August 7, 2019

Comprehensive Primary Care for Older Patients With Multiple Chronic Conditions: “Nobody Rushes You Through” (JAMA. 2010;304(17):1936-1943.)

Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based […]
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Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers’) active engagement in care, and coordination of professionals in care of the patient—all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care—the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)—are described briefly, and steps toward their implementation are discussed.
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http://jama.ama-assn.org/cgi/content/abstract/304/17/1936

August 7, 2019

Interpersonal Continuity of Care and Care Outcomes: A Critical Review

PURPOSE We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care. METHODS A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to find original English […]
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PURPOSE We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care. METHODS A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to find original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence. RESULTS Forty-one research articles reporting the results of 40 studies were identified that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were significantly improved and only 2 were significantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported significantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity. CONCLUSIONS Although the available literature reflects persistent methodologic problems, it is likely that a significant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specific and measurable outcomes and more direct costs and should seek to define and measure interpersonal continuity more explicitly.
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http://www.annfammed.org/cgi/content/abstract/3/2/159

August 7, 2019

Implications of Reassigning Patients for the Medical Home: A Case Study

PURPOSE Improving patient-doctor continuity is one goal of the medical home, but achieving this goal may require physicians to reduce panel size. This article examines the impact on patient experience and utilization of Group Health Cooperative’s process of reassigning patients to new physicians as part of their medical home demonstration […]
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PURPOSE Improving patient-doctor continuity is one goal of the medical home, but achieving this goal may require physicians to reduce panel size. This article examines the impact on patient experience and utilization of Group Health Cooperative’s process of reassigning patients to new physicians as part of their medical home demonstration project. METHODS This work represents a subanalysis of the Group Health medical home pilot evaluation. Study participants include 8,005 adults who received primary care in 2006 and 2007 at an urban practice owned and operated by a not-for-profit integrated delivery system. Approximately one-quarter of patients were selected to be reassigned to a new physician. Primary care, emergency department, secure messaging, and telephone utilization were captured through automated sources. Patients’ experience was measured before and after implementation of the medical home for a subset of 1,098 patients. RESULTS Patients who were retained by their existing physicians were older, sicker, and had longer preexisting patient-doctor relationships. After reassignment, reassigned patients were less likely to use primary care services but equally likely to use the emergency department. They were no less satisfied with their care experience. CONCLUSIONS Informational and managerial continuity may mitigate deleterious effects of reassignment, but more must be done to actively bind reassigned patients to the medical home to improve relational continuity with younger, healthier patients. Key Words: Patient-centered medical home, primary health care, continuity of patient care, physician-patient relations, patient-centered care
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http://www.annfammed.org/cgi/content/abstract/8/6/493

August 7, 2019

Hospital At Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients. (Annals of Internal Medicine, December 6, 2005 vol. 143 no. 11 798-808)

Background: Acutely ill older persons often experience adverse events when cared for in the acute care hospital. Objective: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient’s home in a hospital at home. Design: Prospective quasi-experiment. Setting: 3 Medicare-managed care (Medicare + Choice) health […]
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Background: Acutely ill older persons often experience adverse events when cared for in the acute care hospital. Objective: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home. Design: Prospective quasi-experiment. Setting: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center. Participants: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. Intervention: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital. Measurements: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care. Results: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P?= 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care ($5081 vs. $7480) (P?< 0.001). Limitations: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences. Conclusions: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.
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http://www.annals.org/content/143/11/798.abstract

August 7, 2019

Primary Care Physicians Should Be Coordinators, Not Gatekeepers

Primary care gatekeeping, in which the goal of the primary care physician (PCP) is to reduce patient referrals to specialists and thereby reduce costs, is not an adequate system in which to practice medicine. However, returning to the pre–managed care model of uncoordinated open access to specialists is a poor […]
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Primary care gatekeeping, in which the goal of the primary care physician (PCP) is to reduce patient referrals to specialists and thereby reduce costs, is not an adequate system in which to practice medicine. However, returning to the pre–managed care model of uncoordinated open access to specialists is a poor solution. The primary care model should be retained, but PCPs should be transformed from gatekeepers into coordinators of care, in which the goal of the PCP is to integrate both primary and specialty care to improve quality. Changes in the PCP's daily work process, as well as the referral and payment processes, need to be implemented to reach this goal. This model would eliminate the requirement that referrals to specialists be authorized by the primary care physician or managed care organization. Financial incentives would be needed, eg, to encourage PCPs to provide management of complex cases and discourage both overreferral and underreferral to specialists. Budgeting specialists should control excess costs that might be created by the elimination of the primary care gatekeeper. Pilot projects are needed to test and refine this model of PCP as coordinator of care. KEYWORDS: gatekeepers, health service, managed care, programs, physicians' role, physicians, family, policy perspectives , primary care, physicians, referral and consultation.
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http://jama.ama-assn.org/content/281/21/2045.abstract?sid=1ae98db9-f651-4cb8-8e20-00b423514808

August 7, 2019

Joint Principles of the Patient-Centered Medical Home (March 2007)

The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, a
The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, a
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http://www.medicalhomeinfo.org/downloads/pdfs/jointstatement.pdf

August 7, 2019

Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century

This is the second and final report of the Committee on the Quality of Health Care in America, which was appointed in 1998 to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. The committee’s first report, To Err Is Human: Building a […]
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This is the second and final report of the Committee on the Quality of Health Care in America, which was appointed in 1998 to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. The committee’s first report, To Err Is Human: Building a Safer Health System, was released in 1999 and focused on a specific quality concern—patient safety. This second report focuses more broadly on how the health care delivery system can be designed to innovate and improve care. This report does not recommend specific organizational approaches to achieve the aims set forth. Rather than being an organizational construct, redesign refers to a new perspective on the purpose and aims of the health care system, how patients and their clinicians should relate, and how care processes can be designed to optimize responsiveness to patient needs. The principles and guidance for redesign that are offered in this report represent fundamental changes in the way the system meets the needs of the people it serves. Redesign is not aimed only at the health care organizations and professionals that comprise the delivery system. Change is also required in the structures and processes of the environment in which those organizations and professionals function. Such change includes setting national priorities for improvement, creating better methods for disseminating and applying knowledge to practice, fostering the use of information technology in clinical care, creating payment policies that encourage innovation and reward improvement in performance, and enhancing educational programs to strengthen the health care workforce.
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http://www.nap.edu/openbook.php?isbn=0309072808

August 7, 2019

The incidence and severity of adverse events affecting patients after discharge from the hospital

BACKGROUND Studies of hospitalized patients identify safety as a significant problem, but few data are available regarding injuries occurring after discharge. Patients may be vulnerable during this transition period. OBJECTIVE To describe the incidence, severity, preventability, and “ameliorability” of adverse events affecting patients after discharge from the hospital and to […]
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BACKGROUND Studies of hospitalized patients identify safety as a significant problem, but few data are available regarding injuries occurring after discharge. Patients may be vulnerable during this transition period. OBJECTIVE To describe the incidence, severity, preventability, and “ameliorability” of adverse events affecting patients after discharge from the hospital and to develop strategies for improving patient safety during this interval. DESIGN Prospective cohort study. SETTING A tertiary care academic hospital. PATIENTS 400 consecutive patients discharged home from the general medical service. MEASUREMENTS The three main outcomes were adverse events, defined as injuries occurring as a result of medical management; preventable adverse events, defined as adverse events judged to have been caused by an error; and ameliorable adverse events, defined as adverse events whose severity could have been decreased. Posthospital course was determined by performing a medical record review and a structured telephone interview approximately 3 weeks after each patient's discharge. Outcomes were determined by independent physician reviews. RESULTS Seventy-six patients had adverse events after discharge (19% [95% CI, 15% to 23%]). Of these, 23 had preventable adverse events (6% [CI, 4% to 9%]) and 24 had ameliorable adverse events (6% [CI, 4% to 9%]). Three percent of injuries were serious laboratory abnormalities, 65% were symptoms, 30% were symptoms associated with a nonpermanent disability, and 3% were permanent disabilities. Adverse drug events were the most common type of adverse event (66% [CI, 55% to 76%]), followed by procedure-related injuries (17% [CI, 8% to 26%]). Of the 25 adverse events resulting in at least a nonpermanent disability, 12 were preventable (48% [CI, 28% to 68%]) and 6 were ameliorable (24% [CI, 7% to 41%]). CONCLUSIONS Adverse events occurred frequently in the peridischarge period, and many could potentially have been prevented or ameliorated with simple strategies.
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http://www.annals.org/content/138/3/161.abstract

August 7, 2019

The Hospitalist, March 2009: New Design for Discharge–Four-part process improves patient outcomes, lowers readmission rates

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, […]
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With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process. Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.
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http://www.the-hospitalist.org/details/article/182425/New_Design_for_Discharge.html

August 7, 2019

Redefining and Redesigning Hospital Discharge to Enhance Patient Care: A Randomized Controlled Study

BACKGROUND: Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge processmay improve the continuity and the quality of patient care. OBJECTIVES: To evaluate a low-cost intervention designed to promptly reconnect patients to […]
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BACKGROUND: Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge processmay improve the continuity and the quality of patient care. OBJECTIVES: To evaluate a low-cost intervention designed to promptly reconnect patients to their “medical home” after hospital discharge. DESIGN: Randomized controlled study. Intervention patients received a “user-friendly” Patient Discharge Form, and upon arrival at home, a telephone outreach from a nurse at their primary care site. PARTICIPANTS: A culturally and linguistically diverse group of patients admitted to a small community teaching hospital. MEASUREMENTS: Four undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and historical controls. RESULTS: Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls. CONCLUSIONS: A low-cost discharge–transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital discharge.
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http://www.springerlink.com/content/j81085h6634x2665/fulltext.pdf