Primary Care Capacity Research Articles

Development of type 2 diabetes mellitus quality indicators in general practice by a modified Delphi method in Beijing, China

BackgroundThe service capacity of primary care has improved in China. General practice also takes growing responsibility in the management of type 2 diabetes mellitus, but there are concerns about the paucity of evidence of the quality of care delivered. And there is an absence of systematic quality indicators of type 2 diabetes mellitus in general practice in China. This study aimed to develop a set of type 2 diabetes mellitus quality indicators to facilitate quality measurement in general practice in China.MethodsPreliminary quality indicators were generated and refined by literature review and an expert consultation meeting. Two rounds of email-based Delphi survey and a consensus meeting were carried out to identify quality indicators. Delphi questionnaires with 43 indicators were sent to 30 participants in the first round. There were 16 general practitioners and 10 community health service center leaders from primary care, 3 endocrinologists and a primary care researcher in the first round. And 27 out of the 30 participants participated in the second round. The consensus meeting was held among 9 participants to refine the indicators and a last round of rating was carried out in the meeting. The indicators were rated in terms of importance and feasibility. The agreement criteria were defined as median ≥ 7.0 and ≥ 85.0% of ratings in the 7–9 tertile for importance; median ≥ 7.0 and ≥ 65.0, 70.0, 75.0% of ratings in the 7–9 tertile for feasibility respectively in the three rounds of rating.ResultsAfter 2 rounds of Delphi survey and the consensus meeting, total 38 indicators achieved consensus for inclusion in the final set of indicators. The final set of indicators were grouped into 7 domains: access (5 indicators), monitoring (12 indicators), health counseling (7 indicators), records (2 indicators), health status (7 indicators), patient satisfaction (2 indicators) and self-management (3 indicators).ConclusionsA set of 38 potential quality indicators of type 2 diabetes mellitus in general practice were identified by an iterative Delphi process in Beijing, China. Preliminary approach for measurement and data collection were described. However, the indicators still need to be validated by testing in a further study.

Will Community Health Centers Survive COVID‐19?

Will Community Health Centers Survive COVID‐19?

The role of organizational learning and resilience for change in building quality improvement capacity in primary care.

The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown. The aim of the study was to examine the association of AR and development of QI capacity. One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined. Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure. Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity. Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts.

The Capacity Of Posyandu In Indonesia (Data Analysis Indonesia Family Life Survey (IFLS) 2007)

Each year, about 12 million children under five in developing countries died that the real problem can be prevented. Various interventions have also been made include the establishment of a service model based society Posyandu is a form of implementation of community-based health services. Nutritional problems in Indonesia has a fairly close relation with the activeness of Posyandu activities. The existence of Posyandu activities depend on the willingness of the public contribution to the activity. The purpose of this study is to determine the factors - factors that affect the independence of Posyandu in Indonesia and can formulate appropriate policy as an effort to increase the capacity of Posyandu in Indonesia in improving health of the people, especially women and children. This study is a quantitative analysis of secondary data IFLS 2007. The study population was individuals and households in 13 provinces in Indonesia, using the entire sample of 581 Posyandu in Indonesia who were respondents IFLS 2007. After statistical test showed that 64.89% Posyandu in Indonesia are categorized as independent Posyandu. Factors that most influence on the independence of Posyandu is locating the Posyandu (p value = 0.008), education cadre (p value 0.04), and the availability of funding sources Posyandu originating from the village budget (p value 0.007). The presence of independent Posyandu in Indonesia is still quite high. IHC in rural areas have the capacity of primary health care that is lower than the Posyandu in town. The number of active volunteers who are not always able to be a major factor as a component posyandu independence. Active cadres and cadres of education can be related components as an indicator of the capacity of the Posyandu.

Like using a refrigerator to heat food: capacity and capability funding in primary care and the legacy of the Primary Health Organisation Performance Programme.

INTRODUCTION In 2016, the New Zealand Ministry of Health introduced the System Level Measures (SLM) framework as a new approach to health system improvement that emphasised quality improvement and integration. A funding stream that was a legacy of past primary care performance management was repurposed as 'capacity and capability' funding to support the implementation of the SLM framework. AIM This study explored how the capacity and capability funding has been used and the issues and challenges that have arisen from the funding implementation. METHODS Semi-structured interviews with 50 key informants from 18 of New Zealand's 20 health districts were conducted. Interview transcripts were coded using thematic analysis. RESULTS The capacity and capability funding was used in three different ways. Approximately one-third of districts used it to actively support quality improvement and integration initiatives. Another one-third tweaked existing performance incentive schemes and in the remaining one-third, the funding was passed directly on to general practices without strings attached. Three key issues were identified related to implementation of the capacity and capability funding: lack of clear guidance regarding the use of the funding; funding perceived as a barrier to integration; and funding seen as insufficient for intended purposes. DISCUSSION The capacity and capability funding was intended to support collaborative integration and quality improvement between health sector organisations at the district level. However, there is a mismatch between the purpose of the capacity and capability funding and its use in practice, which is primarily a product of incremental and inconsistent policy development regarding primary care improvement.

Building capacity in primary health care to respond to the needs of asylum seekers and refugees in Melbourne, Australia: the 'GP Engagement' initiative.

Asylum seekers and refugees experience poorer health than the broader Australian population. Universal primary healthcare services play an integral role in supporting and optimising the health and wellbeing of these communities. However, clinical-level issues frequently compromise the quality of care provided to these groups. The 'GP Engagement' initiative, implemented in the south-eastern region of Melbourne, aimed to build capacity within universal primary health care to respond to the needs of asylum seekers and refugees. This involved engaging general practice clinics, resourcing them with tools and frameworks, and undertaking collaborative problem-solving on refugee issues. Evaluation methods included: rigorous record keeping; pre- and post-practice assessments guided by a self-reported '12-Point Checklist'; and participant feedback. Findings from 57 participating health professionals indicated changes in the way that GPs work with asylum seekers and refugees. 'GP Engagement' suggests that it is possible to build primary healthcare responsiveness to asylum seekers and refugees through a strategic regional approach that is firmly grounded in evidence-based practice and considerate of the requirements and constraints of GPs.

Primary Care Comprehensiveness and Care Coordination in Robust Specialist Networks Results in Lower Emergency Department Utilization: A Network Analysis of Medicaid Physician Networks.

Background: Care coordination is an essential and difficult to measure function of primary care. Objective: Our objective was to assess the impact of network characteristics in primary/specialty physician networks on emergency department (ED) visits for patients with chronic ambulatory care sensitive conditions (ACSCs). Subjects and Measures: This cross-sectional social network analysis of primary care and specialty physicians caring for adult Medicaid beneficiaries with ACSCs was conducted using 2009 Texas Medicaid Analytic eXtract (MAX) files. Network characteristic measures were the main exposure variables. A negative binomial regression model analyzed the impact of network characteristics on the ED visits per patient in the panel. Results: There were 42 493 ACSC patients assigned to 5687 primary care physicians (PCPs) connected to 11 660 specialist physicians. PCPs whose continuity patients did not visit a specialist had 86% fewer ED visits per patient in their panel, compared with PCPs whose patients saw specialists. Among PCPs connected to specialists in the network, those with a higher number of specialist collaborators and those with a high degree of centrality had lower patient panel ED rates. Conclusions: PCPs providing comprehensive care (ie, without specialist consultation) for their patients with chronic ACSCs had lower ED utilization rates than those coordinating care with specialists. PCPs with robust specialty networks and a high degree of centrality in the network also had lower ED utilization. The right fit between comprehensiveness of primary care, care coordination, and adequate capacity of specialty availability in physician networks is needed to drive outcomes.

OPEN ARCH: integrated care at the primary-secondary interface for the community-dwelling older person with complex needs.

Optimal care of community-dwelling older Australians with complex needs is a national imperative. Suboptimal care that is reactive, episodic and fragmented, is costly to the health system, can be life threatening to the older person and produces unsustainable carer demands. Health outcomes would be improved if services (health and social) are aligned towards community-based, comprehensive and preventative care. Integrated care is person-focussed in outlook and defies a condition-centric approach to healthcare delivery. Integration is a means to support primary care, with the volume and complexity of patient needs arising from an ageing population. Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) is a targeted model of care that improves access to specialist assessment and comprehensive care for older persons at risk of functional decline, hospitalisation or institutionalised care. OPEN ARCH was developed with primary care as the central integrating function and is built on four values of quality care: preventative health care provided closer to home; alignment of specialist and generalist care; care coordination and enablement; and primary care capacity building. Through vertical integration at the primary-secondary interface, OPEN ARCH cannot only improve the quality of care for clients, but improves the capacity of primary care to meet the needs of this population.

Implementation of HIV Preexposure Prophylaxis in a Homeless Primary Care Setting at the Veterans Affairs.

Objective: Oral preexposure prophylaxis (PrEP) is highly effective in preventing HIV-1 acquisition, yet it is underutilized among at-risk populations. In this pilot quality improvement (QI) initiative, we sought to identify barriers to PrEP implementation and create interventions to improve access to PrEP in a primary care clinic for homeless veterans. Methods: The setting was a large homeless primary care clinic at the Veterans Affairs in an urban area with high HIV prevalence. A root cause analysis was performed to identify barriers to PrEP expansion in the primary care clinic. Targeted interventions to improve provider knowledge and patient access to PrEP were implemented by the QI team. Results: Root cause analysis revealed 3 primary barriers to PrEP expansion in the primary care clinic: institutional limitations for prescribing PrEP, inconsistent screening and recognition of eligible patients by clinic staff, and lack of clinic workflow processes to support PrEP prescription. A multidisciplinary focus group found low levels of PrEP awareness and knowledge, with only 22% of providers reporting comfort discussing PrEP with patients. This improved to 40% of providers following targeted clinic educational interventions. The QI team also developed a pathway for primary care providers to obtain institutional PrEP prescribing privileges and used work groups to develop clinic workflows and protocols for PrEP. At the end of the intervention, at least 50% of primary care providers in the clinic had initiated PrEP in a new patient. Conclusions: We describe a multidisciplinary QI model to implement PrEP within a primary care setting serving Veterans and persons experiencing homelessness. Our program successfully addressed provider knowledge deficits and improved primary care capacity to prescribe PrEP. The primary care clinic can be a viable and important clinical setting to improve access to PrEP for HIV prevention, especially for vulnerable populations.

How Collaborative Mentoring Networks Are Building Capacity in Primary Care.

The need for increased capacity in primary care to treat the growing numbers of patients with complex chronic health conditions is well established (Roberts et al. 2015). Meeting that need requires not only more family physicians but also more support and resources to handle challenging cases. The Collaborative Mentoring Networks (CMNs), created in 2001 by the Ontario College of Family Physicians and funded by the Ontario government, have provided that support and proven particularly successful in improving physicians' competence and confidence in caring for patients struggling with mental health, addictions and chronic pain. The networks give family physicians timely, ongoing access to mentors with greater clinical expertise. In 2017, the networks expanded from two to seven, spreading support to palliative and end-of-life care and medical assistance in dying and focusing on leadership in primary care, early years in practice and rural medicine. CMNs' early impact involved increased primary care capacity in family practice, better-supported family physicians treating more patients with complex conditions, fewer specialist referrals, less isolation and greater retention.

The Role of the National Health Service Corps Clinicians in Enhancing Staffing and Patient Care Capacity in Community Health Centers.

The National Health Service Corps (NHSC) is a federal program to increase the supply of health professionals in underserved communities, but its role in enhancing the capacity of community health centers (CHCs) has not been investigated. This study examined the role of NHSC clinicians in improving staffing and patient care capacity in primary, dental, and mental health care in CHCs. Using 2013-2016 administrative data from CHCs and the NHSC, we used a generalized estimating equation approach to examine whether NHSC clinicians [staff full-time equivalents (FTEs)] complement non-NHSC clinicians in CHCs and whether their productivity (patient visits per staff FTE) was greater than that of non-NHSC clinicians in primary, dental, and mental health care. Each additional NHSC clinician FTE was associated with a significant gain of 0.72 non-NHSC clinician FTEs in mental health care in CHCs and an increase of 0.04 non-NHSC FTEs in primary care in CHCs with more severe staffing shortages. On average, every additional NHSC clinician was associated with an increase of 2216 primary care visits, 2802 dental care visits, and 1296 mental health care visits per center-year. The adjusted visits per additional staff for NHSC clinicians were significantly greater in dental (difference=992) and mental health (difference=423) care, compared with non-NHSC clinicians. The NHSC clinicians complement non-NHSC clinicians in primary care and mental health care. They help enhance the provision of patient care in CHCs, particularly in dental and mental health services, the 2 major areas of service gaps.

PC-FACS

PC-FACS

Pilot study to build capacity for family medicine with abbreviated, low-cost training programme with minimal impact on patient care for a cohort of 84 general practitioners caring for Palestinian refugees in Jordan

PurposeStudies document that primary care improves health outcomes and controls costs. In regions of the world where primary care is underdeveloped, building capacity is essential. Most capacity building programmes are...

Multi-disciplinary training hubs in North West England: the training hub lead perspective

ABSTRACTIntroduction: Increasing the capacity of Primary Care to meet the challenge of providing future complex and multi-disciplinary care in England has led to the increasing establishment of ‘Training Hubs’ [TH]. Other terms are used interchangeably to refer to TH activity: Advanced Training Practices, Enhanced Training Practices and Community Education Providers. The aim of this study was to gather the perceptions of TH Leads in North West England on how they established their TH and lessons learned.Methods: Five semi-structured telephone interviews were undertaken with TH Leads. Thematic analysis of the transcripts was undertaken.Findings: Four themes were identified: Motivation and Expectations of Establishing THs; Benefits to Learners and Practice Staff; Implementation Challenges and Barriers to Scale-Up; Sustainability and Wider Implementation.Discussion: TH Leads highlighted that the establishment of THs enhanced the multi-disciplinary learning experience. However, several barriers for sustaining the quality of the TH learning environments were identified. Difficulties recruiting ‘Spoke Practices’ were greater than expected. Findings identified the following factors for consideration for wider implementation: the maintenance of TH Lead support networks; appropriateness of funding to encourage practices who may be reluctant to take on this additional responsibility; the importance of communication channels between THs and HEIs; careful management of students numbers.

Assessing quality improvement capacity in primary care practices

BackgroundHealthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation.MethodsTo guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors.ResultsThe QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2–5 clinicians had lower QICA scores..ConclusionsThe QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality.Trial registrationThis trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.

LearnOvation: an intervention to foster exploration and exploitation behaviour in health care management in daily practice

BackgroundInnovation has been identified as an important engine for improving the quality, productivity and efficiency of health care. Little is known about how to stimulate innovation capacity in primary health care in general; even less is known about how specific interventions should be designed to support managements’ work with practice-based innovations. Research has shown that if managers and teams are excellent at handling the challenges of production (exploitation) and development (exploration), they are better at innovation. The aim of the study is to develop a dynamic management support programme to increase innovation leadership skills in daily practice.MethodsThe study has an interactive approach that allows the need for empirical and theoretical knowledge to emerge and merge, and a quasi-experimental cross-over design. Eight primary health care centres will participate in the study. In the first phase, the management teams at four health care centres will participate in the intervention, and the other four centres will serve as a control group. Thereafter, the units will switch places and the control group will experience the intervention. All staff at the 8 units will answer questionnaires at four points in time (before, during, after, 6 months later) to evaluate the effects of the intervention.DiscussionThe study will contribute to knowledge on how to organize processes of innovation and support exploitation and exploration behaviours by co-producing and testing a tailor-made management support programme for innovation work in primary health care. An expected long-term effect is that the support system will be disseminated to other centres both within and beyond the participating organizations.

Specialist and family physician collaboration: Insights from primary care-based memory clinics.

Given limited available geriatric specialists and complexity of dementia care, there is a need for greater collaboration between primary care and specialists to better meet the needs of persons with dementia. Meaningful family physician-specialist collaboration has the potential to improve health outcomes, timely access to care and more appropriate healthcare resource utilisation. Primary Care Collaborative Memory Clinics (PCCMCs), which include specialist support, provide a significant opportunity for studying the family physician-specialist interface. This study aimed to explore the nature of collaborative relationships between memory clinic family physicians and specialists caring for persons with memory concerns in PCCMCs across Ontario, Canada. Family physicians (N=71) attending an education session and specialists (N=21) completed a survey in the fall of 2017 that measured frequency and amount of collaboration, perceptions of their relationship and identified factors that enable and challenge collaboration. Descriptive statistics were generated for quantitative data and themes for responses to open-ended questions were explored using descriptive qualitative content analysis. Specialists and memory clinic family physicians valued their collaboration particularly as related to capacity building for dementia care and desired more time devoted to collaboration. Identified enablers and barriers to collaboration have implications for further integration of specialist support to potentially support improved patient care and further build capacity in primary care to manage dementia care. Opportunities exist for expanding and more intentionally supporting how family physicians and specialists interact with the creation of more formalised processes to support optimal collaboration, including a clear delineation of roles, responsibilities and expectations, more formally planned and structured relationship building and monitoring, identifying and addressing unique barriers to collaboration and use of a variety of methods of communication. Study findings have implications for how specialists and family physicians communicate and collaborate in other programmes for complex chronic conditions.

Evaluation of a collaborative care model for integrated primary care of common mental disorders comorbid with chronic conditions in South Africa

BackgroundThe rise in multimorbid chronic conditions in South Africa, large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists demands a task sharing approach to chronic disease management that includes treatment for co-existing CMDs to improve health outcomes. The aim of this study was thus to evaluate a task shared integrated collaborative care package of care for chronic patients with co-existing depressive and alcohol use disorder (AUD) symptoms.MethodsThe complex intervention strengthened capacity of primary care nurse practitioners to identify, diagnose and review symptoms of CMDs among chronic care patients; and implemented a stepped up referral system, that included clinic-based psychosocial lay counsellors, doctors and mental health specialists. Under real world conditions, in four PHC facilities, a repeat cross-sectional Facility Detection Survey (FDS) assessed changes in capacity of nurses to correctly detect CMDs in 1310 patients before implementation and 1246 patients following implementation of the intervention at 12 months; and a non-randomly assigned comparison group cohort study comprising 373 screen positive patients with depressive symptoms using the Patient Health Questionnaire-9 (PHQ9) at baseline, evaluated responses of patients correctly identified and referred for treatment (intervention arm) or not identified and referred (control arm) at three and 12 months.ResultsThe FDS showed a significant increase in the identification of depression and AUD from pre-implementation to 12-month post-implementation. Depression: (5.8 to 16.4%) 95% CI [2.9, 19.1]); AUD: (0 to 13.8%) 95% CI [0.6–24.9]. In the comparison group cohort study, patients with depressive symptoms having more than a 50% reduction in PHQ-9 scores were greater in the treatment group (n = 69, 55.2%) compared to the comparison group (n = 49, 23.4%) at 3 months (RR = 2.10, p < 0.001); and 12 months follow-up (intervention: n = 57, 47.9%; comparison: n = 60, 30.8%; RR = 1.52, p = 0.006). Remission (PHQ-9 ≤ 5) was greater in the intervention group (n = 32, 26.9%) than comparison group (n = 33, 16.9%) at 12 months (RR = 1.72, p = 0.016).ConclusionA task shared collaborative stepped care model can improve detection of CMDs and reduce depressive symptoms among patients with chronic conditions under real world conditions.

The health service capacity of primary health care in West China: different perspectives of physicians and their patients

BackgroundMany countries, including China, have identified the primary health care system as a reform priority. The purpose of this study is to compare the perceived service capacity of primary care from the perspectives of physicians and their patients in Sichuan province of China.MethodsA cross-sectional survey was conducted through Quality and Costs of Primary Care (QUALICOPC) questionnaires. A representative sample of 319 primary care physicians and 641 patients in 48 primary healthcare settings were recruited to take part in the study.ResultsPhysicians perceived equity of care the best, while quality of care was rated the highest from the perspective of patients. They both regarded coordination as the weakest dimension of primary care service capacity.ConclusionsAlthough primary health care reform may have been effective in helping patients acquire better primary care services, our results suggest that coordination is still perceived to be problematic for both physicians and patients. Improving the coordination of care has to be one of the main goals in the future primary care reforms in China.

An Opportunity for Quality: The Need for Better Evaluation of Family Health Teams in Ontario.

In the past decade, primary care has undergone significant changes toward system improvement, which has improved patient outcomes and reduced costs. Family health teams (FHTs) were introduced in Ontario as part of primary care renewal. FHTs address a lack of capacity and integration among providers and service inaccessibility experienced by the population. We explore, the potential for positive impact of FHTs and the lack of built-in evaluation strategies to assess performance. We provide four suggestions to better support rigorous evaluation of FHTs. This commentary considers Ontario's efforts to improve capacity, quality and evaluation in primary care through FHTs.