Dataset Information

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system.

ABSTRACT: 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.

SUBMITTER: Misra-Hebert AD

PROVIDER: S-EPMC6206362 | biostudies-other | 2018 Nov

REPOSITORIES: biostudies-other

ACCESS DATA

Publications

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system.

Misra-Hebert Anita D AD Perzynski Adam A Rothberg Michael B MB Fox Jaqueline J Mercer Mary Beth MB Liu Xiaobo X Hu Bo B Aron David C DC Stange Kurt C KC

Journal of general internal medicine 20180806 11

<h4>Background</h4>Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care.<h4>Objective</h4>To identify practice setting components contributing to uptake of new team-based care models.<h4>Design</h4>Convergent mixed-methods design.<h4>Participants</h4>Employees and patients of primary care practices implementing two team-based models in a large, integrated health system.<h4>Main measures</h4>Field observation ...[more]

PMID: 30084018

Similar Datasets

Project description:BackgroundA high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients' home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation.MethodsOne hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients' medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol.ResultsMean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients.ConclusionsThis mixed-methods process evaluation provided novel insights into practitioners' decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients' readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response.Trial registration( ISRCTN13790648 ). Registered 14 May 2015.

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.

Project description:BackgroundIn 2009 health insurers AOK and Bosch BKK introduced the "FacharztProgramm Kardiologie" - a program for coordinated ambulatory cardiology care in the German state of Baden-Württemberg. It aims for efficient, medical guideline-oriented cardiology care to reduce avoidable hospitalizations as well as costs of care. A high number of cardiologists participate and the program has served as blueprint for programs in other medical fields. With many prerequisites and conditions involved, its implementation cannot be expected to be self-directed. Still, only little data on the actual implementation exists. We aimed to determine to what extent medical specialists and cooperating general practitioners implemented the program, which components they adapted, and which contextual factors they deemed relevant.MethodsWe collected data from primary care practices of medical specialists and general practitioners within Baden-Württemberg. Qualitative data was obtained through structured telephone interviews with participating and non-participating medical specialists as well as general practitioners cooperating with the program and general practitioners not cooperating. Interviews were analyzed through content-structuring qualitative content analyses via MAXQDA. Quantitative data was obtained using anonymous written questionnaires completed by participating and non-participating medical specialists as well as general practitioners cooperating with the program. Analyses were performed using SPSS Statistics, mainly with regard to differences within and between groups of physicians.ResultsMost components of the program regarding medical care were well implemented. However, access to medical care was not completely as intended due to high numbers of patients participating in the program and prioritization by physicians. Procedures for communication and cooperation between medical specialists and general practitioners were only partially adhered to and standardized communication was not implemented. A range of regional and practice-related contextual factors influenced implementation and outcomes.ConclusionsImplementation of this program was mixed. Contextual factors posed individual challenges to participating physicians which can't be captured by an encompassing program. Both control mechanisms and tailoring of the program to medical care seem needed.Trial registrationThough not a clinical study, we deemed registration appropriate to ensure transparency. The study has been registered as a non-interventional observation study at the German Clinical Trials Register under ID: DRKS00013070.

Dataset Information

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system.

Publications

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets