This thesis examines the retention of best practices by clinicians after the implementation of an integrated care pathway for patients with congestive heart failure. While the literature suggests there are many reasons why the implementation of best practices is difficult, there is little information on the sustainability of best practices once implemented.<p>Using a qualitative research design guided by Rogers theory of Diffusion of Innovations the researcher interviewed seven clinicians who participated in the implementation of the pathway. A thematic analysis revealed several themes that ran throughout participants responses. <p>While the participants indicated they see value in best practices, they also identified barriers to getting that knowledge into practice and keeping it there. A spectrum of factors, including individual autonomy, time, resources, organizational support and the organization of the system all played a role.<p>In the end, participants revealed that although small pieces of the pathway remain in practice, the pathway itself is no longer used by clinicians to manage patients with congestive heart failure.

Background: Health systems internationally face a common set of challenges: ageing populations, increasing numbers of patients suffering from multiple long-term conditions (multimorbidity) and severe pressure on health and care budgets. ‘Integrated care’ is pitched as the solution to current health system challenges. But, in the literature, what integrated care actually involves is complex and contested. Aims: 1. What does ‘integrated care’ currently look like in practice in the NHS? 2. What is the effectiveness of current models of ‘integrated care’? 3. To what extent are there differential effects of ‘integrated care’ for different types of multimorbidity? Methods: The thesis utilises routinely collected data, systematic review and meta-analysis, combined with quasi-experimental methods (difference-in-differences, and subgroup analysis, difference-in-difference-in-differences). Results: The current implementation of the concept of integrated care is predominantly carried out through multidisciplinary team (MDT) case management of ‘at risk’ (usually of secondary-care admissions) patients in primary care. This approach, however, has not proven capable of meeting health outcome and utilisation/cost aims. Patient satisfaction, though, is consistently improved by the approach. There might also be positive spill-over effects of increased team-working through MDTs for the wider practice population. There does not appear to be a multimorbidity subgroup which benefits significantly more than others in terms of secondary-care utilisation or cost. However, patients at the end of life and/or those with only primary-care sensitive conditions might benefit slightly more than others. Conclusions: Integrated care, in its current manifestation, is not a silver bullet that will enable health systems to simultaneously accomplish better health outcomes for those with long-term conditions and multimorbidity while increasing their satisfaction with services and reducing costs. The current financial climate might mean that other means of achieving prioritised aims are required in the short-term, with comprehensive primary care and population health strategies employed to better prevent/compress the negative effects of lifestyle-associated conditions in the longer-term.

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This study examined pediatric residents’ responsiveness and experiences in the context of a new pilot program, building an on-site Behavioral Health Consultant (BHC) into their primary care training site. Fifteen pediatric residents were divided so that 9 had access to an on-site BHC and 6 did not. Over the first year of the program, research assistants observed 322 patient visits to record concerns raised, residents’ responses, and visit length. Data regarding BHC activity and residents’ subjective impressions of the program were also collected. Results showed that at least one BH concern was raised in 24% of observed visits. Residents with access to the BHC initiated 89 on-the-spot referrals, resulting in 127 BHC-to-patient interactions. On average, residents spent 10 additional min/visit when BH concerns were raised but those with access to the BHC saved 8 min/visit when BH concerns were raised. Overall, residents utilized the service, particularly first and second year residents. Those with BHC access managed BH concerns in less time than those in the control group. Residents who utilized the BHC were very satisfied, perceived a better quality of care and patient outcomes, and desired future BHC collaboration. Implications for training residents in the area of pediatric behavioral health by using an on-site provider are discussed.

Professional identity drives the development of work force, commitment to goals and objectives, and the extent to which an organization like CFHA flourishes. However, many clinicians have simply "found" their way in terms of professional identity and roles within primary care, and tend to struggle with divergences between their identified disciplines and the roles they find themselves within an integrated care model. Behaviorists who strongly identify with their roles as a primary care provider within integrated care will inherently be a driving force in achieving the objectives of the Triple Aim Model. The aim of the session will be to address how training programs, corporations, and national associations like CFHA can foster professional identity through a lively panel discussion representing various disciplines working in integrated care models. The intent would be to offer up some solutions and ideas leading to improved professional identity, there by positively impacting the cost, outcomes, and effectiveness of patient care as intended by the Triple Aim Model.

Integration in rural primary care has well-delineated advantages, but there are barriers to developing a workforce in these areas. In this presentation, representatives from three novel rural service delivery programs will discuss specific strategies for overcoming these barriers. Attendees will learn how a rural Federally Qualified Health Center grew from 0 to 6 full-time psychologists in two years, how a graduate training program uses telehealth to provide services at rural primary care clinics, and how integrated clinics in the Frontier counties of Nebraska ensure a future workforce starting by targeting high school students.

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Excerpt: Summer gardens everywhere are kicking out crops at last. Just yesterday I pulled six cucumbers from a vine and set three more tomatoes on the kitchen windowsill. Hmmm… with balsamic and oil? Mozzarella and basil? Decisions, decisions! The Psychology Department at East Tennessee State University (ETSU) is at a similar point.

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