Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.
We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.
The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.
Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.
Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).
At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.
The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.
chronic illness; team; joy in work; graduate medical education; ambulatory training; interprofessional training
To facilitate the delivery of excellent patient care, physician-nurse teams must work in a collaborative manner. We found that venues for the joint training of physician-nurse teams to foster collaboration are insufficient.
We developed a novel interprofessional experience in which resident physicians and nurse residents practiced communication and collaboration skills involving a simulated alcohol withdrawal patient care scenario. Theater students portrayed the patients experiencing withdrawal. The team cared for each patient in a fully equipped and functioning hospital room in a simulation center. Together, they collaborated on interventions and a patient plan of care. After the 10-minute bedside scenario, physician and nurse educators facilitated a joint debriefing session for the physician-nurse learning team.
Learners noted an improvement in their ability to identify alcohol withdrawal (44% of participants preencounter to 94% of participants postencounter) and to communicate with team members (55% of participants preencounter to 81% of participants postencounter).
The learners felt the physician-nurse team training experience was exceptionally valuable for its authenticity.
Medical education; physician-nurse collaboration; simulation center
Quality improvement collaboratives are increasingly being used in many countries to achieve rapid improvements in health care. However, there is little independent evidence that they are more cost effective than other methods, and little knowledge about how they could be made more effective. A number of systematic evaluations are being performed by researchers in North America, the UK, and Sweden. This paper presents the shared ideas from two meetings of these researchers. The evidence to date is that some collaboratives have stimulated improvements in patient care and organisational performance, but there are significant differences between collaboratives and teams. The researchers agreed on the possible reasons why some were less successful than others, and identified 10 challenges which organisers and teams need to address to achieve improvement. In the absence of more conclusive evidence, these guidelines are likely to be useful for collaborative organisers, teams and their managers and may also contribute to further research into collaboratives and the spread of innovations in health care.
The U.S. Agency for Healthcare Research and Quality's (AHRQ) Integrated Delivery Systems Research Network (IDSRN) program was established to foster public-private collaboration between health services researchers and health care delivery systems. Its broad goal was to link researchers and delivery systems to encourage implementation of research into practice. We evaluated the program to address two primary questions: 1) How successful was IDSRN in generating research findings that could be applied in practice? and 2) What factors facilitate or impede such success?
We conducted in-person and telephone interviews with AHRQ staff and nine IDSRN partner organizations and their collaborators, reviewed program documents, analyzed projects funded through the program, and developed case studies of four IDSRN projects judged promising in supporting research implementation.
Participants reported that the IDSRN structure was valuable in creating closer ties between researchers and participating health systems. Of the 50 completed projects studied, 30 had an operational effect or use. Some kinds of projects were more successful than others in influencing operations. If certain conditions were met, a variety of partnership models successfully supported implementation. An internal champion was necessary for partnerships involving researchers based outside the delivery system. Case studies identified several factors important to success: responsiveness of project work to delivery system needs, ongoing funding to support multiple project phases, and development of applied products or tools that helped users see their operational relevance. Factors limiting success included limited project funding, competing demands on potential research users, and failure to reach the appropriate audience.
Forging stronger partnerships between researchers and delivery systems has the potential to make research more relevant to users, but these benefits require clear goals and appropriate targeting of resources. Trade-offs are inevitable. The health services research community can best consider such trade-offs and set priorities if there is more dialogue to identify areas and approaches where such partnerships may have the most promise. Though it has unique features, the IDSRN experience is relevant to research implementation in diverse settings.
The Community, Health Center, and Academic Medicine Partnership Project (CHAMPP) is a partnership between medical researchers, community health centers (CHCs), and a community advisory committee focused on reducing cardiovascular morbidity related to hypertension and diabetes for non-Hispanic Black and Hispanic populations in Boston, Massachusetts.
We conducted site visits at seven participating CHCs, located in Boston. The visits were to solicit health center staff opinions about site-specific barriers and enabling factors for optimum preventative cardiovascular care for racial/ethnic minority patients receiving hypertension and diabetes care at their centers.
Site visits included a tour of each health center and a series of directed interviews with center personnel. Site visit notes were reviewed to identify themes that emerged during the course of each site visit. A summary matrix was developed for each health center, which included information regarding the most salient and persistent themes of the visit.
Site visits uncovered several patient-, provider-, CHC-, and community-based factors that either facilitate or hinder optimal care of chronic disease patients. Commonly referenced barriers included the need for improved patient adherence to provider recommendations; insufficient time for providers to address complex health issues presented by patients and the need for a broader range of healthier food options in surrounding communities. Interactive patient groups and community health workers (CHWs) have been well received when implemented.
Recommendations included adopting case management as a part of usual care for chronic disease patients; additionally, widespread implementation of CHWs may to provide a platform for more comprehensive care for patients.
Community-based participatory research; health disparities; health outcomes; cardiovascular diseases; diabetes mellitus; endocrine system diseases
Diabetes care is a challenge in rural areas where primary care practices are faced with limited resources, few clinical information systems, and relative isolation from education programs and diabetes centers with multispecialty teams. This report describes an effective field-based approach to support improved care for patients with diabetes in primary care practices in rural states.
A collaborative effort between diabetes prevention and control programs in Montana and Wyoming and the University of North Dakota was established to provide support to rural primary care practices for improvement in diabetes care. Field teams from each state diabetes program approached primary care practices. After assessment and orientation of office staff, a computer-based registry was established in each practice. Baseline data were collected in 1997 in Montana and in 1998 in Wyoming; follow-up occurred on July 31, 2004. Health department staff provided ongoing technical support for implementing and evaluating quality-improvement interventions.
Forty primary care practices, providing care to more than 7000 patients with diabetes, participated in this quality-improvement effort at follow-up. Of the 37 primary care practices participating in the quality-improvement program for 6 or more months at follow-up, there were significant improvements in Montana in rates of hemoglobin A1c testing, blood glucose control, low-density lipoprotein cholesterol testing, foot and dilated retinal examinations, and pneumococcal vaccinations, and there were significant improvements in pneumococcal vaccinations in Wyoming.
A field-based approach in which individual practices maintain and use their own registries for both clinical care and quality improvement with ongoing support is a sustainable and an effective strategy for improving diabetes care for rural populations.
Interprofessional education is a collaborative approach to develop healthcare students as future interprofessional team members and a recommendation suggested by the Institute of Medicine. Complex medical issues can be best addressed by interprofessional teams. Training future healthcare providers to work in such teams will help facilitate this model resulting in improved healthcare outcomes for patients. In this paper, three universities, the Rosalind Franklin University of Medicine and Science, the University of Florida and the University of Washington describe their training curricula models of collaborative and interprofessional education.
The models represent a didactic program, a community-based experience and an interprofessional-simulation experience. The didactic program emphasizes interprofessional team building skills, knowledge of professions, patient centered care, service learning, the impact of culture on healthcare delivery and an interprofessional clinical component. The community-based experience demonstrates how interprofessional collaborations provide service to patients and how the environment and availability of resources impact one's health status. The interprofessional-simulation experience describes clinical team skills training in both formative and summative simulations used to develop skills in communication and leadership.
One common theme leading to a successful experience among these three interprofessional models included helping students to understand their own professional identity while gaining an understanding of other professional's roles on the health care team. Commitment from departments and colleges, diverse calendar agreements, curricular mapping, mentor and faculty training, a sense of community, adequate physical space, technology, and community relationships were all identified as critical resources for a successful program. Summary recommendations for best practices included the need for administrative support, interprofessional programmatic infrastructure, committed faculty, and the recognition of student participation as key components to success for anyone developing an IPE centered program.
interprofessional; healthcare teams; collaboration; interprofessional education; interprofessional curricula models
To improve equity in access to medical research, successful strategies are needed to recruit diverse populations. Here, we examine experiences of community health center (CHC) staff who guided an informed consent process to overcome recruitment barriers in a medical record review study.
We conducted ten semi-structured interviews with CHC staff members. Interviews were audiotaped, transcribed, and structurally and thematically coded. We used NVivo, an ethnographic data management software program, to analyze themes related to recruitment challenges.
CHC interviewees reported that a key challenge to recruitment included the difficult balance between institutional review board (IRB) requirements for informed consent, and conveying an appropriate level of risk to patients. CHC staff perceived that the requirements of IRB certification itself posed a barrier to allowing diverse staff to participate in recruitment efforts. A key barrier to recruitment also included the lack of updated contact information on CHC patients. CHC interviewees reported that the successes they experienced reflected an alignment between study aims and CHC goals, and trusted relationships between CHCs and staff and the patients they recruited.
Making IRB training more accessible to CHC-based staff, improving consent form clarity for participants, and developing processes for routinely updating patient information would greatly lower recruitment barriers for diverse populations in health services research.
Community-based participatory research; Patient selection; Health status disparities; Informed consent; Poverty; Vulnerable populations
Despite a burgeoning interest in using interprofessional approaches to promote effective collaboration in health care, systematic reviews find scant evidence of benefit. This protocol describes the first cluster randomized controlled trial (RCT) to design and evaluate an intervention intended to improve interprofessional collaborative communication and patient-centred care.
The objective is to evaluate the effects of a four-component, hospital-based staff communication protocol designed to promote collaborative communication between healthcare professionals and enhance patient-centred care.
The study is a multi-centre mixed-methods cluster randomized controlled trial involving twenty clinical teaching teams (CTTs) in general internal medicine (GIM) divisions of five Toronto tertiary-care hospitals. CTTs will be randomly assigned either to receive an intervention designed to improve interprofessional collaborative communication, or to continue usual communication practices.
Non-participant naturalistic observation, shadowing, and semi-structured, qualitative interviews were conducted to explore existing patterns of interprofessional collaboration in the CTTs, and to support intervention development. Interviews and shadowing will continue during intervention delivery in order to document interactions between the intervention settings and adopters, and changes in interprofessional communication.
The primary outcome is the rate of unplanned hospital readmission. Secondary outcomes are length of stay (LOS); adherence to evidence-based prescription drug therapy; patients' satisfaction with care; self-report surveys of CTT staff perceptions of interprofessional collaboration; and frequency of calls to paging devices. Outcomes will be compared on an intention-to-treat basis using adjustment methods appropriate for data from a cluster randomized design.
Pre-intervention qualitative analysis revealed that a substantial amount of interprofessional interaction lacks key core elements of collaborative communication such as self-introduction, description of professional role, and solicitation of other professional perspectives. Incorporating these findings, a four-component intervention was designed with a goal of creating a culture of communication in which the fundamentals of collaboration become a routine part of interprofessional interactions during unstructured work periods on GIM wards.
Registered with National Institutes of Health as NCT00466297.
The number of patients with cardiovascular and kidney disease in the United States continues to grow as the population ages, increasing the demand on the health care system and its providers. Many patients develop chronic conditions in which optimization of care is labor intensive, specifically hypertension, hyperlipidemia, diabetes, heart failure, and chronic kidney disease. Therefore, innovative and collaborative approaches to health care are warranted. Several team-based health care models have evolved and are gaining popularity, including the Patient-Centered Medical Home (PCMH) and Medication Therapy Management (MTM). Team-based care is widely supported in the literature, demonstrating significant improvement in cardiovascular and renal outcomes. This article will review the premises of PCMH and MTM, review the evidence and roles for team-based care specific to cardiovascular and renal outcomes, and introduce fundamentals to implement collaborative practice focusing on pharmacist-provider teams.
Collaboration; Team-based care; Cardiovascular outcomes; Renal outcomes; Pharmacist; Patient-Centered Medical Home; Medication Therapy Management
The Health Disparities Collaboratives (HDC), a quality improvement collaborative incorporating rapid quality improvement (QI), a chronic care model, and learning sessions, have been implemented in over 900 community health centers across the country.
To determine the HDC’s effect on clinical processes and outcomes, their financial impact, and factors important for successful implementation.
Systematic review of the literature.
The HDC improve clinical processes of care over short-term 1–2 year periods, and clinical processes and outcomes over longer 2–4 year periods. Most participants perceive that the HDC are successful and worth the effort. Analysis of the Diabetes Collaborative reveals that it is societally cost-effective with an incremental cost-effectiveness ratio of $33,386/quality-adjusted life year (QALY), but that consistent revenue streams for the initiative do not exist. Common barriers to improvement include lack of resources, time, and staff burnout. Highest ranked priorities for more funding are money for direct patient services, data entry, and staff time for QI. Other common requests for more assistance are help with patient self-management, information systems, and getting providers to follow guidelines. Relatively low-cost ways to increase staff morale and prevent burnout include personal recognition, skills development opportunities, and fair distribution of work.
The HDC have successfully improved quality of care and the Diabetes Collaborative is societally cost-effective, but policy reforms are necessary to create a sustainable business case for these health centers that serve many uninsured and underinsured populations.
quality improvement; community health center; health disparities; cost; diabetes
Obesity and hypertension and their associated health complications disproportionately affect communities of color and people of lower socioeconomic status. Recruitment and retention of these populations in research trials, and retention in weight loss trials has been an ongoing challenge.
Be Fit, Be Well was a pragmatic randomized weight loss and hypertension management trial of patients attending one of three community health centers in Boston, Massachusetts. Participants were asked to complete follow-up assessments every 6-months for two years. We describe challenges encountered and strategies implemented to recruit and retain trial participants over the 24-month intervention. We also identify baseline participant characteristics associated with retention status. Retention strategies included financial incentives, contact between assessment visits, building relationships with health center primary care providers (PCPs) and staff, and putting participant convenience first.
Active refusal rates were low with 130 of 2,631 patients refusing participation (4.9%). Of 474 eligible persons completing telephone screening, 365 (77.0%) completed their baseline visit and were randomized into the study. The study population was predominantly non-Hispanic Black (71.2%), female (68.5%) and reported annual household income of less than $35,000 (70.1%). Recruitment strategies included use of passive approval of potential participants by PCPs, use of part-time staff, and outsourcing calls to a call center. A total of 314 (86.0%) people completed the 24-month visit. Retention levels varied across study visits and intervention condition. Most participants completed three or more visits (69.6%), with 205 (56.2%) completing all four. At 24-months, lower retention was observed for males and the intervention condition. Retention strategies included building strong relationships with clinic staff, flexibility in overcoming participant barriers through use of taxi vouchers, night and weekend appointments, and keeping participants engaged via newsletters and social gatherings.
We were able to retain 86.0% of participants at 24-months. Recruitment and retention of high percentages of racial/ethnic minorities and lower income samples is possible with planning, coordination with a trusted community setting and staff (e.g. community health centers and RAs), adaptability and building strong relationships.
Health disparities; Weight-loss; Obesity; Hypertension; Pragmatic trial; Recruitment; Retention
To develop an in-depth understanding of a shared care model from primary mental health and nutrition care practitioners with a focus on program goals, strengths, challenges and target population benefits.
Qualitative method of focus groups.
The study involved fifty-three practitioners from the Hamilton Health Service Organization Mental Health and Nutrition Program located in Hamilton, Ontario, Canada.
Six focus groups were conducted to obtain the perspective of practitioners belonging to various disciplines or health care teams. A qualitative approach using both an editing and template organization styles was taken followed by a basic content analysis.
Themes revealed accessibility, interdisciplinary care, and complex care as the main goals of the program. Major program strengths included flexibility, communication/collaboration, educational opportunities, access to patient information, continuity of care, and maintenance of practitioner and patient satisfaction. Shared care was described as highly dependent on communication style, skill and expertise, availability, and attitudes toward shared care. Time constraint with respect to collaboration was noted as the main challenge.
Despite some challenges and variability among practices, the program was perceived as providing better patient care by the most appropriate practitioner in an accessible and comfortable setting.
evaluation; interdisciplinary care; mental health; nutrition
The intent of this article is to provide public health and health information exchanges (HIEs) insight into activities and processes for connecting public health with clinical care through HIEs. In 2007 the CDC issued a Request for Proposal (RFP) for the “Situational Awareness through Health Information Exchange” project. The project’s goals are to connect public health with health information exchanges (HIEs) to improve public health’s real-time understanding of communities’ population health and healthcare facility status. This article describes the approach and methodology used by the Northwest Public Health Information Exchange to achieve the project’s goals. The experience of the NWPHIE Collaboration provides an organizational and operational roadmap for implementing a successful regional HIE that ensures secure exchange and use of electronic health information between local and state public health and health care entities.
Data Collection; Electronic Health Records; Health Information Exchange; Information Management; Information Services; Medical Record Linkage; Public Health; Public Health Informatics
Multiorganisational quality improvement (QI) collaborative networks are promoted for improving quality within healthcare. Recently, several large-scale QI initiatives have been conducted in the intensive care unit (ICU) environment with successful quantitative results. However, the mechanisms through which such networks lead to QI success remain uncertain.
We aim to understand ICU staff perspectives on collaborative QI based on involvement in a multiorganisational improvement network and hypothesise about theoretical constructs that might explain the effect of collaboration in such networks.
Qualitative study using a modified grounded theory approach. Key informant interviews were conducted with staff from 12 community hospital ICUs that participated in a cluster randomized control trial (RCT) of a QI intervention using a collaborative approach between 2006 and 2008. Data analysis followed the standard procedure for grounded theory using constant comparative methodology.
The collaborative network was perceived to promote increased intrateam cooperation over interorganisational cooperation, but friendly competition with other ICUs appeared to be a prominent driver of behaviour change. Bedsides, clinicians reported that belonging to a collaborative network provided recognition for the high-quality patient care that they already provided. However, the existing communication structure was perceived to be ineffective for staff engagement since it was based on a hierarchical approach to knowledge transfer and project awareness.
QI collaborative networks may promote behaviour change by improving intrateam communication, fostering competition with other institutions, and increasing recognition for providing high-quality care. Other commonly held assumptions about their potential impact, for instance, increasing interorganisational legitimisation, communication and collaboration, may be less important.
Collaborative, Breakthrough Groups; Critical Care; Healthcare Quality Improvement; Implementation Science
The Chronic Care Model (CCM) is a multidimensional framework designed to improve care for patients with chronic health conditions. The model strives for productive interactions between informed, activated patients and proactive practice teams, resulting in better clinical outcomes and greater satisfaction. While measures for improving care may be clear, measures of residents’ competency to provide chronic care do not exist. This report describes the process used to develop educational measures and results from CCM settings that used them to monitor curricular innovations.
Twenty-six academic health care teams participating in the national and California Academic Chronic Care Collaboratives.
Using successive discussion groups and surveys, participants engaged in an iterative process to identify desirable and feasible educational measures for curricula that addressed educational objectives linked to the CCM. The measures were designed to facilitate residency programs’ abilities to address new accreditation requirements and tested with teams actively engaged in redesigning educational programs.
Field notes from each discussion and lists from work groups were synthesized using the CCM framework. Descriptive statistics were used to report survey results and measurement performance.
Work groups generated educational objectives and 17 associated measurements. Seventeen (65%) teams provided feasibility and desirability ratings for the 17 measures. Two process measures were selected for use by all teams. Teams reported variable success using the measures. Several teams reported use of additional measures, suggesting more extensive curricular change.
Using an iterative process in collaboration with program participants, we successfully defined a set of feasible and desirable education measures for academic health care teams using the CCM. These were used variably to measure the results of curricular changes, while simultaneously addressing requirements for residency accreditation.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1358-1) contains supplementary material, which is available to authorized users.
Chronic Care Model; quality improvement; graduate medical education; ambulatory care; practice-based learning and improvement; systems-based practice
Effective physician–nurse collaboration is an important, but incompletely understood determinant of patient and nurse satisfaction, and patient safety. Its impact on physicians has not been described. This study was undertaken to develop a fuller understanding of the collaboration experience and its outcomes.
Twenty-five medical residents, 32 staff nurses, 5 physician and 5 nurse faculty wrote narratives about successful collaboration; the narratives were then qualitatively analyzed. Narrative analysis was the initial qualitative method iteratively employed to identfy themes. A phenomenological approach was subsequently used to develop a framework for collaborative competence.
Collaboration triggers, facilitative behaviors, outcomes and collaborative competence were the themes identified. Affect was identified in the triggers leading to collaboration and in its outcomes. Practioners typically entered a care episode feeling worrried, uncertain or inadequate and finished the interaction feeling satisfied, understood and grateful to their colleagues. The frequency of affective experience was not altered by gender, profession, or ethnicity. These experiences were particularly powerful for novice practioners of both disciplines and appear to have both formative and transformative potential. Collaborative competence was characterized by a series of graduated skills in clinical and relational domains. Many stories took place in the ICU and afterhours settings.
Despite the prevailing wisdom that nursing and medicine are qualitatively different, the stories from this study illuminate surprising commonalities in the collaboration experience, regardless of gender, age, experience, or profession. Collaborative competence can be defined and its component skills identified. Contexts of care can be identified that offer particularly rich opportunities to foster interprofessional collaboration.
collaboration; competency; relationship-centered practice; teamwork
In health care teams, lack of collaboration or inability to collaborate undermines the goal of providing holistic and comprehensive geriatric care. This study examines relational communication control used by hospice interdisciplinary team members in their attempt to share information and contribute to decision making in team meetings. Eighty-one hospice team discussions were coded for message control types. Analysis of the data found that the nurse’s role as primary reporter implicitly created a struggle for relational control among other team members within the meeting. This study concluded that a majority of interpersonal communication in the team meetings was aimed at gaining control of the information exchange. Future attention should be given to organizational policy aimed at shaping the structure of team meetings.
Quality improvement collaboratives are a popular model used to address gaps between evidence-based practice and patient care. Little is known about use of such collaboratives in emergency medical services, particularly for improving prehospital stroke care. To determine the feasibility of using this approach to improve prehospital stroke care, we conducted a pilot study of the Emergency Medical Services Stroke Quality Improvement Collaborative.
Seventeen Massachusetts emergency medical service agencies participated in the quality improvement collaborative pilot project. We identified 5 prehospital stroke performance measures to assess the quality of prehospital care, guide collaborative activities, and monitor change in performance over time. During learning sessions, participants were trained in quality improvement and performance measurement, analyzed performance measure results, and shared successes and challenges. Focus groups were conducted to understand participants’ experiences with the collaborative.
Participating emergency medical service agencies collected stroke performance measures on 3,009 stroke patients during the pilot study. Adherence to 4 of 5 performance measures increased significantly over time. Participants acknowledged that the collaborative provided them with an efficient and effective framework for stroke quality improvement and peer-learning opportunities.
As evidenced in Massachusetts, quality improvement collaboratives can be an effective tool to improve prehospital stroke care. The data collected, improvements made, participation of emergency medical service agencies, and positive experiences within the collaborative support the continued use of this approach.
The basic premise of this effort is that health care can be made more effective and affordable by applying modern computer technology to improve collaboration among diverse and distributed health care providers.
Information sharing, communication, and coordination are basic elements of any collaborative endeavor. In the health care domain, collaboration is characterized by cooperative activities by health care providers to deliver total and real-time care for their patients. Communication between providers and managed access to distributed patient records should enable health care providers to make informed decisions about their patients in a timely manner. With an effective medical information infrastructure in place, a patient will be able to visit any health care provider with access to the network, and the provider will be able to use relevant information from even the last episode of care in the patient record. Such a patient-centered perspective is in keeping with the real mission of health care providers.
Today, an easy-to-use, integrated health care network is not in place in any community, even though current technology makes such a network possible. Large health care systems have deployed partial and disparate systems that address different elements of collaboration. But these islands of automation have not been integrated to facilitate cooperation among health care providers in large communities or nationally.
CERC and its team members at Valley Health Systems, Inc., St. Marys Hospital and Cabell Huntington Hospital form a consortium committed to improving collaboration among the diverse and distributed providers in the health care arena. As the first contract recipient of the multi-agency High Performance Computing and Communications (HPCC) Initiative, this team of computer system developers, practicing rural physicians, community care groups, health care researchers, and tertiary care providers are using research prototypes and commercial off-the-shelf technologies to develop an open collaboration environment for the health care domain. This environment is called ARTEMIS — Advanced Research TEstbed for Medical InformaticS.
Given the increasing prevalence of diabetes and the lack of patients reaching recommended therapeutic goals, novel models of team-based care are emerging. These teams typically include a combination of physicians, nurses, case managers, pharmacists, and community-based peer health promoters (HPs). Recent evidence supports the role of pharmacists in diabetes management to improve glycemic control, as they offer expertise in medication management with the ability to collaboratively intensify therapy. However, few studies of pharmacy-based models of care have focused on low income, minority populations that are most in need of intervention. Alternatively, HP interventions have focused largely upon low income minority groups, addressing their unique psychosocial and environmental challenges in diabetes self-care. This study will evaluate the impact of HPs as a complement to pharmacist management in a randomized controlled trial.
The primary aim of this randomized trial is to evaluate the effectiveness of clinical pharmacists and HPs on diabetes behaviors (including healthy eating, physical activity, and medication adherence), hemoglobin A1c, blood pressure, and LDL-cholesterol levels. A total of 300 minority patients with uncontrolled diabetes from the University of Illinois Medical Center ambulatory network in Chicago will be randomized to either pharmacist management alone, or pharmacist management plus HP support. After one year, the pharmacist-only group will be intensified by the addition of HP support and maintenance will be assessed by phasing out HP support from the pharmacist plus HP group (crossover design). Outcomes will be evaluated at baseline, 6, 12, and 24 months. In addition, program and healthcare utilization data will be incorporated into cost and cost-effectiveness evaluations of pharmacist management with and without HP support.
The study will evaluate an innovative, integrated approach to chronic disease management in minorities with poorly controlled diabetes. The approach is comprised of clinic-based pharmacists and community-based health promoters collaborating together. They will target patient-level factors (e.g., lack of adherence to lifestyle modification and medications) and provider-level factors (e.g., clinical inertia) that contribute to poor clinical outcomes in diabetes. Importantly, the study design and analytic approach will help determine the differential and combined impact of adherence to lifestyle changes, medication, and intensification on clinical outcomes.
ClinicalTrials.gov identifier: NCT01498159
(3–10): Diabetes mellitus/drug therapy; Patient compliance; Patient education; Pharmacists; Community health workers
Objective: To develop a framework for understanding factors affecting the use of patient survey data in quality improvement.
Design: Qualitative interviews with senior health professionals and managers and a review of the literature.
Setting: A quality improvement collaborative in Minnesota, USA involving teams from eight medical groups, focusing on how to use patient survey data to improve patient centred care.
Participants: Eight team leaders (medical, clinical improvement or service quality directors) and six team members (clinical improvement coordinators and managers).
Results: Respondents reported three types of barriers before the collaborative: organisational, professional and data related. Organisational barriers included lack of supporting values for patient centred care, competing priorities, and lack of an effective quality improvement infrastructure. Professional barriers included clinicians and staff not being used to focusing on patient interaction as a quality issue, individuals not necessarily having been selected, trained or supported to provide patient centred care, and scepticism, defensiveness or resistance to change following feedback. Data related barriers included lack of expertise with survey data, lack of timely and specific results, uncertainty over the effective interventions or time frames for improvement, and consequent risk of perceived low cost effectiveness of data collection. Factors that appeared to have promoted data use included board led strategies to change culture and create quality improvement forums, leadership from senior physicians and managers, and the persistence of quality improvement staff over several years in demonstrating change in other areas.
Conclusion: Using patient survey data may require a more concerted effort than for other clinical data. Organisations may need to develop cultures that support patient centred care, quality improvement capacity, and to align professional receptiveness and leadership with technical expertise with the data.
Project Leonardo represented a feasibility study to evaluate the impact of a
disease and care management (D&CM) model and of the introduction of
“care manager” nurses, trained in this specialized
role, into the primary health care system.
Patients and methods
Thirty care managers were placed into the offices of 83 general practitioners
and family physicians in the Apulia Region of Italy with the purpose of
creating a strong cooperative and collaborative
“team” consisting of physicians, care managers,
specialists, and patients. The central aim of the health team collaboration
was to empower 1,160 patients living with cardiovascular disease (CVD),
diabetes, heart failure, and/or at risk of cardiovascular disease (CVD risk)
to take a more active role in their health. With the support of dedicated
software for data collection and care management decision making, Project
Leonardo implemented guidelines and recommendations for each condition aimed
to improve patient health outcomes and promote appropriate resource
Results show that Leonardo was feasible and highly effective in increasing
patient health knowledge, self-management skills, and readiness to make
changes in health behaviors. Patient skill-building and ongoing monitoring
by the health care team of diagnostic tests and services as well as
treatment paths helped promote confidence and enhance safety of chronic
patient management at home.
Physicians, care managers, and patients showed unanimous agreement regarding
the positive impact on patient health and self-management, and attributed
the outcomes to the strong “partnership” between the
care manager and the patient and the collaboration between the physician and
the care manager. Future studies should consider the possibility of
incorporating a patient empowerment model which considers the patient as the
most important member of the health team and care managers as key health
care collaborators able to enhance and support services to patients provided
by physicians in the primary health care system.
partnerships; health team; patient empowerment; care coordination
Hurricane Katrina was one of the most catastrophic natural disasters to hit the United States. It had a major impact on health care in New Orleans, LA and the surrounding region, not only in relation to acute illness but also chronic disease. When Hurricane Katrina struck New Orleans on August 29, 2005, there were 193 participants being followed in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial at Tulane University Health Sciences Center. In the immediate aftermath of the storm, the Tulane University ACCORD Study site, in collaboration with the Study Coordinating Center and the Southeast Clinical Center Network office of the trial at Wake Forest University Health Sciences in North Carolina, took several actions in order to locate the participants, ensure their safety, and maintain the scientific integrity of the trial. We describe the actions taken and the relative success/failure of such actions.
Clinical interventions based on collaborative models require effective communication between primary care providers (PCPs) and collaborative support teams. Despite growing interest in collaborative care, we have identified no published studies describing how PCPs prefer to communicate and interact with collaborative support teams. This manuscript examines the communication and interaction preferences of PCPs participating in an ongoing randomized clinical trial of a collaborative intervention for chronic pain and depression.
The trial is being conducted in five primary care clinics of a Veterans Affairs Medical Center. Twenty-one PCPs randomized to the study intervention completed a survey regarding preferences for interacting with the collaborative support team.
A majority of PCPs identified email (95%) and telephone calls (68%) as preferred modes for communicating with members of the support team. In contrast, only 29% identified in-person communications as preferred. Most PCPs preferred that the care manager and physician pain specialist assess patients (76%) and make initial treatment changes (71%) without first conferring with the PCP. One-half wanted to be designated cosigners of all support team notes in the electronic medical record, one-half wanted to receive brief and focused information rather than in-depth information about their patients, and one-half wanted their practice nurses automatically included in communications. Panel size was strongly associated (p < 0.001) with preference for brief, to-the-point discussions about patients.
The substantial variation in PCP communication preferences suggests the need for knowledge of these preferences when designing and implementing collaborative interventions. Additional research is needed to understand relationships between clinician and practice characteristics and interaction preferences.