Is It Worth the Wait? Patient Perceptions of Wait Time at a Primary Care Clinic

Background and Objectives: A patient’s wait to see a provider before scheduled appointments may impact their experience at the primary care clinic. This survey study examined how long patients are willing to wait, where they prefer to wait, and whether punctual care in the clinic may be more prioritized than quality care. Methods: We disseminated a survey in the waiting room of an urban adult primary care office to assess patient perceptions and evaluate the importance of punctuality. We completed subgroup analyses to examine any differences by age and gender in patient expectations and values. Results: The survey was completed by 180 respondents (92% response rate). Patients report they can wait up to 20 minutes (95% CI 19.1-22.0) before seeing their provider. A subgroup analysis determined that age alone cannot be used as a screening tool to identify patients who require the most punctual care. Women expressed a more explicit preference for quality rather than punctuality compared to men (P=.0017). Conclusions: Results suggest that patients are unwilling to forego quality care for punctuality alone. Our findings may help providers better understand patient perceptions of waiting at a primary care clinic.

Lessons Learned From a Pilot Project on Telemedicine Advance Care Planning in an Urban Geriatric Primary Care Office

Purpose: There is a dearth of literature regarding the documentation of advance care planning (ACP) in the geriatric population, despite the controversial, yet well-studied need for ACP. The purpose of this pilot study was to provide an update to a prior study from our institution that outlined the need for increased documentation of advance care planning (ACP) in an urban geriatric population. Methods: Our study involved using telemedicine to conduct dedicated ACP visits and an electronic medical record (EMR) note-template specifically designed for these visits in an attempt to increase the amount of documented ACP in the EMR in this population. Results: The study did not yield significant results due to the inability to schedule enough patients for these dedicated visits. Discussion: While our study was ultimately unsuccessful, 3 crucial lessons were identified that will inform and fuel future interventions by the authors to further the study of documentation of ACP.

Scope and Complexities of the Clinical Issues

Individuals with chronic pain are a very diverse group of patients. The etiology of their pain may be very complex and difficult to identify using traditional diagnostic studies. Furthermore, many of these patients manifest very complicated and dynamic psychological/psychiatric issues. Patients present to a variety of settings, including pain clinics and the primary care office. No matter the level of training or experience, clinicians are confronted with all manner of diagnostic and therapeutic dilemmas. For some patients, their psychological/psychiatric issues dominate their presentation, requiring immediate, and often long-term, attention. Community resources may be limited, leaving the clinician feeling beleaguered. However, equipping oneself with some basic principles and strategies can contribute to developing meaningful and beneficial therapeutic relationships. The goals of treatment have to be considered very careful and may require some flexibility. Firm, yet compassionate, care and skillful communication offer the best opportunity for success.

Medication Reconciliation and Patient Education at a Primary Care Office in South Florida

Mediation reconciliation is a process that is crucial for ensuring drug safety among patients who demonstrate low medication adherence. Medication reconciliation at the Primary Care office is achieved by educating patients about the purpose of prescribed medicines, drug-to-drug, and drug-to-food interactions. Besides, patients are consulted about interactions between conventional and complementary and alternative medicine, and the dangers of consuming substances (illicit drugs, alcohol, nicotine) together with prescribed drugs. This approach is planned to be accomplished by means of combining printed medication reconciliation lists followed by open-ended questions included to check patients’ pharmacovigilance and conduct patient engagement. In addition, the innovative approach of the present project is inclusion of patients’ significant others in the process of advancing their treatment adherence. Direct participation of patients and their family member in medication reconciliation is expected to bring significant positive results. This project is valuable for advanced nurse practicing because it demonstrates the new ways to improve nurse-patient interactions, advance communication with patients’ family members and in overall, advance their pharmacovigilance.

Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy

Background Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.

Improving Medication Adherence in an ACO Primary Care Office With a Pharmacist­Led Clinic: A Report From the ACORN SEED

Background: As health care moves into the era of value-based medicine, both ambulatory and acute settings are being held accountable for the quality of care provided to patients. Previous studies have shown improved clinical outcomes through medication therapy management (MTM) due to improved medication adherence. Objective: The purpose of this study is to assess the effects of a pharmacist-led MTM clinic in an accountable care organization (ACO) affiliated primary care office on adherence to renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported through Healthcare Effectiveness Data and Information Set (HEDIS) Medicare Star Ratings. Methods: In this retrospective cohort study, data were collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated with a RAS antagonist, statin, or diabetic medication. The primary outcome of this investigation was a change in Star Rating scores for medication adherence to RAS antagonists, diabetic medications, and statins from pre- and postpharmacist MTM intervention. Results: A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25 interventions. One year prior to MTM clinic implementation, most Star Ratings were consistently 3 (out of 5) for RAS antagonists, diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Conclusion: Implementing a pharmacist-led MTM clinic in the ACO primary care setting improves Medicare Star Ratings in patients with chronic conditions.