Implementation of Patient Safety Structures and Processes in the Patient-Centered Medical Home.

ABSTRACT: Although most patient-clinician interactions occur in ambulatory care, little research has addressed measuring ambulatory patient safety or how primary care redesign such as the patient-centered medical home (PCMH) addresses patient safety. Our objectives were to identify PCMH standards relevant to patient safety, construct a measure of patient safety activity implementation, and examine differences in adoptions of these activities by practice and community characteristics. Using a consensus process, we selected elements among a widely adopted, nationally representative PCMH program representing activities that, according to a physician panel, represented patient safety overall and in four domains (diagnosis, treatment delays, medications, and communication and coordination) and generated a score for each. We then evaluated this score among 5,007 practices with the highest PCMH recognition level. Implementation of patient safety activities varied; the few military practices (2.4%) had the highest, and community clinics the lowest, patient safety score, both overall (82.0 and 72.0, respectively, p < .001) and across specific domains. Other practice and community characteristics were not associated with the patient safety score. Understanding better what factors are associated with implementation of patient safety activities may be a key step in improving ambulatory patient safety.

The medical home and integrated behavioral health: advancing the policy agenda.

There has been a considerable expansion of the patient-centered medical home model of primary care delivery, in an effort to reduce health care costs and to improve patient experience and population health. To attain these goals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often first present in the primary care setting, and they significantly affect physical health. At the 2013 Patient-Centered Medical Home Research Conference, an expert workgroup convened to determine policy recommendations to promote the integration of primary care and behavioral health. In this article we present these recommendations: Build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models, and develop population-based measures to evaluate integration.

A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients.

BACKGROUND: African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations. OBJECTIVE: To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups. DESIGN: Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland. PARTICIPANTS: Forty-one primary care physicians and 279 hypertension patients. INTERVENTIONS: Physician communication skills training and patient coaching by community health workers. MAIN MEASURES: Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control. KEY RESULTS: Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (ß = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (ß = +0.22 vs. -0.17, p = 0.03) and information exchange (ß = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg). CONCLUSION: Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.

Design of a quality and performance improvement project for small primary care practices: reflections on the Center for Practice Innovation.

BACKGROUND: Small practices often lack the human, financial and technical resources to make necessary practice improvements and infrastructure investments in order to achieve sustainable change that promotes quality and efficiency. AIMS: To report on an effort to assist small primary care practices in improving quality of care and efficiency of practice management to meet the needs of patients, improve physician satisfaction and enhance the ability of these small practices to survive. METHODS: We report on an intervention design and the reflections of the implementers on what they learned and what went well or poorly during implementation. Results of the intervention are reported separately (in Quality in Primary Care). Thirty practices underwent the entire intervention. The practices were selected on the basis of practice size, diversity in patient factors, apparent dedication to making practice improvements and geographic location. The main components of the intervention were two site visits to the participating practices by Center for Practice Innovation (CPI); now known as the Centre for Practice Improvement and Innovation, team members. The CPI team provided ongoing advice and support in focus areas selected by practices after initial site visit and assessment. RESULTS: A customised session focusing on the practice report and on helping practices to think about which areas they wished to improve was more effective in engaging practices than didactic presentation. Quality and practice management improvements were observed in information posting, patient education, staff communication and patient safety practices. Having a strong physician champion and a strong office manager determined to make quality improvement changes were important elements for successful change. In addition, practices with greater stability of staff and strong finances were more likely to meet project goals. CONCLUSIONS: Small practices today are facing a range of important challenges. The CPI sought to provide successful guidance to small practices with evidence of positive change in some clinical measures, patient satisfaction and practice motivation to implement quality of care and practice management improvements.

Patient-centered medical home cyberinfrastructure current and future landscape.

The patient-centered medical home (PCMH) is an approach that evolved from the understanding that a well-organized, proactive clinical team working in a tandem with well-informed patients is better able to address the preventive and disease management needs in a guideline-concordant manner. This approach represents a fundamental shift from episodic acute care models and has become an integral part of health reform supported on a federal level. The major aspects of PCMH, especially pertinent to its information infrastructure, have been discussed by an expert panel organized by the Agency for Healthcare Research and Quality at the Informatics for Consumer Health Summit. The goal of this article is to summarize the panel discussions along the four major domains presented at the summit: (1) PCMH as an Evolving Model of Healthcare Delivery; (2) Health Information Technology (HIT) Applications to Support the PCMH; (3) Current HIT Landscape of PCMH: Challenges and Opportunities; and (4) Future HIT Landscape of PCMH: Federal Initiatives on Health Informatics, Legislation, and Standardization.

A simple intervention promoting patient safety improvements in small internal medicine practices.

BACKGROUND: small primary care practices may face difficulties in staying abreast of patient safety recommendations and implementing them. Some safety issues, however, may be easily and inexpensively addressed, given the necessary information on what is required. AIM: to assess changes in patient safety measures in small practices and describe simple mechanisms that appear to have facilitated change. METHODS: The design uses pre-post bivariate tests to determine the effect of a quality improvement intervention provided by the Center for Practice Innovation (CPI) of the American College of Physicians (ACP) to 34 small internal medicine practices. Compliance with safety measures was reassessed in 30 practices after the intervention. The CPI intervention involved two site visits, a practice assessment, self-selection of clinical, operational and financial focus areas for improvement and ongoing 'directed guidance' of the practices in their efforts, including weekly 'Practice tips' email alerts. Data used in this study came from the practice assessment form completed by the CPI team, which included 21 safety measures. The Wilcoxon signed-rank test and McNemar's test were used to compare the practices' safety compliance before and after the intervention. RESULTS: many safety measures had high compliance rates at the first site visit; for other safety measures, fewer than half the practices followed the recommended procedures. The intervention was associated with statistically significant positive change on over 70% of the 21 safety issues. The positive effects were most profound in safety measures regarding how a practice managed sharps, hazardous materials, medications and vaccines. CONCLUSION: this study provides insights into mechanisms that assist practices to make initial steps to improve patient safety and care quality. The study also suggests that with concrete recommendations, small practices can make significant changes in a short period of time and at relatively low cost.

Lessons for the new CMS innovation center from the Medicare health support program.

The Patient Protection and Affordable Care Act establishes a new Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services (CMS). The center is intended to enhance the CMS's role in promoting much-needed improvements in payment and service delivery. Lessons from the Medicare Health Support Program, a chronic care pilot program that ran between 2005 and 2008, illustrate the value of drawing on experience in planning for the center and future pilot programs. The lessons include the importance of strong leadership; collaboration and flexibility to foster innovation; receptivity of beneficiaries to care management; and the need for timely data on patients' status. The lessons also highlight pitfalls to be avoided in planning future pilot programs, such as flawed strategies for selecting populations to target when testing payment and service delivery reforms.

Specialists/subspecialists and the patient-centered medical home.

This article provides an overview of the Patient-Centered Medical Home (PCMH) care model. It provides a history and definition of the concept, a discussion of its growing acceptance by the health-care community, and a review of current public and public-private demonstration projects testing the concept. The role of specialty/subspecialty practices within the PCMH model is described, with a focus on the potential for these practices to serve as a PCMH for a subgroup of patients or, alternatively, as a PCMH "neighbor" that interfaces effectively with PCMH practices. The authors conclude that the model for effective connections between the PCMH and specialty/subspecialty practices requires further development, including the cross-specialty establishment of guidelines and processes regarding referrals, information flow, transitions in care, and accountability. The efforts of the American College of Physicians' Council of Subspecialty Societies PCMH Workgroup to further develop this model are described. The authors encourage involvement from all interested stakeholders to ensure that the issues and challenges identified are addressed through collaboration and consensus based on available evidence.

A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045.

BACKGROUND: Disparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons. OBJECTIVE: This paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control. METHODS: A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs. CONCLUSION: The Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.