scholarly journals Management of High-Need, High-Cost Patients: A “Best Fit” Framework Synthesis, Realist Review, and Systematic Review

2021 ◽  
Author(s):  
Nancy D. Berkman ◽  
Eva Chang ◽  
Julie Seibert ◽  
Rania Ali ◽  
Deborah Porterfield ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Realist Review ◽  
Healthcare Services ◽  
The United States ◽  
System Level ◽  
Care Providers ◽  
Healthcare Use ◽  
Best Fit ◽  
Best Fit Framework Synthesis

Background. In the United States, patients referred to as high-need, high-cost (HNHC) constitute a very small percentage of the patient population but account for a disproportionally high level of healthcare use and cost. Payers, health systems, and providers would like to improve the quality of care and health outcomes for HNHC patients and reduce their costly use of potentially preventable or modifiable healthcare services, including emergency department (ED) and hospital visits. Methods. We assessed evidence of criteria that identify HNHC patients (best fit framework synthesis); developed program theories on the relationship among contexts, mechanisms, and outcomes of interventions intended to change HNHC patient behaviors (realist review); and assessed the effectiveness of interventions (systematic review). We searched databases, gray literature, and other sources for evidence available from January 1, 2000, to March 4, 2021. We included quantitative and qualitative studies of HNHC patients (high healthcare use or cost) age 18 and over who received intervention services in a variety of settings. Results. We included 110 studies (117 articles). Consistent with our best fit framework, characteristics associated with HNHC include patient chronic clinical conditions, behavioral health factors including depression and substance use disorder, and social risk factors including homelessness and poverty. We also identified prior healthcare use and race as important predictors. We found limited evidence of approaches for distinguishing potentially preventable or modifiable high use from all high use. To understand how and why interventions work, we developed three program theories in our realist review that explain (1) targeting HNHC patients, (2) engaging HNHC patients, and (3) engaging care providers in these interventions. Theories identify the need for individualizing and tailoring services for HNHC patients and the importance of building trusting relationships. For our systematic review, we categorized evidence based on primary setting. We found that ED-, primary care–, and home-based care models result in reduced use of healthcare services (moderate to low strength of evidence [SOE]); ED, ambulatory intensive caring unit, and primary care-based models result in reduced costs (low SOE); and system-level transformation and telephonic/mail models do not result in changes in use or costs (low SOE). Conclusions. Patient characteristics can be used to identify patients who are potentially HNHC. Evidence focusing specifically on potentially preventable or modifiable high use was limited. Based on our program theories, we conclude that individualized and tailored patient engagement and resources to support care providers are critical to the success of interventions. Although we found evidence of intervention effectiveness in relation to cost and use, the studies identified in this review reported little information for determining why individual programs work, for whom, and when.

Systematic review of barriers and enablers to the delivery of palliative care by primary care practitioners

2019 ◽  
Vol 33 (9) ◽  
pp. 1131-1145 ◽  
Author(s):  
Mariko L Carey ◽  
Alison C Zucca ◽  
Megan AG Freund ◽  
Jamie Bryant ◽  
Anne Herrmann ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Palliative Care ◽  
Care Delivery ◽  
Primary Care Providers ◽  
Healthcare Services ◽  
Care Providers ◽  
Eligibility Criteria ◽  
Barriers And Enablers ◽  
Primary Care Practitioners

Background: There is increasing demand for primary care practitioners to play a key role in palliative care delivery. Given this, it is important to understand their perceptions of the barriers and enablers to optimal palliative care, and how commonly these are experienced. Aim: To explore the type and prevalence of barriers and enablers to palliative care provision reported by primary care practitioners. Design: A systematic review of quantitative data-based articles was conducted. Data sources: Medline, Embase and PsychINFO databases were searched for articles published between January 2007 and March 2019. Data synthesis: Abstracts were assessed against the eligibility criteria by one reviewer and a random sample of 80 articles were blind coded by a second author. Data were extracted from eligible full-texts by one author and checked by a second. Given the heterogeneity in the included studies’ methods and outcomes, a narrative synthesis was undertaken. Results: Twenty-one studies met the inclusion criteria. The most common barriers related to bureaucratic procedures, communication between healthcare professionals, primary care practitioners’ personal commitments, and their skills or confidence. The most common enablers related to education, nurses and trained respite staff to assist with care delivery, better communication between professionals, and templates to facilitate referral to out-of-hours services. Conclusion: A holistic approach addressing the range of barriers reported in this review is needed to support primary care providers to deliver palliative care. This includes better training and addressing barriers related to the interface between healthcare services.

scholarly journals Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review

10.2196/13042 ◽  
2019 ◽  
Vol 7 (4) ◽  
pp. e13042 ◽  
Author(s):  
Freda Mold ◽  
Jane Hendy ◽  
Yi-Ling Lai ◽  
Simon de Lusignan
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Health Care ◽  
The United States ◽  
Care Staff ◽  
Cochrane Library ◽  
Small Scale ◽  
Care Providers ◽  
Long Term Conditions ◽  
Electronic Consultation

Background Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain. Objective This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care. Methods A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis. Results This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes. Conclusions E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.

scholarly journals Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review (Preprint)

2018 ◽  
Author(s):  
Freda Mold ◽  
Jane Hendy ◽  
Yi-Ling Lai ◽  
Simon de Lusignan
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Health Care ◽  
The United States ◽  
Care Staff ◽  
Cochrane Library ◽  
Small Scale ◽  
Care Providers ◽  
Long Term Conditions ◽  
Electronic Consultation

BACKGROUND Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain. OBJECTIVE This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care. METHODS A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis. RESULTS This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes. CONCLUSIONS E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.

scholarly journals 145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S83-S83
Author(s):  
Shelby J Kolo ◽  
David J Taber ◽  
Ronald G Washburn ◽  
Katherine A Pleasants
Keyword(s):  
Primary Care ◽  
Respiratory Infections ◽  
Primary Care Providers ◽  
The United States ◽  
Delivery Mode ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Care Providers ◽  
Intervention Period ◽  
Provider Education

Abstract Background Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold). Methods This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period. The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes. Results Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. Conclusion Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates. Disclosures All Authors: No reported disclosures

scholarly journals Complementary and Integrative Health Knowledge and Practice in Primary Care Settings: A Survey of Primary Care Providers in the Northwestern United States

2021 ◽  
Vol 10 ◽  
pp. 216495612110233
Author(s):  
Malaika R Schwartz ◽  
Allison M Cole ◽  
Gina A Keppel ◽  
Ryan Gilles ◽  
John Holmes ◽  
...  
Keyword(s):  
United States ◽  
Primary Care ◽  
Health Knowledge ◽  
Care Delivery ◽  
Primary Care Providers ◽  
The United States ◽  
Research Network ◽  
Care Providers ◽  
Integrative Health ◽  
And Training

Background The demand for complementary and integrative health (CIH) is increasing by patients who want to receive more CIH referrals, in-clinic services, and overall care delivery. To promote CIH within the context of primary care, it is critical that providers have sufficient knowledge of CIH, access to CIH-trained providers for referral purposes, and are comfortable either providing services or co-managing patients who favor a CIH approach to their healthcare. Objective The main objective was to gather primary care providers’ perspectives across the northwestern region of the United States on their CIH familiarity and knowledge, clinic barriers and opportunities, and education and training needs. Methods We conducted an online, quantitative survey through an email invitation to all primary care providers (n = 483) at 11 primary care organizations from the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region Practice and Research Network (WPRN). The survey questions covered talking about CIH with patients, co-managing care with CIH providers, familiarity with and training in CIH modalities, clinic barriers to CIH integration, and interest in learning more about CIH modalities. Results 218 primary care providers completed the survey (45% response rate). Familiarity with individual CIH methods ranged from 73% (chiropracty) to 8% (curanderismo). Most respondents discussed CIH with their patients (88%), and many thought that their patients could benefit from CIH (41%). The majority (89%) were willing to co-manage a patient with a CIH provider. Approximately one-third of respondents had some expertise in at least one CIH modality. Over 78% were interested in learning more about the safety and efficacy of at least one CIH modality. Conclusion Primary care providers in the Northwestern United States are generally familiar with CIH modalities, are interested in referring and co-managing care with CIH providers, and would like to have more learning opportunities to increase knowledge of CIH.

scholarly journals VitalSign6: A Primary Care First (PCP-First) Model for Universal Screening and Measurement-Based Care for Depression

2019 ◽  
Vol 12 (2) ◽  
pp. 71 ◽  
Author(s):  
Madhukar Trivedi ◽  
Manish Jha ◽  
Farra Kahalnik ◽  
Ronny Pipes ◽  
Sara Levinson ◽  
...  
Keyword(s):  
Mental Health ◽  
Primary Care ◽  
Mental Health Professionals ◽  
Health Professionals ◽  
Universal Screening ◽  
Primary Care Providers ◽  
The United States ◽  
Care Providers ◽  
Similar Treatment ◽  
Measurement Based Care

Major depressive disorder affects one in five adults in the United States. While practice guidelines recommend universal screening for depression in primary care settings, clinical outcomes suffer in the absence of optimal models to manage those who screen positive for depression. The current practice of employing additional mental health professionals perpetuates the assumption that primary care providers (PCP) cannot effectively manage depression, which is not feasible, due to the added costs and shortage of mental health professionals. We have extended our previous work, which demonstrated similar treatment outcomes for depression in primary care and psychiatric settings, using measurement-based care (MBC) by developing a model, called Primary Care First (PCP-First), that empowers PCPs to effectively manage depression in their patients. This model incorporates health information technology tools, through an electronic health records (EHR) integrated web-application and facilitates the following five components: (1) Screening (2) diagnosis (3) treatment selection (4) treatment implementation and (5) treatment revision. We have implemented this model as part of a quality improvement project, called VitalSign6, and will measure its success using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. In this report, we provide the background and rationale of the PCP-First model and the operationalization of VitalSign6 project.

scholarly journals Patient Suffering in Chronic Digestive Diseases: Will Primary Care-Specialist Collaboration With Effective Interactive Communication and Integrative Medicine in the Plan of Care Improve Quality of Life?

2020 ◽  
Vol 7 (6) ◽  
pp. 989-993
Author(s):  
Andrew Thomas ◽  
Annie Thomas
Keyword(s):  
Quality Of Life ◽  
Primary Care ◽  
Health Care ◽  
Health Care Providers ◽  
The United States ◽  
Care Providers ◽  
Physician Visits ◽  
Digestive Diseases ◽  
Care Specialist

Acute and chronic digestive diseases are causing increased burden to patients and are increasing the United States health care spending. The purpose of this case report was to present how nonconfirmatory and conflicting diagnoses led to increased burden and suffering for a patient thus affecting quality of life. There were many physician visits and multiple tests performed on the patient. However, the primary care physician and specialists could not reach a confirmatory diagnosis. The treatment plans did not offer relief of symptoms, and the patient continues to experience digestive symptoms, enduring this burden for over 2 years. The central theme of this paper is to inform health care providers the importance of utilizing evidence-based primary care specialist collaboration models for better digestive disease outcomes. Consistent with patient’s experience, the authors propose to pilot/adopt the integrative health care approaches that are proven effective for treating digestive diseases.

scholarly journals A Systematic Review of the Use of Telemedicine in the Military Forces Worldwide

2020 ◽  
Vol 21 (11) ◽  
Author(s):  
Reza Mohammadi ◽  
Zeinab Tabanejad ◽  
Shahabeddin Abhari ◽  
Behnam Honarvar ◽  
Mina Lazem ◽  
...  
Keyword(s):  
Systematic Review ◽  
Data Extraction ◽  
Healthcare Providers ◽  
Military Medicine ◽  
Healthcare Services ◽  
Developed Countries ◽  
The United States ◽  
Positive Effects ◽  
Military Forces ◽  
The Military

Context: Considering the pivotal role of telemedicine in providing healthcare services for remote areas, some of the military medical centers, especially in developed countries, use different types of telemedicine programs. Objectives: The present study aimed at identifying the implemented telemedicine projects in military medicine worldwide and introducing their features. Evidence Acquisition: The current systematic review was performed in 2018. PubMed, Scopus, Embase, and Web of Science databases were searched for articles published from 2014 to 2018 by a combination of related keywords, and the related original articles were then selected based on the inclusion and exclusion criteria. Data were collected by a data extraction form, and then the data were summarized and reported based on the study objectives. Results: Of the 173 articles retrieved from the first round of search, 12 were included in the study; five (41.66%) studies had used the synchronous (real-time telemedicine) method. The United States, with nine studies, had the highest number of projects in military telemedicine. Most studies (n = 7) were performed on tele-psychology and the application of telemedicine in psychology. All selected studies reported the positive effects of telemedicine on providing healthcare for military forces. Conclusions: The proper utilization of telemedicine equipment is effective in saving time for both patients and healthcare providers, reducing costs, supporting in natural disasters, and satisfying patients with military medicine. To achieve telemedicine program objectives, they should be set precisely. Considering the importance of timely healthcare services, it is suggested to utilize synchronous methods and tools such as video conferencing.

Sign in / Sign up

Export Citation Format

Share Document