Lessons from global health have long informed efforts to improve primary health care (PHC) in the United States (US). Despite this history, no generalizable framework exists to guide US stakeholders ...in the identification and application of ideas from abroad related to the key PHC components of community engagement and service delivery. We sought to develop such a framework.
We reviewed the experience of Global to Local, a community-based organization (CBO) founded with a mission to apply global health strategies to improve the health in vulnerable populations in the US, and examined the experience of care delivery organizations in the US that have successfully implemented global-to-local solutions. Based on that experience, and supported by the advice of an expert panel, we developed a framework for applying global learning to improve US PHC.
The framework includes six change concepts under three broad categories. The first category focuses on the need to actively and intentionally incorporate a global perspective in organizational program design and improvement activities. The second category addresses approaches to identifying global solutions related to community engagement and to health service delivery. The third category focuses on adaptation and implementation of lessons from global health in domestic contexts by applying relevant insights from dissemination and implementation science and diffusion of innovation theory.
In the absence of a robust literature providing implementation guidance to US health systems and CBOs open to adopting or adapting PHC strategies and practices from other countries, the proposed framework synthesizing the experience of organizations that have done so can inform efforts to apply lessons from global health to improve PHC in the US.
Improving outcomes in pilonidal sinus disease Braungart, Sarah; Powis, Mark; Sutcliffe, Jonathan R ...
Journal of pediatric surgery,
02/2016, Letnik:
51, Številka:
2
Journal Article
Recenzirano
Abstract Background Optimal surgical treatment for pilonidal sinus disease remains controversial. Studies in children are uncommon with overall high postoperative recurrence and infection rates ...(20%). Our unit adopted a technique for excision of the pilonidal sinus with primary midline closure using a full-thickness flap. We present our results of this technique in the pediatric age group. Methods Single-center retrospective review and telephone follow-up was performed, including all children undergoing pilonidal sinus excision from 2005 to 2014 using the same operative technique and preoperative/postoperative care. Results 19 children were identified. Median age was 15 years, and 47% were male. All had previously infected sinuses, with 5 requiring abscess drainage. Median follow-up was 13 months (3.5–67 months). Histology confirmed pilonidal sinus in 18/19 cases (one developmental malformation excluded from subsequent analysis). Recurrence requiring further surgery occurred in 4/18 (22%) patients at a median of 9 months (range 8–36), wound dehiscence in 8/18 (44%), and wound infection in 5/18 (28%) cases. Laser hair removal of the natal cleft was performed in 7/18 (39%) patients with no further recurrence. Conclusion This is the first report of this technique in children which showed a higher incidence of complications than a comparable adult study. Our study underlines the importance of accurate long-term outcomes when introducing new techniques to evaluate operation-associated morbidity. Our preliminary results of laser hair removal are promising but need to be evaluated with a prospective study.
Background: Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects ...have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. Objectives: To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. Design: Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. Subjects: Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. Measures: We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. Results: All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. Conclusions: Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.
Despite a large body of evidence describing care processes known to reduce the incidence of surgical site infections, many are underutilized in practice.
Fifty-six hospitals volunteered to redesign ...their systems as part of the National Surgical Infection Prevention Collaborative, a 1-year demonstration project sponsored by the Centers for Medicare & Medicaid Services. Each facility selected quality improvement objectives for a select group of surgical procedures and reported monthly clinical process measure data.
Forty-four hospitals reported data on 35,543 surgical cases. Hospitals improved in measures related to appropriate antimicrobial agent selection, timing, and duration; normothermia; oxygenation; euglycemia; and appropriate hair removal. The infection rate decreased 27%, from 2.3% to 1.7% in the first versus last 3 months.
The Collaborative demonstrated improvement in processes known to be associated with reduced risk of surgical site infections. Quality improvement organizations can be effective resources for quality improvement in the surgical arena.
Background: Although coordinating care is a defining characteristic of primary care, evidence suggests that both patients and providers perceive failures in communication and care when care is ...received from multiple sources. Objectives: To examine the utility of a newly developed Care Coordination Model in improving care coordination among participating practices in the Safety Net Medical Home Initiative (SNMHI). Research Design: In this paper, we used correlation analysis to evaluate whether application of the elements of the Care Coordination Model by SNMHI sites, as measured by the Key Activities Checklist (KAC), was associated with more effective care coordination as measured by another instrument, the PCMH-A. Measures: SNMHI measures are practice self-assessments based on the 8 change concepts that define a PCMH, one of which is Care Coordination. For this study, we correlated 12 KAC items that describe activities felt to improve coordination of care with 5 PCMH-A items that indicate the extent to which a practice has developed the capability to effectively coordinate care. Practice staff indicated whether any of the KAC activities were being test, implemented, sustained, or not on 4 occasions. Results: The Care Coordination Model elements—assume accountability, build relationships with care partners, support patients through the referral or transition process, and create connections to support information exchange—were positively correlated with some PCMH-A care coordination items but not others. Activities related to the model were most strongly correlated with following up patients seen in the Emergency Department or discharged from hospital. Conclusions: The analysis provides suggestive evidence that activities consistent with the 4 elements of the Care Coordination Model may enable safety net primary care to better coordinate care for its patients, but further study is clearly needed.
Academic medical centers (AMCs) need new approaches to delivering higher-quality care at lower costs, and engaging trainees in the work of high-functioning primary care practices.
In 2012, the ...Harvard Medical School Center for Primary Care, in partnership with with local AMCs, established an Academic Innovations Collaborative (AIC) with the goal of transforming primary care education and practice. This novel two-year learning collaborative consisted of hospital- and community-based primary care teaching practices, committed to building highly functional teams, managing populations, and engaging patients. The AIC built on models developed by Qualis Health and the Institute for Healthcare Improvement, optimized for the local AMC context. Foundational elements included leadership engagement and development, application of rapid-cycle process improvement, and the creation of teams to care for defined patient populations. Nineteen practices across six AMCs participated, with nearly 260,000 patients and 450 resident learners. The collaborative offered three 1.5-day learning sessions each year featuring shared learning, practice coaches, and improvement measures, along with monthly data reporting, webinars, and site visits.
Validated self-reports by transformation teams showed that practices made substantial improvement across all areas of change. Important factors for success included leadership development, practice-level resources, and engaging patients and trainees.
The AIC model shows promise as a path for AMCs to catalyze health system transformation through primary care improvement. In addition to further evaluating the impact of practice transformation, expansion will require support from AMCs and payers, and the application of similar approaches on a broader scale.
In 2007, the major primary care professional societies collaboratively introduced a new model of primary care: the patient-centered medical home (PCMH). The published document outlines the basic ...attributes and expectations of a PCMH but not with the specificity needed to help interested clinicians and administrators make the necessary changes to their practice. To identify the specific changes required to become a medical home, the authors reviewed literature and sought the opinions of two multi-stakeholder groups. This article describes the eight consensus change concepts and 32 key changes that emerged from this process, and the evidence supporting their inclusion.
Behavioral health problems are common, yet most patients do not receive effective treatment in primary care settings. Despite availability of effective models for integrating behavioral health care ...in primary care settings, uptake has been slow. The Behavioral Health Integration Implementation Guide provides practical guidance for adapting and implementing effective integrated behavioral health care into patient-centered medical homes. The authors gathered input from stakeholders involved in behavioral health integration efforts: safety net providers, subject matter experts in primary care and behavioral health, a behavioral health patient and peer specialist, and state and national policy makers. Stakeholder input informed development of the Behavioral Health Integration Implementation Guide and the GROW Pathway Planning Worksheet. The Behavioral Health Integration Implementation Guide is model neutral and allows organizations to take meaningful steps toward providing integrated care that achieves access and accountability.
Empanelment is a foundational strategy for building or improving primary health care systems and a critical pathway for achieving effective universal health coverage. However, there is little ...international guidance for defining empanelment or understanding how to implement empanelment systems in low- and middle-income countries. To fill this gap, a multi-country collaborative within the Joint Learning Network for Universal Health Coverage developed this empanelment overview, proposing a people-centered definition of empanelment that reflects the responsibility to proactively deliver primary care services to all individuals in a target population. This document, building on existing literature on empanelment and representing input from 10 countries, establishes standard concepts of empanelment and describes why and how empanelment is used. Finally, it identifies key domains that may influence effective empanelment and that must be considered in deciding how empanelment can be implemented. This document is designed to be a useful resource for health policymakers, planners and decision-makers in ministries of health, as well as front line providers of primary care service delivery who are working to ensure quality people-centered primary care to everyone everywhere.
Background: Despite widespread interest in supporting primary care transformation, few evidence-based strategies for technical assistance exist. The Safety Net Medical Home Initiative (SNMHI) sought ...to develop a replicable and sustainable model for Patient-centered Medical Home practice transformation. Objectives: This paper describes the multimodal technical assistance approach used by the SNMHI and the participating practices' assessment of its value and helpfulness in supporting their transformation. Results: Components of the technical assistance framework included: (1) individual site-level coaching provided by local medical home facilitators and supplemented by expert consultation; (2) regional and national learning communities of participating practices that included in-person meetings and field trips; (3) data monitoring and feedback including longitudinal feedback on medical home implementation as measured by the Patient-centered Medical Home-A; (4) written implementation guides, tools, and webinars relating to each of the 8 Change Concepts for Practice Transformation; and (5) small grant funds to support infrastructure and staff development. Overall, practices found the technical assistance helpful and most valued in-person, peer-to-peer-learning opportunities. Practices receiving technical assistance from membership organizations with which they belonged before the SNMHI scored higher on measures of medical home implementation than practices working with organizations with whom they had no prior relationship. Conclusions: There is an important role for both local and national organizations to provide nonduplicative, mutually reinforcing support for primary care transformation. How (in-person, between-peers) and by whom technical assistance is provided may be important to consider.
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