A Mixed Methods Study of Change Processes Enabling Effective Transition to Team-Based Care.
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SUBMITTER: Kyle MA
PROVIDER: S-EPMC8295944 | biostudies-literature | 2021 Aug
REPOSITORIES: biostudies-literature
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A Mixed Methods Study of Change Processes Enabling Effective Transition to Team-Based Care.
Kyle Michael Anne MA Aveling Emma-Louise EL Singer Sara S
Medical care research and review : MCRR 20191015 4
Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically affiliated primary care practices participating in a learning collaborative, using longitudinal staff survey data to measure progress toward team-based care and qualitative interviews with practice staff to und ...[more]
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Project description:PURPOSE Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness. METHODS We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure—aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire—from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators. RESULTS Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators. CONCLUSIONS Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.
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Project description:BACKGROUND:Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care. OBJECTIVE:To identify practice setting components contributing to uptake of new team-based care models. DESIGN:Convergent mixed-methods design. PARTICIPANTS:Employees and patients of primary care practices implementing two team-based models in a large, integrated health system. MAIN MEASURES:Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team. KEY RESULTS:Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups-high, partial, and low uptake of new team-based models. Uptake was related to (1) practices' responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices' ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices. CONCLUSION:Uptake of new team-based care delivery models is related to practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.
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Project description:BackgroundOwing to the shortage of medical professionals, as well as demographic and structural challenges, new care models have emerged to find innovative solutions to counter medical undersupply. Team-based primary care using medical delegation appears to be a promising approach to address these challenges; however, it demands efficient communication structures and mechanisms to reinsure patients and caregivers receive a delegated, treatment-related task. Digital health care technologies hold the potential to render these novel processes effective and demand driven.ObjectiveThe goal of this study is to recreate the daily work routines of general practitioners (GPs) and medical assistants (MAs) to explore promising approaches for the digital moderation of delegation processes and to deepen the understanding of subjective and perceptual factors that influence their technology assessment and use.MethodsWe conducted a combination of 19 individual and group interviews with 12 GPs and 14 MAs, seeking to identify relevant technologies for delegation purposes as well as stakeholders' perceptions of their effectiveness. Furthermore, a web-based survey was conducted asking the interviewees to order identified technologies based on their assessed applicability in multi-actor patient care. Interview data were analyzed using a three-fold inductive coding procedure. Multidimensional scaling was applied to analyze and visualize the survey data, leading to a triangulation of the results.ResultsOur results suggest that digital mediation of delegation underlies complex, reciprocal processes and biases that need to be identified and analyzed to improve the development and distribution of innovative technologies and to improve our understanding of technology use in team-based primary care. Nevertheless, medical delegation enhanced by digital technologies, such as video consultations, portable electrocardiograms, or telemedical stethoscopes, can counteract current challenges in primary care because of its unique ability to ensure both personal, patient-centered care for patients and create efficient and needs-based treatment processes.ConclusionsTechnology-mediated delegation appears to be a promising approach to implement innovative, case-sensitive, and cost-effective ways to treat patients within the paradigm of primary care. The relevance of such innovative approaches increases with the tremendous need for differentiated and effective care, such as during the ongoing COVID-19 pandemic. For the successful and sustainable adoption of innovative technologies, MAs represent essential team members. In their role as mediators between GPs and patients, MAs are potentially able to counteract patients' resistance toward using innovative technology and compensate for patients' limited access to technology and care facilities.
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Project description:BackgroundCommunication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record.ObjectiveThe objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research.MethodsThe study was a hybrid type II mixed methods design to simultaneously evaluate Loop's clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system.ResultsWe recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop's potential value for engaging the patient and caregiver, and for improving communication within the patient's circle of care, Loop's relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care.ConclusionsFundamental structural and implementation challenges persist toward realizing Loop's potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.
| S-EPMC8294640 | biostudies-literature
Project description:ObjectivesTo conceptualize new methods for integrating patient-centered measurement into team-based care.MethodsA standalone portal was introduced into a rural clinic to support conceptualization of new methods for integration of patient-centered measurement in team-based care. The portal housed mental health-related online resources, three patient-reported measures and a self-action plan. Six providers and four patients used the portal for four months. Our data collection techniques included clinic discussions, one-on-one interviews, workflow diagrams and data generated through the portal. Analysis was supported through coding interview transcripts, looking across multiple sources of research data and research team discussions.ResultsOur research team conceptualized five team-based patient-centered measurement methods through this study. Patient-centered measurement Team Mapping offfers a technique to provide greater clarity of care-team roles and responsibilities in data collected through patient-centered measurement. Longitudinal Care Alignment can guide the care-team on incorporating patient-centered measurement into ongoing provider-patient interactions. Digital Tool Exploration can be used to evaluate a team's readiness toward digital tool adoption, and the impact of these tools. Team-based quality improvement serves as a framework for engaging teams in patient-centered quality improvement. Shared learning is a method that promotes patientprovider interactions that validate patient's perspectives of their care.ConclusionThe portal illuminated new methods for the integration of patient-centered measurement in team-based care. The first three proposed patient-centered measurement methods provides ways to assess how a clinic can incorporate patient-centered measurement methods into team-based care. The latter two methods focus on the aim of patient-generated data in which patient's values and perspectives are represented and quality of patient-centered care can be evaluated. Further testing is needed to assess the utility of these patient-centered measurement methods across different clinical settings and domains.
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Project description:Background Team-Based Learning (TBL) is an established educational strategy which has become increasingly popular in the training of healthcare professionals. TBL is highly suitable for teaching Family Medicine (FM) especially that teamwork and collaborative care, in this medical discipline, are at the core of safe and effective practice. Despite the established suitability of TBL for teaching FM, there are no empirical studies that capture the students’ perception of a TBL in FM undergraduate learning experience in the Middle East and North Africa region (MENA). Objective The overall objective of this study was to investigate the perception of students regarding a TBL in FM intervention (in Dubai, United Arab Emirates), that was designed and implemented in alignment with a constructivist learning theory. Methods A convergent mixed methods study design was utilized to develop a thorough understanding of the students’ perceptions. Qualitative and quantitative data were concurrently collected and independently analyzed. The output of thematic analysis was systematically merged with the quantitative descriptive and inferential findings using the iterative joint display process. Results The qualitative findings shed light on the students’ perception of TBL in FM, and the interplay between team cohesion and engagement with the course. As for the quantitative findings, they showed that the percentage of the total average of the Satisfaction with TBL in FM score was 88.80%. As for change in impression of FM discipline, the percentage of the total average was 83.10%. The perception of team cohesion, with a mean of agreement of 8.62(1.34), seemed to be significantly associated with the students’ perception of the team test phase component, only (P < 0.05). As for the perception of the level of engagement with the course, with a mean of agreement of 9.29(0.84), it turned out to be significantly associated with the change in impression of FM discipline (P < 0.05). Lastly, the joint display analysis showed how the quantitative and qualitative findings built upon each other, revealing how best to leverage TBL in FM trainings. Conclusion The current study showed that TBL embedded in a FM clinical clerkship was well-received by students. It is worth leveraging the lessons learned from the first-hand experience reported upon in the current study to optimize the utilization of TBL in FM. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-023-04240-1.
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Project description:BACKGROUND:Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED). METHODS:RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate. RESULTS:We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching. CONCLUSIONS:RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.
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Project description:ObjectiveTo use the experience from a health services research evaluation to provide guidance in team development for mixed methods research.MethodsThe Research Initiative Valuing Eldercare (THRIVE) team was organized by the Robert Wood Johnson Foundation to evaluate The Green House nursing home culture change program. This article describes the development of the research team and provides insights into how funders might engage with mixed methods research teams to maximize the value of the team.ResultsLike many mixed methods collaborations, the THRIVE team consisted of researchers from diverse disciplines, embracing diverse methodologies, and operating under a framework of nonhierarchical, shared leadership that required new collaborations, engagement, and commitment in the context of finite resources. Strategies to overcome these potential obstacles and achieve success included implementation of a Coordinating Center, dedicated time for planning and collaborating across researchers and methodologies, funded support for in-person meetings, and creative optimization of resources.ConclusionsChallenges are inevitably present in the formation and operation of effective mixed methods research teams. However, funders and research teams can implement strategies to promote success.
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Project description:Multidisciplinary team meetings are a current international practice in cancer care, but to date, few data exist on the specificity of its practice in hematology.In this manuscript, we present the result of the first national study, realized with quantitative and qualitative methods in France, which brings new insights in order to improve the collegial decision-making process.To improve the effectiveness of MDTMs, the needs to focus on complex cases, to enhance patient centeredness and teamwork are relevant aspects, and a specific focus on hematological particularities is warranted to truly improve process.Background Understanding the Multidisciplinary team meetings (MDTMs) process in different medical specialties facilitates the identification of core factors supporting effective MDTM work. Our mixed-methods study explores the participants' perceptions of hematology MDTMs.Design Online questionnaires collected data concerning the decision-making process, benefits and inconveniences of MDTMs for both patients and professionals. Semi-directive phone interviews were conducted and analyzed, thereby supplying qualitative data.Results A total of 205 professionals responded to the questionnaire and 22 participated in the qualitative interviews. The data indicate the unique characteristics of hematology, including a specific definition of collegiality, the frequent solicitation of expert advice and the anticipation of treatment even prior to the occurrence of MDTMs. Additional information concerning patients' wishes and psychosocial conditions are also needed. Participants emphasize the subjective aspects and the impact of the climate of MDTMs on medical decisions.Conclusion Although MDTMs are recognized to be a valuable tool, organizational and relational issues may interfere with their efficiency.To improve the effectiveness of MDTMs, the needs to focus on complex cases, to enhance patient centeredness and teamwork are relevant aspects. A specific focus on hematological particularities might be warranted to truly improve the collegial decision-making process in the context of hematology.
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Project description:Some euglenids, a family of aquatic unicellular organisms, can develop highly concerted, large amplitude peristaltic body deformations. This remarkable behavior has been known for centuries. Yet, its function remains controversial, and is even viewed as a functionless ancestral vestige. Here, by examining swimming Euglena gracilis in environments of controlled crowding and geometry, we show that this behavior is triggered by confinement. Under these conditions, it allows cells to switch from unviable flagellar swimming to a new and highly robust mode of fast crawling, which can deal with extreme geometric confinement and turn both frictional and hydraulic resistance into propulsive forces. To understand how a single cell can control such an adaptable and robust mode of locomotion, we developed a computational model of the motile apparatus of Euglena cells consisting of an active striated cell envelope. Our modeling shows that gait adaptability does not require specific mechanosensitive feedback but instead can be explained by the mechanical self-regulation of an elastic and extended motor system. Our study thus identifies a locomotory function and the operating principles of the adaptable peristaltic body deformation of Euglena cells.
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