A frequently cited reason for poor quality of care in the ambulatory care setting is the lack of optimally designed systems to address care for those with preventive or chronic care needs. Organizational theory suggests that culture plays an important role in the shaping of these types of programs. The purpose of this cross-sectional study is to understand through descriptive and regression analysis of secondary data, the relationship between the existence of cultural characteristics such as collegiality, quality emphasis and autonomy, and the systems employed to improve quality of care within primary care practices. The study uses an integrated theoretical framework consisting of organizational culture, social network and organizational learning theories to better understand the rationale for the relationships. The analysis is an outgrowth of a previous National Committee for Quality Assurance (NCQA) project conducted in Minnesota where 300 staff across 42 office practices were asked to answer questions on a self-report survey to assess the presence and function of clinical practice systems. To evaluate organizational culture, validated questions from the work of Kralewski and colleagues were also asked. Descriptive analysis results showed a large range in consistency of practice system use, with clinical information systems as most used and care management systems as least used. Results of the multivariate analysis showed collegiality and quality emphasis as significantly related to the use of practice systems. More specifically, both collegiality and quality emphasis were seen to positively influence the use of clinical quality evaluation and improvement systems and an emphasis of quality was seen to positively influence the use of clinician reminders and clinical information systems. A statistically significant relationship between autonomy and practice systems use was not seen. As the study shows that culture does influence the use of certain systems for care improvement, it provides an increased understanding and avenue for intervention/change in the continued quest for improved quality of care. Policymakers and practice leadership may want to focus energy on understanding primarily whether the culture of practices places an emphasis on quality and collegiality. Ultimately it may foster the use of practice systems for quality of care improvement.

Health care today harms too frequently and routinely fails to deliver its potential benefits. Significant evidence suggests that high quality primary care can positively affect health outcomes. I explored three related topics mentioned frequently in current United States health reform €“ Electronic Health Records (EHR), physician profiling and Medical Home. An investment in these areas is expected to significantly improve quality of care and efficiency; however, there is only a patchwork of evidence supporting such claims. To achieve EHR promises, my research employed a standardization lens to study the dynamics between EHR embedded structures and primary care processes. Using grounded theory, a standardization dynamics model was created describing the influencers, conditions and consequences of the process state. A matrix of two conditions, information exchange and patient complexity, identified four distinct pathways that require a different balance between standardization and flexibility. The value of such pathways is that they frame choices about how to use embedded IT structures to support effective delivery processes. Physician profiling is an emerging methodology used in health care quality improvement programs. Efforts to measure performance at the individual physician level face a number of challenges, including the need for sufficient sample size to support reliable measurement. A process for creating a physician profiling model was developed, and a model designed for a case study site. Results indicate that reliable physician profiling is possible across care domains using a hierarchical composite model. Patient-Centered Medical Home (PCMH) is a new care delivery approach for providing comprehensive primary care that seeks to strengthen the physician-patient relationship. This exploratory study utilizes Pearson correlation coefficients to test four hypotheses about relationships between two sources of data: (1) PPC-PCMH Survey results that measure adoption of PCMH structures and (2) patient experience data from Massachusetts Health Quality Partners (MHQP). The results showed that the PPC-PCMH structures of access and communication were negatively correlated with the related patient experience measure. This study contributes to the literature by addressing deficiencies in how EHR-enabled processes, physician profiling models and Medical Home constructs are measured, to support improved outcomes.

OBJECTIVE: Immigrants to the United States represent a variety of ethnocultural backgrounds, experiences, and languages. They face stressors unique to migration that may exacerbate or cause mental health concerns. Despite this increased risk, immigrants access treatment at rates far below their native-borne counterparts. Structural and cultural barriers to mental health service utilization expound this disparity. The present thesis proposes a novel system to provide psychosocial support for US immigrants seeking treatment at Massachusetts General Hospital (MGH).  METHODS: Recognizing the need for a new paradigm of care, an Immigrant Mental Health Center prototype was conceptualized using a Human-Centered Design approach. The foundations for this prototype align with the Patient-Centered Medical Home approach to integrated primary and mental healthcare. Narrative reviews informed the theoretical basis of the prototype. A brief review of the existing literature yielded five integrated care themes, forming the basis for prototype evaluation criteria. Communication materials for stakeholder meetings and expert advisory panels were prepared as the next step in the Human-Centered Design approach.  RESULTS: The prototype extended care to a diverse spectrum of US immigrants within the MGH healthcare network. It involved a multidisciplinary team of specialists, whole-patient orientation, a personal practitioner, increased accessibility, and viable internal (MGH) and external (community) linkages.  CONCLUSIONS: The next steps in the Human-Centered Design approach include iteratively designing solutions to co-optimize the prototype for implementation at the MGH Center for Immigrant Health. Recommendations for the iterative refinement stage include clarifying financial metrics and addressing structural barriers to treatment accessibility. A series of feasibility pilot trials and efficacy randomized-controlled trials precede implementation. Future directions include extending the target population to second or third-generation immigrants, attending to severe mental illnesses, and fostering inpatient mental healthcare linkages as a bridge to long-term care.

No description available.

The Patient-Centered Medical Home (PCMH) is an innovative, team-based health care model that was applied during the implementation of the Affordable Care Act (ACA). However, the competencies for PCMH health care social worker team members are not identified within this model. Thus, the purpose of this phenomenological study focused on identifying the core competencies that will enable social workers to perform competently in PCMHs. This study also explored the roles and training needs as related to improving the competence of social workers. Sandberg's and Parry's conceptualization of the competency model was used as the theoretical framework. Data were acquired through interviews with 10 PCMH social workers. These data were then inductively coded and analyzed using a modified Moustakas method. Key findings indicated that these social workers believed that improvements in competencies may include training and knowledge with mental health and physical health knowledge which consist of diagnoses, interventions, medications, symptoms, and terminology. It was also noted that knowledge of evidence-based practices for mental health interventions and patient-centered, team-based principles were essential to ACA policy implementation. The positive social change implications of this study include recommendations to health care leadership, educational institutions, and other PCMH providers to develop competency-based training for social workers. Recommendations are also put forth to adapt social work curriculum to ensure the effective implementation of the principles of the ACA policy and to improve social work practice in PCMH health care settings.

Purpose: To describe family perceptions about pediatric primary care management following diagnosis of type 1 diabetes mellitus (T1DM) in preschool-aged children living in the Pacific Northwest region of the United States. Study Design and Method: Mothers of children diagnosed with T1DM before the fifth birthday and within the past two years were recruited anonymously through two regional support groups. Perceptions about pediatric primary care management following T1DM diagnosis were elicited through an anonymous 30-item online survey. Demographic characteristics of mother and child were obtained as well as information about five important domains of health care management for a young child with T1DM: (1) multidisciplinary, (2) holistic and compassionate, (3) accessible and communicative, (4) uses current standards and technology, and (5) actively promotes safe self-management. Results: Twenty-one biological mothers participated in this study, each on behalf of a child diagnosed with T1DM who fit inclusion criteria. Overall mothers held positive perceptions about care management by PCPs and endocrinologists within context of each of the five domains. Most mothers felt included in care planning, valued periodic well-child exams, and believed the child's providers were accessible, communicated effectively, and usually demonstrated consideration/compassion for the family. Although a majority of mothers at least somewhat agreed that the PCP used current standards and technology to care for the child, and functioned as the center of his/her health care coordination, these domains elicited a slightly greater number of responses indicating uncertainty or disagreement. Clinical Implications: Nurses and pediatric practitioners can use findings from this study to plan continued exploration into the perceptions and care management needs of families following diagnosis of a very young child with T1DM. The domains of care used to assess mothers' perceptions about care management-based on tenets of the Chronic Care Model (CCM) and Patient Centered Medical Home (PCMH)-can be used by pediatric PCPs and endocrinologists to dialogue with patients and staff about how care management may be improved for these families. Providing opportunities for feedback to the families of young children with T1DM should be encouraged so future research can examine relationships between care management variables and clinical outcomes.

No description available.

Provider incentives are a commonly used policy tool to mold provider behaviors.1 However, while we frequently measure the change in patient outcomes, failure to consistently produce changes in outcomes does not mean that providers are not changing their behavior. This paper focuses on two programs with null or inconsistent quality outcomes to try to identify why such inconsistency occurs. The two programs, both ratified in the Affordable Care Act, are 1) patient-centered medical homes (PCMHs), and 2) the Medicare Hospital Value-Based Purchasing (HVBP) program. Chapter 1: Using data from the Medical Expenditure Panel survey (MEPS), I match provider characteristic surveys to member experience with care in order to evaluate characteristics key to patient-centered medical homes. I find that patient-perceived patient-centeredness of a practice is not related to the number of PCMH attributes a practice reports. However, some characteristics do play specific and significant roles in patient perception and outcomes. For instance, case management is not only associated with increased patient perception of after-hours access to care, but overall costs were reduced. Interestingly, having after hours clinic hours was more common with practices highly consistent with PCMH criteria, but these hours did not result in decreased emergency department use or cost of care. Chapter 2: The second provider incentive studied is the Medicare Hospital Value-Based Purchasing Program (HVBP). This program assigns payment adjustments based on performance on a series of rotating quality metrics. To date, changes in patient outcomes cannot be attributed to the program; however, it should not be concluded that hospitals are not responding at all. I identify changes in staffing by provider type as an early indicator of hospital response to payment incentives. Data come from the Virginia Health Information (VHI) Hospital Cost Report, 2010-2017. Using a generalized linear model, I find that when receiving a penalty, hospitals reduce staffing among the most and least expensive personnel (physicians and nursing aides). Hospitals increase nursing and administrative staff following a bonus. These findings are consistent with hospitals responding to incentives both by aiming to improve efficient use of resources and maintain or improve quality of care. Chapter 3: Finally, I assess potential unintended consequences of the HVBP program, specifically the provision of charity care. Using the VHI cost reports for year 2013 to 2017 with a regression discontinuity model, I find that hospitals receiving a bonus decrease their charity care among the lowest income patients (under 100% federal poverty level (FPL)). Hospitals receiving a penalty tend to reduce charity care among higher income patients (100%-200% FPL). These findings are consistent with two separate responses to the incentives. Hospitals receiving bonuses appear to be cream-skimming healthier, wealthier individuals while hospitals receiving penalties appear to be shifting the focus of their charity care to the most needy, likely in an effort to reduce cost of care levels overall while maintaining their community benefit programs, potentially as a result of goal gradient cognitive bias.

Ineffectively managed chronic diseases such as diabetes mellitus (DM) increase overall health care expenditures and negatively affects health outcomes such as exacerbations, functional decline, disability, and death. The purpose of this systematic review (SR) was to review the DM outcomes reported by patient-centered medical homes (PCMHs). The goal was to determine how care coordination and evidence-based clinical management impacted financial and health outcomes. The SR followed the Cochrane protocol and complied with the PRISMA evidence-based minimum set for reporting. Overall, DM management in the PCMH demonstrated statistically significant completion rates for essential screenings and preventive care, including HgA1c (p = 0.0013), lipid management (p

The Patient Protection and Affordable Care Act (PPACA) represents one of the most significant pieces of legislation in the history of United States healthcare. The PPACA has two main goals: to increase the insured patient population in the US and to reduce the overall cost while improving the quality of healthcare in the US. To accomplish the latter goal, healthcare providers are experiencing a movement toward integrated, team-oriented models that place increasing accountability on the providers and institutions. At the same time, these integrative models emphasize effective preventive care, which is critical in reducing the country’s overall healthcare costs. As more health care institutions and providers across the country adopt the healthcare reform models of the Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) directly under the PPACA, the demand for pharmacists is increasing. In addition, the role of the pharmacist through Medication Therapy Management (MTM) is growing as more public and private sectors adopt MTM and its standards are being used as the medication-related cornerstone for the ACOs. There is a call for lower costs and higher quality outcomes in healthcare, and the pharmacists are increasingly integrated into direct patient care and medication management. The newly integrated responsibilities of the pharmacist are numerous and almost limitless. The roleof pharmacists is expanding, and as many studies suggest, their contributions produce auspicious results.