Mobility Action Group: Using Quality Improvement Methods to Create a Culture of Hospital Mobility.

BACKGROUND/OBJECTIVES: To describe the Mobility Action Group (MACT), an innovative process to enhance implementation of hospital mobility programs and create a culture of mobility in acute care. DESIGN: Continuous quality improvement intervention with episodic data review. SETTING: Inpatient units including medical, surgical, and intensive care settings. PARTICIPANTS: A total of 42 hospitals of varying sizes across the United States. INTERVENTIONS: The MACT and Change Package were developed to provide a conceptual framework, road map, and step-by-step guide to enable mobility teams to implement mobility programs successfully and meet their mobilization goals. Participants were encouraged to select two to three change tactics to pursue during the first action cycle and select and implement additional tactics in subsequent cycles. Nine learning sessions were held via webinar from April 27, 2017, to October 5, 2017, during which faculty provided brief presentations, facilitation, and group discussion. MEASUREMENTS: Implementation of programs, walks per day, use of bed and chair alarms, and participant satisfaction. RESULTS: Successful implementation of mobility programs was achieved at most (76%) sites. The proportion of patients who received at least three walks per day increased from 9% to 19%. The proportion of patients who were placed on a bed or chair alarm decreased from 36% to 20%. On average, 69% of participants reported they were "strongly satisfied" with the learning sessions. Most participants found the Change Package (58%) and Toolkit (63%) "very helpful." Since the conclusion of the active initiative, the Change Package has been downloaded 1,200 times. Of those who downloaded it, 48% utilized it to establish a mobility program, and 58% used it at their organization at least once a month. CONCLUSION: The MACT and Change Package provides an innovative approach emphasizing systemwide change that can help catalyze a culture of mobility in hospitals across the nation, improving the quality of care for hospitalized older adults. J Am Geriatr Soc 68:2373-2381, 2020.

Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

PURPOSE: Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. METHODS: We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. RESULTS: CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CONCLUSIONS: CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services.

Behavioral Health and the Comprehensive Primary Care (CPC) Initiative: findings from the 2014 CPC behavioral health survey.

BACKGROUND: Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation. METHOD: We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores. RESULTS: One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers. CONCLUSIONS: This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.

Implementation of the REACH model of dementia caregiver support in American Indian and Alaska Native communities.

The Resources for Enhancing Alzheimer's Caregivers Health in the VA (REACH VA) dementia caregiving intervention has been implemented in the VA, in community agencies, and internationally. As identified in the 2013 and 2015 National Plan to Address Alzheimer's Disease, REACH is being made available to American Indian and Alaska Native communities. Implementation activities are carried out by local Public Health Nursing programs operated by Indian Health Service and Tribal Health programs, and Administration for Community Living/Administration on Aging funded Tribal Aging program staff already working in each community. The implementation is described using the Fixsen and Blasé implementation process model. Cultural, community, health system, and tribe-specific adaptations occur during the six implementation stages of exploration and adoption, program installation, initial implementation, full operation, innovation, and sustainability. Adaptations are made by local staff delivering the program. Implementation challenges in serving AI/AN dementia caregivers include the need to adapt the program to fit the unique communities and the cultural perceptions of dementia and caregiving. Lessons learned highlight the importance of using a clinically successful intervention, the need for support and buy-in from leadership and staff, the fit of the intervention into ongoing routines and practices, the critical role of modifications based on caregiver, staff, and organization needs and feedback, the need for a simple and easily learned intervention, and the critical importance of community receptivity to the services offered.

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.

Do correlates of dual use by American Indian and Alaska Native Veterans operate uniformly across the Veterans Health Administration and the Indian Health Service?

OBJECTIVE: To determine if the combined effects of patient-level (demographic and clinical characteristics) and organizational-level (structure and strategies to improve access) factors are uniformly associated with utilization of Indian Health Service (IHS) and/or Veterans Health Administration (VHA) by American Indian and Alaska Native (AIAN) Veterans to inform policy which promotes dual use. METHODS: We estimated correlates and compared two separate multilevel logistic regression models of VHA-IHS dual versus IHS-only and VHA-IHS dual versus VHA-only in a sample of 18,892 AIAN Veterans receiving care at 201 VHA and IHS facilities during FY02 and FY03. Demographic, diagnostic, eligibility, and utilization data were drawn from administrative records. A survey of VHA and IHS facilities defined availability of services and strategies to enhance access to healthcare for AIAN Veterans. RESULTS: Facility level strategies that are generally associated with enhancing access to healthcare (e.g., population-based services and programs, transportation or co-location) were not significant factors associated with dual use. In both models the common variable of dual use was related to medical need, defined as the number of diagnoses per patient. Other significant demographic, medical need and organizational factors operated in opposing manners. For instance, age increased the likelihood of dual use versus IHS-only but decreased the likelihood of dual use versus VHA-only. CONCLUSIONS: Efforts to enhance access through population-based and consumer-driven strategies may add value but be less important to utilization than availability of healthcare resources needed by this population. Sharing health records and co-management strategies would improve quality of care while policies allow and promote dual use.

Adaptation, dissemination, and evaluation of a cancer palliative care curriculum for the Indian health system.

In 2006, the Indian Health Service (IHS) and the National Cancer Institute (NCI) collaborated to develop an interdisciplinary palliative training program for health professionals in the Indian health system. Their goal was to improve clinician knowledge and skills in palliative care, to train future trainers, and to increase access to palliative care for American Indians and Alaska Natives. The combined program of participant self-study utilizing a multimedia CD-ROM and train-the-trainer seminars followed the curriculum entitled Education in Palliative and End-of-Life Care for Oncology (EPEC-O) with American Indian and Alaska Native Cultural Considerations. Three seminars trained 89 interdisciplinary health providers from throughout the Indian health system. Evaluations demonstrated increased clinician self-reported knowledge and confidence to train and high satisfaction with training. Forty-two of 67 participants completed an anonymous post-conference Web questionnaire. Nearly half had conducted or definitively planned palliative education sessions, and 57 percent started new palliative services at their practice sites.

Veterans Health Administration and Indian Health Service: healthcare utilization by Indian Health Service enrollees.

BACKGROUND: The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans. OBJECTIVES: To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies. METHODS: Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03. RESULTS: Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS. CONCLUSIONS: Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.

Identification of American Indian and Alaska Native veterans in administrative data of the Veterans Health Administration and the Indian Health Service.

We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.

Palliative care in the Pueblo of Zuni.

The American Indian and Alaska Native population is aging and the leading causes of death for those aged 55 and older are chronic diseases such as cancer, heart disease, and the complications of diabetes. There are limited formal palliative care services available to rural and reservation dwelling American Indians and Alaska Natives. This collaboration between a tribally operated home health care agency and a federally operated Indian Health Service hospital, with the support of a palliative care center within an academic medical center, has established a palliative care program in the Pueblo of Zuni. The program is based in the tribal home health agency. Barriers to development included the rural setting with limited professional workforce, competing demands in a small agency, the need for coordination across distinct organizations, and the need to address the dying process in a culturally proficient manner. Family-focused interviews and other techniques were used to tailor the palliative care program to the unique cultural setting. The program has sought to integrate inpatient care of terminally ill patients at the Indian Health Service (IHS) hospital with outpatient hospice care. The initial goal of obtaining certification as a Medicare Hospice provider has not been met and remains a goal. Meanwhile alternative mechanisms for funding the services have been found. The experience of this collaboration suggests that a tribally based, culturally proficient palliative care program can be developed within an American Indian/Alaska Native community and that it can drive the local health system toward improved end-of-life care.