Perceptions of Responsibilities by Primary Care Staff in a Patient-Centered Medical Home.

OBJECTIVE: To examine the extent to which Veterans Health Administration (VHA) Patient-Aligned Care Team (PACT) members have a shared understanding/ agreement upon and enact responsibilities within the team. BACKGROUND: The PACT model focuses on team-based care management. However, lack of a shared understanding of team-based care management roles and responsibilities makes system-wide implementation a challenge. METHODS: Quantitative and qualitative analysis of national survey data collected in 2022 from primary care personnel working in a VHA-affiliated primary care facility. RESULTS: Significant discrepancies exist in responses about what core team members say they do and what others perceive they should be doing, indicating either a lack of agreement, knowledge, or training about what core team members should do. CONCLUSIONS: Successful implementation of a team-based model requires adequate support and training for teamwork including shared mental models to work according to their clinical competency. Clear guidance and communication of expectations are critical for role clarity.

The impact of patient-provider relationships on choosing between VA and VA-purchased care: A qualitative study of health care decision-making among rural veterans.

PURPOSE: Since the Choice Act in 2014, many Veterans have had greater options for seeking Veteran Affairs (VA)-purchased care in the community. We investigated factors that influence rural Veterans' decisions regarding where to seek care. METHODS: We utilized semi-structured telephone interviews to query Veterans living in rural or highly rural areas of Midwestern states about their health care options, preferences, and experiences. Interviews were recorded and transcribed, thematically coded, and deductively analyzed using a socioecological approach. FINDINGS: Forty rural Veterans (20 men/20 women) ages 28-76 years completed interviews in 2019. We found that rural Veterans often spoke about their relationships and interactions with providers as an important factor in deciding where to seek care. They expressed three socioecological qualities of patient-provider relationships that affected their decisions: (1) personal level-rural Veterans traveled longer distances for more compatible patient-provider relationships; (2) interpersonal level-they sought stable patient-provider relationships that encouraged familiarity, trust, and communication; and (3) organizational level-they emphasized shared identities and expertise that fostered a sense of belonging with their provider. Participants also described how impersonal interactions, status differences, and staff turnover impacted their choice of provider and were disruptive to patient-provider relationships. CONCLUSIONS: Rural Veterans' interview responses suggest exploring innovative ways to measure socioecological dimensions (i.e., personal, interpersonal, and organizational) of access-related decisions and patient-provider relationships to better understand health care barriers and needs. Such measures align with the VA's Whole Health approach that emphasizes person-centered care and the value of social relationships to Veterans' health.

Delegation of Work Within a Patient-Centered Medical Home.

OBJECTIVE: The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work. BACKGROUND: Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams. METHODS: This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey. RESULTS: Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants. CONCLUSIONS: Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation.

Care Management and Care Coordination Within a Patient-Centered Medical Home.

OBJECTIVE: The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH). BACKGROUND: The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care. METHODS: A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted. RESULTS: Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems. CONCLUSIONS: Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.

Patient Perspectives on Opioids: Views of Inpatient Veterans with Chronic Pain.

OBJECTIVE: To elucidate perspectives on opioids and opioid use from hospitalized veterans with comorbid chronic pain using qualitative methods. DESIGN: This was an analysis of individual qualitative interviews. The semistructured interview guide was developed by a hospitalist with clinical expertise in pain treatment with guidance from a medical anthropologist. Interviews aimed to understand participants' experiences of chronic pain. SETTING: A Midwestern Veterans Health Administration inpatient hospital unit. SUBJECTS: Nineteen inpatient veterans with a history of chronic pain or antecedent opioid use. METHODS: Recently admitted veterans were screened for chronic pain diagnosis on admission and antecedent opioid use. Eligible veterans were approached to participate in an in-person interview during their hospitalization. RESULTS: The following themes were identified in relation to opioid use: other patients as the problem (by misusing opioids resulting in broad limits to opioid access), empathy for providers (perceived to be working under prescribing constraints), and opioids as a last resort. CONCLUSIONS: Although participants were not specifically questioned about opioid medications, discussion of opioids was prevalent in discussions of chronic pain. Findings suggest the potential utility of engaging hospitalized veterans in conversations about opioids and alternative pain management strategies.

The empowerment paradox as a central challenge to patient centered medical home implementation in the veteran's health administration.

In this paper we present results of a mixed methods study conducted to identify barriers to team function among staff implementing patient aligned care teams - the Department of Veterans Affairs' patient centered medical home (PCMH) model. Using a convergent mixed methods design, we administered a standardized survey measure (Team and Individual Role Perception Survey) to assess work role challenge and engagement; and conducted discussion groups to gather context pertaining to role change. We found that the role of primary care providers is highly challenging and did not become less difficult over the initial year of implementation. Unexpectedly over the course of the first year nurse care managers reported a decrease in their perceptions of empowerment and clerical associates reported less skill variety. Qualitative data suggest that more skilled team members fail to delegate and share tasks within their teams. We characterize this interprofessional knowledge factor as an empowerment paradox where team members find it difficult to share tasks in ways that are counter to traditionally structured hierarchical roles. Health care systems seeking to implement PCMH should dedicate resources to facilitating within-team role knowledge and negotiation.

"All the money in the world " patient perspectives regarding the influence of financial incentives.

OBJECTIVE: To analyze patient perspectives of the use of financial incentives in a hypertension intervention. Study Setting. Twelve Veterans Affairs primary care clinics over a 9-month period. STUDY DESIGN: Qualitative semistructured interviews conducted with 54 hypertensive veterans participating in an intervention to promote guideline-consistent therapy. Intervention components included an intervention letter requesting patients talk with their providers, an offer of U.S.$20 to bring in the letter to their provider, and a health educator phone call. DATA COLLECTION METHODS: Semistructured interviews were conducted. Transcripts were coded for thematic content. The financial incentive theme was then subcoded for more detailed analysis. PRINCIPLE FINDINGS: Most participants (n=48; 88.9 percent) stated the incentive had (or would have) no effect on their decision to initiate a discussion with their provider. Some participants articulated reservations about the effectiveness and/or appropriateness of financial incentives in health care decisions; however, a few expressed the opinion that there may be some potential benefits to the use of financial incentives if they encourage patients to be active in their health care. CONCLUSION: The findings of this study raise questions about the appropriateness and unintended consequences of employing patient-directed financial incentives in health care settings.