Strategic use of tobacco treatment specialists as an innovation for tobacco cessation health systems change within health care organizations.

BACKGROUND: Tobacco screening interventions have demonstrated effectiveness at improving population health, yet many people who want to quit using tobacco lack access to professional assistance. One way to address this gap is to train members of the clinical team as tobacco treatment specialists (TTSs). PURPOSE: The purpose of this study was to understand how TTSs have been used across a variety of health care organizations implementing health systems change for tobacco treatment and examine the sustainability of TTSs as a health systems change innovation for tobacco cessation. METHODOLOGY: This study used qualitative interviews ( n = 25) to identify themes related to implementing TTSs as a health systems change innovation and examined these themes within the constructs of the theory of innovation implementation. RESULTS: Insights about implementing TTSs as an innovation primarily aligned with four theoretical constructs: implementation policies and practices, implementation climate, innovation-values fit, and implementation effectiveness. Specific themes were perceived to facilitate the sustainability of TTSs including team-based TTS efforts, widespread awareness of TTS roles, leadership buy-in, and recognized value of TTS services. Barriers to sustainability included inadequate resources (e.g., time and staff), lack of tracking outcomes, inappropriate referrals, and lack of reimbursement. PRACTICE IMPLICATIONS: Health care organizations planning to implement health systems change for tobacco cessation can encourage committed use of TTSs as an innovation by considering the insights provided in this study. These primarily related to five overarching implementation considerations: staff selection and training, tracking and dissemination of impacts, adequate resources, referrals and workflow, and billing and reimbursement.

Assessment of structured data elements for social risk factors.

OBJECTIVES: Computable social risk factor phenotypes derived from routinely collected structured electronic health record (EHR) or health information exchange (HIE) data may represent a feasible and robust approach to measuring social factors. This study convened an expert panel to identify and assess the quality of individual EHR and HIE structured data elements that could be used as components in future computable social risk factor phenotypes. STUDY DESIGN: Technical expert panel. METHODS: A 2-round Delphi technique included 17 experts with an in-depth knowledge of available EHR and/or HIE data. The first-round identification sessions followed a nominal group approach to generate candidate data elements that may relate to socioeconomics, cultural context, social relationships, and community context. In the second-round survey, panelists rated each data element according to overall data quality and likelihood of systematic differences in quality across populations (ie, bias). RESULTS: Panelists identified a total of 89 structured data elements. About half of the data elements (n = 45) were related to socioeconomic characteristics. The panelists identified a diverse set of data elements. Elements used in reimbursement-related processes were generally rated as higher quality. Panelists noted that several data elements may be subject to implicit bias or reflect biased systems of care, which may limit their utility in measuring social factors. CONCLUSIONS: Routinely collected structured data within EHR and HIE systems may reflect patient social risk factors. Identifying and assessing available data elements serves as a foundational step toward developing future computable social factor phenotypes.

Public Health and Health Care Partnerships for Improved Tobacco Cessation.

CONTEXT: Tobacco use remains a leading cause of preventable death and disease. While most tobacco users are interested in quitting, few receive professional assistance. PROGRAM: This state health department-led project leveraged partnerships to build capacity and support 9 health care organizations in implementing system-level initiatives to improve delivery of tobacco cessation. IMPLEMENTATION: Participating organizations' initiatives targeted 3 focus areas: implementing best practices for tobacco cessation; quality improvement; and utilization of the electronic health record. EVALUATION: A qualitative study was conducted to examine facilitators and barriers to tobacco cession systems change among participating health care organizations. Common barriers included time constraints, staffing issues, and organizational structure. These factors often differed by organization type (eg, large vs small). Facilitators included leadership buy-in, organizational priority, technical assistance, teams/teamwork, and IT support. DISCUSSION: Initial findings suggest that this type of partnership model can be leveraged to gain organizational support, build capacity, address key barriers, and ensure that systems change strategies align with best practices for tobacco cessation across a diverse set of health care organizations. Findings presented in this report provide insights for other public health and health care organizations looking to implement similar initiatives.

Adoption of Health Information Technology Among US Nursing Facilities.

OBJECTIVES: Nursing facilities have lagged behind in the adoption of interoperable health information technology (ie technologies that allow the sharing and use of electronic patient information between different information systems). The objective of this study was to estimate the nationwide prevalence of electronic health record (EHR) adoption among nursing facilities and to identify the factors associated with adoption. DESIGN: Cross-sectional survey. SETTING & PARTICIPANTS: We surveyed members of the Society for Post-Acute & Long-Term Care Medicine (AMDA) about their organizations' health information technology usage and characteristics. MEASUREMENTS: Using questions adopted from existing instruments, the survey measured nursing home's EHR adoption, the ability to send, receive, search and integrate electronic information, as well as barriers to usage. Additionally, we linked survey responses to public use secondary data sources to construct measurements for 8 determinants known to be associated with organizational adoption: innovativeness, functional differentiation, role specialization, administrative intensity, professionalism, complexity, technical knowledge resources, and slack resources. A series of regression models estimated the association between potential determinants and technology adoption. RESULTS: 84% of nursing facilities reported using an EHR. After controlling for all other factors, respondents who characterized their organization as more innovative had more than 6 times the odds (adjusted odds ratio = 6.39, 95% confidence interval = 2.69, 15.21) of adopting an EHR. Organization innovativeness was also associated with an increased odds of being able to send, integrate, and search for electronic information. The most commonly identified barrier to sharing clinical information among nursing facilities with an EHR was a reported absence of interoperability (57%). CONCLUSIONS/IMPLICATIONS: An organizational culture that fosters innovation and awareness campaigns by professional societies may facilitate further adoption and effective use of technology. This will be increasingly important as policy makers continue to emphasize the use of EHRs and interoperability to improve the quality of care in nursing facilities.

Concern about the Expanding Prescription Drug Epidemic: A Survey of Licensed Prescribers and Dispensers.

BACKGROUND: Prescription drug misuse and abuse has reached epidemic levels in the U.S., and stands as a leading cause of death. As the primary gatekeepers to the medications contributing to this epidemic, it is critical to understand the views of licensed health care professionals. OBJECTIVE: In this study, we examine health care professionals' concern regarding prescription drug abuse in their communities and the impact their concern has had on their prescribing and dispensing practices. STUDY DESIGN: An online survey of licensed health care providers. SETTING: Conducted in Indiana. METHODS: This study was a state-wide evaluation of Indiana's prescription drug monitoring program. The questionnaire asked respondents how concerned they were about prescription drug abuse in their community. Variation in the level of concern was examined using ordinary least squares regression and information about the respondents' demographic background and clinical experience. In addition, we used logistic regression to examine whether concern was associated with changing prescribing and/or dispensing behavior. RESULTS: The majority of providers indicated they were "moderately" or "extremely concerned" about prescription drug abuse in their communities. The level of concern, however, varied significantly by profession, with pharmacists, physicians, nurse practitioners/physician assistants being more concerned than dentists. Additional analyses indicate that providers with higher levels of concern were those who also reported recently changing their prescribing and/or dispensing behavior. LIMITATIONS: The voluntary nature and geographical focus of the study limits the generalizability of the findings. CONCLUSION: Concern about prescription drug abuse is generally high across the major health care professions; however, a significant minority of providers, particularly among dentists, expressed little or no concern about the epidemic. Increasing health care providers' general level of concern about prescription drug abuse may be an effective public health tool for encouraging voluntary reductions in prescribing and/or dispensing controlled substances.

The iatrogenic epidemic of prescription drug abuse: county-level determinants of opioid availability and abuse.

BACKGROUND: Opioid use and abuse in the United States continues to expand at an alarming rate. In this study, we examine the county-level determinants of the availability and abuse of prescription opioids to better understand the socio-ecological context, and in particular the role of the healthcare delivery system, on the prescription drug abuse epidemic. METHODS: We use community-level information, data from Indiana's prescription drug monitoring program in 2011, and geospatial regression methods to identify county-level correlates of the availability and abuse of prescription opioids among Indiana's 92 counties. RESULTS: The findings suggest that access to healthcare generally, and to dentists and pharmacists in particular, increases the availability of prescription opioids in communities, which, in turn, is associated with higher rates of opioid abuse. CONCLUSIONS: The results suggest that the structure of the local healthcare system is a major determinant of community-level access to opioids adding to a growing body of evidence that the problem of prescription opioid abuse is, at least in part, an "iatrogenic epidemic."

Service utilization, expenditures, and success in a well-established system of care for young people with serious emotional disorders.

A major challenge in the implementation of systems of care is creating mechanisms to pay for services that are provided across social services systems and by multiple agencies. Using a managed care approach to coordinate service provision may be one way to effectively bridge the gap across agencies while also providing quality care. The authors explore the benefits of a managed care approach to service delivery within a well established system of care by describing the treatment planning process used by the system of care; describing the type and patterns of services provided to young people; and by describing the process used to bill for services. The authors also examine the impact of client and service characteristics on overall expenditures as well as the effect that patterns of service utilization and expenditures of care have on the likelihood that young people and their families will successfully meet their clinical objectives.

The nature and impact of conflict within service coordination teams for children and adolescents with serious emotional and behavioral challenges.

While both theory and empirical research regarding work team performance suggests that conflict can play an important role in determining productivity and other outcomes, the impact of conflict on the effectiveness of service coordination teams is not well understood. In this study, the team records and charts of 189 young people maintained by service coordinators in a system of care initiative were analyzed to identify the number of intra-team conflicts, the participants involved in each conflict, the theme of each conflict and their relationship with the likelihood that young people were successful in meeting their treatment goals. Findings indicate that interpersonal concerns and concerns about team member follow-through were the most frequent types of conflict. More important, our analyses suggest that more frequent conflicts significantly increased the likelihood that a child and family team (CFT) was unsuccessful in helping the youth and family achieve the desired treatment goals. The results underline the need for further research on how structure and functioning of services coordination teams impact youth and family outcomes.

The Dawn Project: a model for responding to the needs of children with emotional and behavioral challenges and their families.

Systems of care represent a fundamental departure from traditional service provision by espousing genuine family-centered, culturally competent philosophies and blending the funding streams of multiple payers (e.g., education, mental health, child welfare). In Marion County, Indiana, local leaders created a system of care based on these principles called the Dawn Project. Currently, a comprehensive, multidisciplinary evaluation is being implemented to evaluate the program. Preliminary findings from initial evaluation efforts suggest that for youth in the project, there is significant clinical improvement during the first year of receiving services, a reduction in the use of more restrictive settings, and a decrease in recidivism among those who successfully complete the program.