactivity on quality of life of the old-old.

Objective This research explored the long-term benefits of engaging in proactive health promotion efforts among old-old residents of Sunbelt retirement communities to empirically test components of the Preventive and Corrective Proactivity (PCP) Model of Successful Aging. Specifically, we examined the contributions of exercise, tobacco use, moderate alcohol use, and annual medical checkups to multidimensional quality of life indicators of physical health, psychological well-being, and mortality. Method Data were obtained from a longitudinal study of adaptation to aging. Annual in-home interviews were conducted with 1000 older adults over a 9-year period. Whether health promotion behaviors at baseline predicted quality of life outcomes 8 years later was examined, controlling for the baseline outcome, sociodemographic variables, and, as an additional test, baseline health conditions. Results Exercise was predictive of fewer IADL limitations and greater longevity, positive affect, and meaning in life 8 years later. Avoiding tobacco was predictive of longevity. Before controlling for health conditions, exercise predicted decreased risk of basic activities of daily living limitations and having more goals; moderate alcohol use predicted longevity; annual health checkup predicted more IADL limitations; and having once smoked predicted having more IADL limitations and negative affect. Conclusions Among the old-old, exercise had long-term and multifaceted benefits over an 8-year period. Tobacco avoidance also contributed to long-term positive outcomes. These results lend support to the long-term preventive value of health-promoting proactivity spontaneously engaged in by old-old persons proposed in the framework of the PCP model.

Nurse practitioner-led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/group visits.

Purpose: To describe the roles of nurse practitioners (NPs) in a novel model of healthcare delivery for patients with chronic disease: shared medical appointments (SMAs)/group visits based on the chronic care model (CCM). To map the specific skills of NPs to the six elements of the CCM: self‐management, decision support, delivery system design, clinical information systems, community resources, and organizational support. Data sources: Case studies of three disease‐specific multidisciplinary SMAs (diabetes, heart failure, and hypertension) in which NPs played a leadership role. Conclusions: NPs have multiple roles in development, implementation, and sustainability of SMAs as quality improvement interventions. Although the specific skills of NPs map out all six elements of the CCM, in our context, they had the greatest role in self‐management, decision support, and delivery system design. Implications for practice: With the increasing numbers of patients with chronic illnesses, healthcare systems are increasingly challenged to provide necessary care and empower patients to participate in that care. NPs can play a key role in helping to meet these challenges.

Implementation of quality improvement skills by primary care teams: case study of a large academic practice.

Background: Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects. Objective: To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to (b) develop action plans to facilitate QI work into primary care teams. Design: We obtained qualitative and quantitative information about existing primary care team QI initiatives. Participants: Eleven interdisciplinary primary care teams and 4 facilitators/coaches. Methods: We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators. Results: In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress. Conclusions: In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.

Implementation and evaluation of a multicomponent quality improvement intervention to improve efficiency of hepatitis C screening and diagnosis.

BACKGROUND Given recent advances in hepatitis C virus (HCV) treatment, health systems must ensure that patients with a positive HCV antibody receive timely determination of their HCV status through viral testing. At the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, viral testing was completed within six months of the first instance of a positive HCV antibody test for only 45% of patients. Beginning in 2008, three sequential improvements were implemented to close this care gap. METHODS The three sequential improvements phases were as follows: (1) improving patient-centeredness of screening process in ambulatory patients, (2) local implementation of the Department of Veterans Affairs national HCV reflex testing policy, and (3) local evaluation of the efficiency and effectiveness of local implementation of reflex testing. RESULTS From 2005 through 2013, 40 to 150 unique patients/quarter required viral testing following a positive antibody test. The firsts and second-phase improvements resulted in a 68% and 96% completion rate for timely viral testing during respective improvement phases. In the third improvement phase, remaining process problems related to the reflex testing process were identified using a locally developed electronic HCV population management application, resulting in a sustained rate of 100% completion of timely viral testing. Interrupted time series analysis revealed that the implementation of HCV reflex testing had the largest impact on the ability to complete timely viral testing. CONCLUSIONS A continuous quality improvement approach, supported by an HCV population management application, achieved the complete closure of an important HCV care gap. Reflex testing should be initiated at facilities that have yet to adopt this approach.

Teaching quality improvement in the midst of performance measurement pressures: mixed messages?

Background While the importance of teaching quality improvement (QI) is recognized, formal opportunities to teach it are limited and are not always successful at getting physician trainee buy-in. We summarize findings that emerged from a QI curriculum designed to promote physician trainee insights into the evaluation and improvement of quality of care. Methods Grounded-theory approaches to thematic coding of responses from 24 trainees to open-ended items about aspects of a QI curriculum. The 24 trainees were subsequently divided into 9 teams that provided group responses to open-ended items about assessing quality care. Coding was also informed by notes from group discussions. Results Successes associated with QI projects reflected several aspects of optimizing care such as approaches to improving processes and enabling providers. Counterproductive themes included aspects of compromising care such as creating blinders and complicating care delivery. Themes about assessing care included absolute versus process trade-offs, time frame, documentation completeness, and the underrecognized role of the patient/provider dynamic. Conclusions Our mapping of the themes provides a useful summary of issues and ways to approach the potential lack of buy-in from physician trainees about the value of QI and the “mixed-messages” regarding inconsistencies in the application of presumed objective performance measures.

Quality of care by a hypertension expert: A cautionary tale for pay-for-performance approaches

Context Pay-for-performance programs may be widely implemented, but gaps remain in our understanding of the implementation of performance measurement approaches. Objectives To compare 3 approaches to hypertension quality measurement as applied to high-quality care delivered by a hypertension expert. Methods Care of 23 patients treated by a single hypertension expert was assessed by 3 measurement approaches: (1) outcome, (2) a multicomponent process, and (3) “outcome-linked” process. Exemplary case studies were identified to illustrate additional challenges to applying the approaches. Results Forty-four percent of patients (n = 10) had complete concordance between the outcome and outcome-linked process approaches, 22% of patients (n = 5) had complete concordance between the outcome and multicomponent process approaches, 52% of patients (n = 12) had complete concordance between outcome-linked process and multicomponent process approaches, and 22% of patients (n = 5) had uniform agreement among all 3 approaches. Case studies revealed numerous opportunities for misinterpretation or gaming by providers. Conclusions Currently available measurement approaches resulted in a varied assessment of provider performance under optimal hypertension care conditions suggesting that caution is required before their use for provider compensation.

Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems

Effective team-based models of care, such as the Patient-Centered Medical Home, require electronic tools to support proactive population management strategies that emphasize care coordination and quality improvement. Despite the spread of electronic health records (EHRs) and vendors marketing population health tools, clinical practices still may lack the ability to have: (1) local control over types of data collected/reports generated, (2) timely data (eg, up-to-date data, not several months old), and accordingly (3) the ability to efficiently monitor and improve patient outcomes. This article describes a quality improvement project at the hospital system level to develop and implement a flexible panel management (PM) tool to improve care of subpopulations of patients (eg, panels of patients with diabetes) by clinical teams. An in-depth case analysis approach is used to explore barriers and facilitators in building a PM registry tool for team-based management needs using standard data elements (eg, laboratory values, pharmacy records) found in EHRs. Also described are factors that may contribute to sustainability; to date the tool has been adapted to 6 disease-focused subpopulations encompassing more than 200,000 patients. Two key lessons emerged from this initiative: (1) though challenging, team-based clinical end users and information technology needed to work together consistently to refine the product, and (2) locally developed population management tools can provide efficient data tracking for frontline clinical teams and leadership. The preliminary work identified critical gaps that were successfully addressed by building local PM registry tools from EHR-derived data and offers lessons learned for others engaged in similar work. (Population Health Management 2016;19:232-239).

TeleVisit Keeps IT Local

The Diabetes Telemedicine Clinic at the Cleveland VHA facility provides real-time specialty consultation and continuing education for patients with diabetes mellitus and their healthcare providers in community clinics known as community-based outpatient clinics (CBOCs). Specifically, a patient at a CBOC is able to use a locally based videoconferencing system to have a virtual visit with an endocrinologist located at the Cleveland VHA’s main campus (VAMC). Figure 11.1 compares the usual face to face referral process with the new referral process, which uses a telehealth system to enable a virtual consult with a specialist. In the usual process, a decision is made by the primary care provider in the community clinic that referral for a diabetes consultation is required.

Shared Medical Appointments: Implementing Diabetes SMAs to Improve Care for High Risk Patients and Maximize Provider Expertise

Worldwide, the burden of diabetes continues to increase to staggering numbers. A recent report from the International Diabetes Foundation estimated that 366 million people have this chronic condition. Additionally, despite advances in diabetes treatment and prevention over the past 30 years, this number continues to rise. This increase applies to both the developing world and the developed world. For example, in 2010, the US Center for Disease Control fact sheet stated 26 million patients in the United States now have diabetes and 79 million have pre-diabetes. Much of the increase is related to the rising rates of obesity. As the numbers of patients with diabetes increases, so does their associated health care expenditures. Not surprisingly, the challenge of diabetes management is greater in those with mental health conditions, (Frayne et al., 2005) the elderly, and minority populations (www.ahrq.gov, 2011). Overall, diabetes and its complications and the often ineffective approaches to delivery of care lead to demonstrable quality gaps and increased costs. As a result, treatment strategies designed to improve outcomes are needed.