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Operational integration in primary health care: patient encounters and workflows.

ABSTRACT: Despite several countrywide attempts to strengthen and standardise the primary healthcare (PHC) system, Greece is still lacking a sustainable, policy-based model of integrated services. The aim of our study was to identify operational integration levels through existing patient care pathways and to recommend an alternative PHC model for optimum integration.The study was part of a large state-funded project, which included 22 randomly selected PHC units located across two health regions of Greece. Dimensions of operational integration in PHC were selected based on the work of Kringos and colleagues. A five-point Likert-type scale, coupled with an algorithm, was used to capture and transform theoretical framework features into measurable attributes. PHC services were grouped under the main categories of chronic care, urgent/acute care, preventive care, and home care. A web-based platform was used to assess patient pathways, evaluate integration levels and propose improvement actions. Analysis relied on a comparison of actual pathways versus optimal, the latter ones having been identified through literature review.Overall integration varied among units. The majority (57%) of units corresponded to a basic level. Integration by type of PHC service ranged as follows: basic (86%) or poor (14%) for chronic care units, poor (78%) or basic (22%) for urgent/acute care units, basic (50%) for preventive care units, and partial or basic (50%) for home care units. The actual pathways across all four categories of PHC services differed from those captured in the optimum integration model. Certain similarities were observed in the operational flows between chronic care management and urgent/acute care management. Such similarities were present at the highest level of abstraction, but also in common steps along the operational flows.Existing patient care pathways were mapped and analysed, and recommendations for an optimum integration PHC model were made. The developed web platform, based on a strong theoretical framework, can serve as a robust integration evaluation tool. This could be a first step towards restructuring and improving PHC services within a financially restrained environment.

SUBMITTER: Sifaki-Pistolla D

PROVIDER: S-EPMC5706391 | biostudies-literature | 2017 Nov

REPOSITORIES: biostudies-literature

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Operational integration in primary health care: patient encounters and workflows.

Sifaki-Pistolla Dimitra D Chatzea Vasiliki-Eirini VE Markaki Adelais A Kritikos Kyriakos K Petelos Elena E Lionis Christos C

BMC health services research 20171129 1

<h4>Background</h4>Despite several countrywide attempts to strengthen and standardise the primary healthcare (PHC) system, Greece is still lacking a sustainable, policy-based model of integrated services. The aim of our study was to identify operational integration levels through existing patient care pathways and to recommend an alternative PHC model for optimum integration.<h4>Methods</h4>The study was part of a large state-funded project, which included 22 randomly selected PHC units located ...[more]

PMID: 29187189

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Project description:Although previous studies suggest an association between provider burnout and suboptimal self-reported communication, no studies relate physician burnout to observed patient-physician communication behaviors.To investigate the relationship between physician burnout and observed patient-physician communication outcomes in patient-physician encounters.Longitudinal study of enrollment data from a trial of interventions to improve patient adherence to hypertension treatment.Fifteen urban community-based clinics in Baltimore, MD.Forty physicians and 235 of their adult hypertensive patients, with oversampling of ethnic minorities and poor persons. Fifty-three percent of physicians were women, and the average practice experience was 11.2 years. Among the 235 patients, 66% were women, 60% were African-American, and 90% were insured.Audiotape analysis of communication during outpatient encounters (one per patient) using the Roter Interaction Analysis System and patients' ratings of satisfaction with and trust and confidence in the physician.The median time between the physician burnout assessment and the patient encounter was 15.1 months (range 5.6-30). Multivariate analyses revealed no significant differences in physician communication based on physician burnout. However, compared with patients of low-burnout physicians, patients of high-burnout physicians gave twice as many negative rapport-building statements (incident risk ratio 2.06, 95% CI 1.58-2.86, p < 0.001). Physician burnout was not significantly associated with physician or patient affect, patient-centeredness, verbal dominance, or length of the encounter. Physician burnout was also not significantly associated with patients' ratings of their satisfaction, confidence, or trust.Physician burnout was not associated with physician communication behaviors nor with most measures of patient-centered communication. However, patients engaged in more rapport-building behaviors. These findings suggest a complex relationship between physician burnout and patient-physician communication, which should be investigated and linked to patient outcomes in future research.

Project description:BackgroundWith the increasing adoption of electronic health record (EHR) systems, documentation-related burdens have been increasing for health care providers. Recent estimates indicate that primary care providers spend about one-half of their workdays interacting with the EHR, of which about half is focused on clerical tasks. To reduce documentation burdens associated with the EHR, health care systems and physician practices are increasingly implementing medical scribes to assist providers with real-time documentation. Scribes are typically unlicensed paraprofessionals who assist health care providers by documenting notes electronically under the direction of a licensed practitioner or physician in real time. Despite the promise of scribes, few studies have investigated their effect on clinical encounters, particularly with regard to patient-provider communication.ObjectiveThe purpose of this quasi-experimental pilot study was to understand how scribes affect patient-physician communication in primary care clinical encounters.MethodsWe employed a convergent mixed methods design and included a sample of three physician-scribe pairs and 34 patients. Patients' clinical encounters were randomly assigned to a scribe or nonscribe group. We conducted patient surveys focused on perceptions of patient-provider communication and satisfaction with encounters, video recorded clinical encounters, and conducted physician interviews about their experiences with scribes.ResultsOverall, the survey results revealed that patients across both arms reported very high satisfaction of communication with their physician, their physician's use of the EHR, and their care, with very little variability. Video recording analysis supported patient survey data by demonstrating high measures of communication among physicians in both scribed and nonscribed encounters. Furthermore, video recordings revealed that the presence of scribes had very little effect on the clinical encounter.ConclusionsFrom the patient's perspective, scribes are an acceptable addition to clinical encounters. Although they do not have much impact on patients' perceptions of satisfaction and their impact on the clinical encounter itself was minimal, their potential to reduce documentation-related burden on physicians is valuable. Physicians noted important issues related to scribes, including important considerations for implementing scribe programs, the role of scribes in patient interactions, how physicians work with scribes, characteristics of good scribes, and the role of scribes in physician workflow.

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Project description:AimsThe aim of this paper is to introduce an operational checklist to serve as a tool for policymakers in the WHO European Region to strengthen primary health care (PHC) services and address the COVID-19 pandemic more effectively and to present the results from piloting the tool in Armenia.BackgroundsPHC has the potential to play a fundamental role in countries' responses to COVID-19. However, this potential remains unrealized in many countries. To assist countries, the WHO Regional Office for Europe developed a guidance document - Strengthening the Health Systems Response to COVID-19: Adapting Primary Health Care Services to more Effectively Address COVID-19 - that identifies strategic actions countries can take to strengthen their PHC response to the pandemic. Based on this guidance document, an operational checklist was developed to serve as a tool for policymakers to operationalize the recommended actions.MethodsThe operational checklist was developed by transforming key points in the guidance document into questions in order to identify potentially modifiable factors to strengthen PHC in response to COVID-19. The operational checklist was then piloted in Armenia in June 2020 as part of a WHO mission to provide technical advice on strengthening Armenia's PHC response to COVID-19. Two WHO experts performed semi-structured, face-to-face interviews with nine key informants (both facility managers and clinical staff) in three PHC facilities (two in a rural and one in an urban area). The data collected were analyzed to identify underlying challenges limiting PHC providers' ability to effectively and efficiently respond to COVID-19 and maintain essential health services.FindingsThe paper finds that making adjustments only to health services delivery will be insufficient to address most of the challenges identified by PHC providers in the context of COVID-19 in Armenia. In particular, strategic responses to the pandemic were missed, due, in part, to the absence of COVID-19 management teams at the facility level. Furthermore, the absence of PHC experts in Armenia's national pandemic response team meant that health system issues identified at the facility level could not easily be communicated to or addressed by policymakers. The checklist therefore helps policymakers identify critical challenges - at both the facility and health system level - that need to be addressed to strengthen the PHC response to the COVID-19 pandemic.

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Operational integration in primary health care: patient encounters and workflows.

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Operational integration in primary health care: patient encounters and workflows.

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