Innovative Health Care Delivery Models Research Articles

The relationships between access to and use of a patient-centered medical home and healthcare utilization and costs: A cohort study using Medical Expenditure Panel Survey data from 2007 to 2010

Objective The patient-centered medical home has emerged as an innovative healthcare delivery model that holds the conceptual promise to improve healthcare quality while reducing costs. This study is among the first to examine how patient perceived patient-centered medical home is related to utilization and costs for emergency department and inpatient care nationwide in the U.S. Methods This retrospective cohort study used data from the 2007–2010 Medical Expenditure Panel Survey. This study focused upon insured individuals aged 18 and older. In each two-year cohort, we measured and identified a full patient-centered medical home group, a partial patient-centered medical home group (with a usual source of care but not a patient-centered medical home), and an unknown patient-centered medical home group. Using negative binomial regression and generalized linear models, we conducted the analysis while controlling for covariates at baseline. Given the nature of the complex survey design, we adjusted weights and variance. Results The study sample consisted of 15,595 individuals, representing a total of 368 million people in the U.S. In the trend of outcome changes from the baseline to the follow-up year, the full and partial patient-centered medical home groups demonstrated reduced efficiency for the 2007–2008 cohort, but increased efficiency for the 2009–2010 cohort, as compared to the no regular provider group. Conclusions Overall, the empirical evidence does not indicate whether patient-centered medical home models reduce healthcare utilization and costs, but it does suggest their potential as mechanisms for achieving healthcare system efficiency, when primary care practices have grown from early to middle stage of patient-centered medical home transformation. A longer observation window and holistic view on all stages of patient-centered medical home growth may be more informative on patient-centered medical home’s efficiency.

Research on Multiple Chronic Conditions

Research on Multiple Chronic Conditions

Providing and funding breast health services in urban nurse-managed health centers

Nurse-managed health centers (NMHCs) are an innovative health care delivery model that serves as an important point of health care access for populations at risk for disparities in health outcomes. This article describes the process and outcomes of clinical breast health services in two NMHCs located in a large Midwestern city. Findings indicate that client's knowledge about breast health was increased after they received breast health services from NMHC nurses. Significant positive changes in behavior related to the early detection of breast cancer were found in the study. NMHCs, identified for expansion in the Patient Protection and Affordable Care Act, offer a unique health care services delivery model that promotes access to care and early identification of breast cancer in very low-income and uninsured women.

High‐Intensity Telemedicine‐Enhanced Acute Care for Older Adults: An Innovative Healthcare Delivery Model

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models.

The Garbose Family Special Delivery Unit: A new paradigm for maternal–fetal and neonatal care

Birth defects remain the leading cause of infant mortality in the United States according to the Centers for Disease Control. For many anomalies, etiology remains unknown, management and outcome vary widely, and treatment is costly. Great strides have been made in prenatal diagnosis, yet standardized prenatal care and delivery protocols are needed for women carrying fetuses with specific birth defects such as diaphragmatic hernia, lung lesions, abdominal wall defects, congenital heart disease and so forth. In an effort to standardize and improve the overall care for mother and baby with a known birth defect, the Garbose Family Special Delivery Unit was opened at the Children's Hospital of Philadelphia in June 2008. This paper describes an innovative healthcare delivery model focusing on the rationale for developing a specialized delivery unit, the facility design and development process, care model, team and services, and the types of fetal diagnoses and maternal admission criteria for the SDU.

Patient Portals in Primary Care: Impacts on Patient Health and Physician Productivity

Interest in innovative health care delivery models has increased due to measures such as the Aordable Care Act, which is designed to expand insurance coverage and contain health care costs. The goal of these innovations is to increase physician productivity without sacricing quality of care. One innovation that has been forwarded as a low-cost alternative to physician oce visits is \e-visits, or secure messaging between patients and physicians via patient portals. We evaluate the eect of e-visit adoption on patient health and physician productivity using a six-year panel dataset from a large primary care provider in the United States. The main challenge in evaluating e-visits is that there could be unobservable selection: in particular,

An Innovative Canadian Solution for Improved Access to Care for Knee Injuries Using “Non-Physician Experts”: The Calgary Acute Knee Injury Clinic

There is a significant burden of musculoskeletal (MSK) disorders on the Canadian healthcare system which emphasizes the need for improved patient flow and integrated services throughout the MSK clinical care pathway. Improving accessibility, effectiveness, acceptability and efficiency of safe and appropriate care of MSK health using innovative models of healthcare delivery has become an important issue for Canada. This paper is a prospective study that describes and evaluates an evidence-based model for management acute knee injuries in Calgary, Alberta, Canada: the Calgary Acute Injury Knee Clinic model (C-AKIC). C-AKIC model development consisted of three stages: 1) development, implementation and evaluation of a new non-physician expert (NPE) curriculum; 2) identification of the logistics for opening the C-AKIC within an urban setting; and 3) evaluation of the accessibility, effectiveness, acceptability and efficiency of the C-AKIC model relative to the current healthcare system. NPE curriculum improved both theoretical knowledge (12% average increase) and clinical competence (33.5% average increase). NPEs evaluated and managed acute knee injuries in an interdisciplinary team (2 NPEs and a primary care physician) at the C-AKIC. Patients were significantly more satisfied with the new clinical care pathway (M = 91.20 out of 100) compared to patients who went through the existing/traditional pathway (M = 75.58 out of 100). Patients also saw fewer healthcare providers in C-AKIC clinical care pathway (M = 2.14) in a shorter period of time (M = 2.09 months) compared to the existing system: M = 2.76 months and; M = 7.24 months, respectively. This project demonstrated a unique and efficient approach to evaluation and management acute knee injuries in an urban setting by providing a potentially viable solution to the need for human resources in the healthcare workforce.

The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: a systematic review.

The prevalence of diabetes mellitus is ubiquitous. Complications and costs of diabetes are rising and are depleting limited resources. It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions. An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit. Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting. The review objective was to conduct a systematic review and meta-analysis to synthesize the best available evidence related to effectiveness of group medical visits on HbA1c, blood pressure and cholesterol measurements/levels for adult patients with type II diabetes in outpatient settings. A three-step literature search for studies in English language from 1990 to 2010 was conducted utilising (a) a primary search of Medline, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials, (b) a secondary search of non-indexed databases, and (c) a search of the grey literature. In addition, a manual review of the reference lists of all identified reports and articles was performed to identify additional studies. All randomised and quasi-experimental studies of adult patients (>18) with type II diabetes mellitus seen in outpatient health settings were considered if they met one or more of the following diagnostic outcome measurements: haemoglobin A1c, systolic and diastolic blood pressure, and low density lipoprotein cholesterol. Each of the eligible articles was reviewed by two independent reviewers. Disagreements between the reviewers were resolved through discussion, or with a third reviewer. Studies that met the inclusion criteria were assessed for methodological quality using the JBI standardized critical appraisal tools. Data extraction was undertaken using the standardised data extraction tool from JBI-MAStARI. The search strategy identified 2,040 articles in the published and unpublished literature. Of these, 11 randomised controlled trials and 4 quasi-experimental trials met the inclusion criteria and represented 2240 patients included in the final review.There are clear benefits of group medical visits for patients' HbA1c levels which are consistent in the post-intervention and change from baseline effect sizes. The most significant effect observed is with the change from baseline results. Some evidence suggests post-intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe. There is no evidence that group visits improve LDL cholesterol values of the group visit participants. Group medical visits should be considered by clinicians as an effective non-pharmacologic intervention that can have a positive impact on biologic markers such as haemoglobin A1c and systolic blood pressure. The evidence suggests that the most powerful model of Group medical visits (GMV) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs. Future research should include this GMV intervention in randomised controlled trials across different health systems and socio-economic and ethnic groups.

The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: a systematic review

Background The prevalence of diabetes mellitus is ubiquitous. Complications and costs of diabetes are rising and are depleting limited resources. It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions. An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit. Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting. Objectives The review objective was to conduct a systematic review and meta-analysis to synthesize the best available evidence related to effectiveness of group medical visits on HbA1c, blood pressure and cholesterol measurements/levels for adult patients with type II diabetes in outpatient settings. Search strategy A three-step literature search for studies in English language from 1990 to 2010 was conducted utilising (a) a primary search of Medline, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials, (b) a secondary search of non-indexed databases, and (c) a search of the grey literature. In addition, a manual review of the reference lists of all identified reports and articles was performed to identify additional studies. Inclusion criteria All randomised and quasi-experimental studies of adult patients (>18) with type II diabetes mellitus seen in outpatient health settings were considered if they met one or more of the following diagnostic outcome measurements: haemoglobin A1c, systolic and diastolic blood pressure, and low density lipoprotein cholesterol. Critical appraisal, data collection and analysis Each of the eligible articles was reviewed by two independent reviewers. Disagreements between the reviewers were resolved through discussion, or with a third reviewer. Studies that met the inclusion criteria were assessed for methodological quality using the JBI standardized critical appraisal tools. Data extraction was undertaken using the standardised data extraction tool from JBI-MAStARI. Main results The search strategy identified 2,040 articles in the published and unpublished literature. Of these, 11 randomised controlled trials and 4 quasi-experimental trials met the inclusion criteria and represented 2240 patients included in the final review. There are clear benefits of group medical visits for patients’ HbA1c levels which are consistent in the post-intervention and change from baseline effect sizes. The most significant effect observed is with the change from baseline results. Some evidence suggests post-intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe. There is no evidence that group visits improve LDL cholesterol values of the group visit participants. Conclusions Group medical visits should be considered by clinicians as an effective non-pharmacologic intervention that can have a positive impact on biologic markers such as haemoglobin A1c and systolic blood pressure.

Physician-Led Outpatient Breastfeeding Medicine Clinics in the United States

Attrition of exclusive breastfeeding is highest during the first 3 months postpartum. Timely management of breastfeeding in the outpatient setting through innovative models of healthcare delivery may increase its duration and exclusivity. Our goal was to examine the structure and function of physician-led clinics in the United States that specialize in providing outpatient clinical support for breastfeeding-related issues ("breastfeeding medicine clinics"). We posted a survey on Listservs of the American Academy of Pediatrics, American Academy of Family Physicians, and Academy of Breastfeeding Medicine. The survey collected information on (1) clinic and physician demographics, (2) visit characteristics, (3) referral and reimbursement, (4) clinical activities, (5) continuing education resources, (6) teaching/education activities, and (7) advocacy activities, of physician-led outpatient breastfeeding medicine clinics. Lead physicians from 13 clinics responded to the survey. Their clinics provided clinical care for time-intensive breastfeeding problems. The clinics we described that were in existence longer than 2 years appeared to be economically sustainable. Most physicians who had provided specialized breastfeeding support for more than 5 years reported that their income was commensurate with others in their specialty. Most physicians who provided specialized breastfeeding medicine care additionally provided primary care services within the same clinical setting. Further research into fiscal and organizational aspects of establishing specialized physician-led breastfeeding clinics is needed. The potential of such clinics in contributing to collaborative practice-based research, as well as medical student and house staff education, needs to be explored.

Preventing Cardiovascular Disease

The occurrence of coronary heart disease (CHD) in successive generations of families was first observed by Sir William Osler almost 100 years ago.1 Since then, numerous cross-sectional and some longitudinal studies of diverse populations have reported clustering of CHD in families.2–7 While the specific mechanisms remain to be fully clarified, the interplay of genetic and shared common environmental factors including lifestyle behaviors has been implicated in familial aggregation of CHD. Several very recent reports add uniquely to the existing database and underscore the importance of family history of CHD in risk prediction and disease prevention.8–12 Specifically, results from the Framingham Offspring Study indicate that early-onset parental CHD is an independent predictor of offspring cardiovascular events in middle-aged men and women (mean age, 44 years).8 After adjustment for other risk factors, premature CHD in at least 1 parent was associated with a significant doubling in risk for men and a 70% increase in risk for women over a period of 8 years. Parental CHD was found to discriminate risk best among offspring with intermediate levels of cardiovascular risk as predicted by individual traditional risk factors and multivariable risk equations.8 Other recent studies of population-based cohorts demonstrate associations of familial CHD with subclinical atherosclerosis including increased carotid intima-media thickness and coronary artery calcium (CAC), a surrogate measure of the presence and burden of coronary atherosclerosis.9–12 Results from a recent study conducted by Nasir and colleagues9 are particularly noteworthy and suggest that sibling history of CHD may be more strongly associated with subclinical atherosclerosis than parental history of premature CHD. In this cross-sectional study of 8549 asymptomatic individuals (69% men; mean age 52 ± 9 years), the association of a reported family history of early-onset (before age 55 years) CHD with the presence and extent of CAC measured by electron beam tomography was examined. After adjustment for other risk factors, the odds ratio for the presence of CAC was 2.5 in men and 1.9 in women with a positive family history in both a sibling and a parent. Those who reported a premature CHD event in a sibling had a 2.5 odds risk (150% more likely) of having CAC; individuals with a history of premature CHD in parents had a 1.3 odds risk (30% more likely) of having CAC.9 Taken together, the results of these studies provide additional support for the inclusion of family history of premature CHD in risk assessment and stratification and for family-based approaches to CHD prevention.13 Current guidelines for primary and secondary prevention of CHD in children and adults advocate for family-based approaches to cardiovascular health promotion and risk reduction.14–18 The National Cholesterol Education Program (NCEP), for example, suggests a high-risk approach to identifying children at risk of CHD on the basis of family history of premature disease and/or parental dyslipidemia.14 Recent American Heart Association guidelines support and extend this approach to include early identification and vigilant follow-up of children with family history of CHD and other established risk factors including hypertension and obesity.15 Although family history is not incorporated into some widely used multivariable risk algorithms including the NCEP's Adult Treat Panel (ATP III) guidelines,18 family-based approaches to risk reduction including therapeutic lifestyle modification are emphasized by the NCEP and in the American Heart Association's prevention guidelines for adults.16,17 Across healthcare and community settings, cardiovascular nurse-clinicians are well-positioned and prepared to identify persons at risk of CHD on the basis of family history. For example, in the acute care and cardiac cath lab settings, first- and second-degree relatives of persons with early-onset disease (≤55 in men; ≤65 in women) could be identified, counseled, and/or referred to their primary healthcare provider for assessment and management of risk factors. In view of the evidence indicating intrafamilial associations of CHD-related lifestyle behaviors as well as traditional independent risk factors, family-based approaches to cardiovascular health promotion and risk reduction are clearly warranted. Given the state of the science in this area of CHD prevention, cardiovascular nurse scientists are presented with numerous research opportunities such as determining how family history of CHD can be used to educate and motivate those at risk to modify health behaviors, developing and testing family-based therapeutic lifestyle interventions, and developing and implementing innovative models of healthcare delivery that enable more effective and more efficient family-focused cardiovascular care.

Depression, service need, and use in vulnerable populations

Health care reform has created opportunities for mental health nurses to develop innovative health care delivery models to provide integrated behavioral health and primary health care. A community health analysis is one method to ensure appropriate services are planned. This study examined the health care services most needed and those used by depressed and nondepressed participants (N = 231), and their satisfaction with these services. Individual and system characteristics were examined using a framework developed by Anderson and Aday. Significant differences were found between the 2 groups for predisposing characteristics, enabling characteristics, need for care, service use, and satisfaction with services. Copyright © 2000 by W.B. Saunders Company