Abstract Purpose The objective of this study was to elucidate the effect of facilitation on practice outcomes in the 2-year patient-centered medical home (PCMH) National Demonstration Project (NDP) ...intervention, and to describe practices' experience in implementing different components of the NDP model of the PCMH. Methods Thirty-six family practices were randomized to a facilitated intervention group or a self-directed intervention group. We measured 3 practice-level outcomes: (1) the proportion of 39 components of the NDP model that practices implemented, (2) the aggregate patient rating of the practices' PCMH attributes, and (3) the practices' ability to make and sustain change, which we term adaptive reserve. We used a repeated-measures analysis of variance to test the intervention effects. Results By the end of the 2 years of the NDP, practices in both facilitated and self-directed groups had at least 70% of the NDP model components in place. Implementation was relatively harder if the model component affected multiple roles and processes, required coordination across work units, necessitated additional resources and expertise, or challenged the traditional model of primary care. Electronic visits, group visits, team-based care, wellness promotion, and proactive population management presented the greatest challenges. Controlling for baseline differences and practice size, facilitated practices had greater increases in adaptive reserve (group difference by time, P = .005) and the proportion of NDP model components implemented (group difference by time, P = .02); the latter increased from 42% to 72% in the facilitated group and from 54% to 70% in the self-directed group. Patient ratings of the practices' PCMH attributes did not differ between groups and, in fact, diminished in both of them. Conclusions Highly motivated practices can implement many components of the PCMH in 2 years, but apparently at a cost of diminishing the patient's experience of care. Intense facilitation increases the number of components implemented and improves practices' adaptive reserve. Longer follow-up is needed to assess the sustained and evolving effects of moving independent practices toward PCMHs
Electronic health records (EHRs) have had mixed effects on the workflow of ambulatory primary care. In this study, we update previous research on the time required to care for patients in primary ...care clinics with EHRs.
We directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The FPs were purposely chosen to reflect a diversity of patient care styles. We measured total visit time, previsit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time.
The mean (SD) visit length was 35.8 (16.6) minutes, not counting resident precepting time. The mean time components included 2.9 (3.8) minutes working in the EHR prior to entering the room, 16.5 (9.2) minutes of face-to-face time not working in the EHR, 2.0 (2.1) minutes working in the EHR in the room (which occurred in 73.4% of the visits), 7.5 (7.5) minutes of non-face time (mostly EHR time), and 6.9 (7.6) minutes of EHR work outside of normal clinic operational hours (which occurred in 64.6% of the visits). The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents. Multivariable linear regression analysis revealed many factors associated with total visit time including patient, physician, and clinic infrastructure factors.
Primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits.
Abstract Purpose We describe the experience of practices in transitioning toward patient-centered medical homes (PCMHs) in the National Demonstration Project (NDP). Methods The NDP was launched in ...June 2006 as the first national test of a model of the PCMH in a diverse sample of 36 family practices, randomized to facilitated and self-directed intervention groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical records, and patient and practice surveys. The evaluation team reviewed data from all practices as they became available and produced interim summaries. Four 2-to 3-day evaluation team retreats were held during which case summaries of all practices were discussed and patterns were described. Results The 6 themes that emerged from the data reflect major shifts in individual and practice roles and identities, as well as changes in practices' management strategies. The themes are (1) practice adaptive reserve is critical to managing change, (2) developmental pathways to success vary considerably by practice, (3) motivation of key practice members is critical, (4) the larger system can help or hinder, (5) practice transformation is more than a series of changes and requires shifts in roles and mental models, and (6) practice change is enabled by the multiple roles that facilitators play. Conclusions Transformation to a PCMH requires more than a sequence of discrete changes. The practice transformation process may be fostered by promoting adaptive reserve and local control of the developmental pathway.
INTRODUCTION: Cardiovascular diseases are the leading causes of death in our country and in the world. In our study, we aimed to show the approach of physicians at different academic stages in family ...medicine discipline to the treatment of dyslipidemia, which is one of the most important risk factors of cardiovascular diseases. METHODS: Our study was conducted between 01.01.2019 - 01.03.2019 in 189 (73%) of 259 family physicians actively working in the city of Kadıköy and its district, with face-to-face interviews and online survey filling. Opinions of the physicians participating in the study about their dyslipidemia and statin treatment were obtained with a questionnaire consisting of 32 questions about the demographic data, diagnosis and follow-up of dyslipidemic patients, their knowledge and experience about statin treatment. RESULTS: It was observed that resident family physicians followed more chronic diseases than both specialist and general practitioners (p <0.001). Specialist family physicians think that they have more information about the diagnosis and treatment of dyslipidemia than general practitioner family physicians and general practitioner family physicians (p= 0.001). It has been observed that assistant and specialist family physicians follow drug efficacy, duration of treatment and side effects more than general practitioners (p= 0.001). 29.8% (n= 25) of practitioner family physicians, 50.8% of assistant family physicians (n=31) and 68.3% (n=28) of specialist family physicians stated that they follow the latest guidelines. It has been observed that specialist family physicians follow more guidelines than assistant family physicians and assistant family physicians follow general practitioners (p <0.001). DISCUSSION AND CONCLUSION: The fact that family physicians perform diagnosis, treatment and follow-up with cardiovascular diseases along with current guidelines will increase the quality of life of the patient in the first step and decrease the accumulation in the 2nd and 3rd step health facilities. However, the rapid change of these guidelines requires physicians to renew themselves quickly.
ObjectiveTimely access to care and continuity with a specific provider are important determinants of patient satisfaction when booking appointments in primary care settings. Advanced access booking ...systems restrict the majority of providers’ appointment spots for same-day appointments and keep the number of prebooked appointments to a minimum. In the teaching clinic environment, continuity with the same provider can be a challenge. This study examines trade-offs that patients may consider during appointment bookings for six different clinical scenarios across a number of key access and continuity attributes using a discrete choice experiment (DCE) method.DesignCross-sectional survey.SettingTwo urban family medicine teaching clinics in Canada.ParticipantsConvenience sample of 430 patients of family medicine clinics aged 18 and older.InterventionDiscrete choice conjoint experiment survey.Primary outcome measuresPatient preferences on six attributes: appointment booking method, appointment wait time, time spent in the waiting room, appointment time convenience, familiarity with healthcare provider and position of healthcare provider. Data were analysed by hierarchical Bayes analysis to determine estimates of part-worth utilities for each respondent.ResultsPatients rated appointment wait time as the most highly valued attribute, followed by position of provider, then familiarity with the provider. Patients showed a significant preference (p<0.02) for their own physician for booking of routine annual check-ups and other logical preferences across attributes overall and by clinical scenario.ConclusionsPatients preferred timely access to their primary care team over other attributes in the majority of health state scenarios tested, especially urgent issues, however they were willing to wait for a check-up. These results support the notion that advanced access booking systems which leave the majority of appointment spots for same day access and still leave a few for continuity (check-up) bookings, align well with trends in patient preferences.
Telehealth is an emerging field of clinical practice but current UK health policy has not taken account of the perceptions of front-line healthcare professionals expected to implement it.
To ...investigate telehealth care for people with long-term conditions from the perspective of the front-line health professional.
A qualitative study in three sites within the UK (Kent, Cornwall, and the London Borough of Newham) and embedded in the Whole Systems Demonstrator evaluation, a large cluster randomised controlled trial of telehealth and telecare for patients with long-term and complex conditions.
Semi-structured qualitative interviews with 32 front-line health professionals (13 community matrons, 10 telehealth monitoring nurses and 9 GPs) involved in the delivery of telehealth. Data were analysed using a modified grounded theory approach.
Mixed views were expressed by front-line professionals, which seem to reflect their levels of engagement. It was broadly welcomed by nursing staff as long as it supplemented rather than substituted their role in traditional patient care. GPs held mixed views; some gave a cautious welcome but most saw telehealth as increasing their work burden and potentially undermining their professional autonomy.
Health care professionals will need to develop a shared understanding of patient self-management through telehealth. This may require a renegotiation of their roles and responsibilities.
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