Organized Care Delivery Research Articles

Toward Higher-Value Health Care: A Multifaceted Approach

Summary This issue of NEJM Catalyst Innovations in Care Delivery includes articles, case studies, and research reports on organizing care delivery around conditions and accompanying insights on value-based care, primary care redesign, multidimensional approaches to measuring health care quality, improving treatment of heart failure, striving for zero harm, and home-based care.

A Health Equity-Oriented Research Agenda Requires Comprehensive Community Engagement.

Health policy and research communities have taken new approaches to addressing health equity, going beyond traditional methods that often excluded the contributions of health care consumers and persons with lived experience. This reevaluation has the potential to drive critical improvements in how we conduct research and innovate policy toward reducing health and health care disparities in the United States. Such considerations have led Fountain House, the founder of the Clubhouse model for peer-based psychosocial rehabilitation for persons with histories of serious mental illness, to incorporate community-based participatory action research (CBPAR) protocols within their research and service programs. The combination of CBPAR research methods within novel participatory care settings like Clubhouse programs presents unique and informative opportunities for the advancement of innovative health equity approaches to consumer empowerment in health care. In this piece, the authors (two staff researchers and one member researcher) propose how CBPAR research methods conducted in Clubhouses can uniquely advance equity-focused research methods, and how the benefit and enhancements from equity-focused research are continuously applied, practiced, and accountable to the communities within which the research is conducted. Embedding CBPAR practices within participatory care settings like Clubhouses, creates novel opportunities for research work to not only become more equitable but also become a part of the rehabilitative process, empowering the main beneficiaries of the research with the means to sustain and achieve further improvements for themselves. Such experiences are particularly important within rehabilitation settings, where there is a process of reclaiming empowerment and self-efficacy over a disability or illness and the social circumstances surrounding those conditions. Different stakeholders can all play important roles in advancing health equity–oriented research agendas by leveraging CBPAR principles. Academics and others in the research community can more comprehensively embed CBPAR methods into the design of their research studies. A critical link exists among how researchers conduct their studies, how providers organize care delivery and support, and how health plans pay for and evaluate care. CBPAR-generated research needs to fully engage clinical teams to ensure that ongoing community-involved care settings have direct applications to real-world care delivery. It is equally important that providers fully engage with their communities as they adjust their approaches to supporting the populations they serve.

Information technologies that facilitate care coordination: provider and patient perspectives.

Health information technology is a core infrastructure for the chronic care model, integrated care, and other organized care delivery models. From the provider perspective, health information exchange (HIE) helps aggregate and share information about a patient or population from several sources. HIE technologies include direct messages, transfer of care, and event notification services. From the patient perspective, personal health records, secure messaging, text messages, and other mHealth applications may coordinate patients and providers. Patient-reported outcomes and social media technologies enable patients to share health information with many stakeholders, including providers, caregivers, and other patients. An information architecture that integrates personal health record and mHealth applications, with HIEs that combine the electronic health records of multiple healthcare systems will create a rich, dynamic ecosystem for patient collaboration.

Is patient satisfaction with organizational aspects of their general practitioner's practice associated with patient and doctor gender? An observational study.

BackgroundNo study has assessed the association between patients’ and doctors’ gender and patient satisfaction with organizational aspects of health care in primary care. However, just like satisfaction regarding communication styles or technical skills, satisfaction towards organization of the general practitioner (GP) practice could also depend on doctors’ and/or patients’ gender. Different expectations between female and male patients regarding the organization of the practice or different ways of organizing care delivery between female and male GPs could act on this satisfaction. We aimed to compare female and male patients’ satisfaction towards their GP overall, and according to GPs’ gender.MethodsIn a cross-sectional study in Geneva, 23 randomly selected GPs (participation rate: 31 %) were asked to recruit up to 100 consecutive patients coming to the practice for a scheduled medical consultation. The patients completed an anonymous questionnaire about their satisfaction with their GP. Patient satisfaction was assessed using the six questions from the Europep questionnaire regarding organizational aspects of health care in terms of accessibility and availability, and presented in two different ways: % of patients very satisfied and mean score (SD). Multivariate analyses adjusting for patient and GP characteristics were conducted to compare outcomes between genders.ResultsOne thousand six hundred thirty-seven patients agreed to participate (participation rate: 97 %, women: 63 %, mean age: 54 years). The majority of patients were very satisfied (women 96.2 %, men 95.3 %, p = 0.38). Mean satisfaction scores were slightly higher in women (for overall satisfaction: women 4.7/5 (SD 0.6), men 4.6/5 (SD 0.6), p = 0.02) and in women visiting male GPs (women 4.6 (SD 0.6), men 4.5 (SD 0.6), p = 0.01), and the gender differences showed consistency across satisfaction items. These differences were small and no longer statistically significant in multivariate analyses.ConclusionsThese findings suggest that patients are highly satisfied with the organization of their GP’s practice, regardless of patients’ and GPs’ gender. As patients’ and GPs’ gender are known to influence patient satisfaction towards primary care delivery and as the current study is the first to explore this aspect in relation to organizational aspects of GP practice, further studies are needed in various primary care settings to confirm our results.

Predictors of Rural Health Clinics Managers' Willingness to Join Accountable Care Organizations.

The implementation of the Patient Protection and Affordable Care Act has facilitated the development of an innovative and integrated delivery care system, Accountable Care Organizations (ACOs). It is timely, to identify how health care managers in rural health clinics are responding to the ACO model. This research examines RHC managers' perceived benefits and barriers for implementing ACOs from an organizational ecology perspective. A survey was conducted in Spring of 2012 covering the present RHC network working infrastructures - 1) Organizational social network; 2) organizational care delivery structure; 3) ACO knowledge, perceived benefits, and perceived barriers; 4) quality and disease management programs; and 5) health information technology (HIT) infrastructure. One thousand one hundred sixty clinics were surveyed in the United States. They cover eight southeastern states (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and California. A total of ninety-one responses were received. RHC managers' personal perceptions on ACO's benefits and knowledge level explained the most variance in their willingness to join ACOs. Individual perceptions appear to be more influential than organizational and context factors in the predictive analysis. The study is primarily focused in the Southeastern region of the U.S. The generalizability is limited to this region. The predictors of rural health clinics' participation in ACOs are germane to guide the development of organizational strategies for enhancing the general knowledge about the innovativeness of delivering coordinated care and containing health care costs inspired by the Affordable Care Act. Rural health clinics are lagged behind the growth curve of ACO adoption. The diffusion of new knowledge about pros and cons of ACO is essential to reinforce the health care reform in the United States.

Disruptive and Deliberate Innovations in Healthcare

Disruptive and Deliberate Innovations in Healthcare

Building platforms for collaborative care and clinical research in testicular cancer (TC): New approaches for care delivery for a model neoplasm.

308 Background: TC is a “model of a curable neoplasm.” In expert centers, more than 95% of patients are cured and enjoy long, high quality survivorship. Unfortunately, emerging data demonstrate variations in quality outcomes seen in high volume centers. Result are not fully replicated in U.S. community settings, low resources countries or in settings of uneven access. We hypothesize that real time, electronic information exchange in TC can influence favorably clinical decision making, patient-centered outcomes, value and quality of survivorship across business and geographic boundaries. Further, we speculate that aggregated, de-identified clinical/ biological information will serve as a template for a rapid learning system to refine clinical management and advance biological understanding. Methods: Our primary objectives were to (1) Build organizational/administrative capacity. (2) Engage patients/local providers. (3) Develop the information infrastructure to accomplish real time exchange of live patient-permitted clinical data (patient reported inputs, laboratory, imaging) and timely transmission of clinical decision support and ongoing oversight of care delivery in the community. (4) Establish a proof-of-principle demonstration in a community-based, electronically organized care delivery system. Results: Organizational: TC Commons, a nonprofit organization, was founded to house this effort. Leading academic institutions form the knowledge base, initial data sharing network and administrative structure for this electronic cooperative group. Early implementation has utilized cloud-based resources and telepresence. Community Engagement: We are utilizing organized social media efforts and partnering with patient advocacy groups. IT Infrastructure: We are creating public/private collaboratives to house the electronic capacity with appropriate privacy concerns. Proof of Principle: We are selecting community partner organizations and planning grant submissions. Conclusions: Expert platforms to enhance care delivery, patient value and experience, and clinical research can be built using a “bootstapping,” cost-sensitive approach.

A Cross-Country Check-Up in Healthcare

• Restructuring of healthcare governance and professional regulatory approaches; • Changes to organizational care delivery systems and the scopes of practice of nurses and other disciplines; • The aging of the nursing leadership and the lack of concerted succession planning; • Funding challenges and cost-containment initiatives in light of increasing service demands; • The focus on patient safety and quality of work life; and • The need to invest in information technology.

Innovations: ‘Medical Home’ Or Medical Motel 6?

Innovations: ‘Medical Home’ Or Medical Motel 6?

Enhancing Cancer Registry Data to Promote Rational Health System Design

Those of us in large chaotic health-care systems, like that in the United States, look with particular interest at the experience in smaller more contained health systems, like that in The Netherlands, to glean how we might apply rational principles to organizing care delivery. In classical epidemiology, we have learned a tremendous amount by examining the experiences of those in The Netherlands and other countries, such as Scandinavia, who couple meticulous records on the vital status and health of their populations with high-quality cancer registries. Similarly, in clinical epidemiology and health services research, we gain enormously from evaluating the experiences of other health-care systems with different models of care delivery. It is therefore with great interest that we examine the study from The Netherlands by Vernooij et al. ( 1 ) that compares delivery of ovarian cancer care among generalized, semispecialized, and specialized hospitals. The authors sought to obtain information as to whether ovarian cancer patients who receive their care in specialty cancer hospitals have superior survival outcomes compared with those who receive their care in semispecialized or general hospitals. Using tumor registry data, they compared survival outcomes for the 40% of Dutch women who received ovarian cancer care at general hospitals with that of the 40% who received care at hospitals with some cancer expertise and the 20% who received care at specialty cancer centers. They found a 5-year relative survival of 38% at general hospitals, 39.4% at semispecialized hospitals, and 40.3% at specialty hospitals. They relied on 5-year relative survival — that is, the ratio of the observed survival to the survival that was expected based on the age- and period-specifi c mortality of the general population — as a proxy for cancer-specifi c survival, which is not reliably tracked by the cancer registry that they used. The limitations of the analysis by Vernooij et al. (1) and by others ( 2 – 4 ) are those that are inherent in their data source — population-based tumor registries. Although tumor registries in The Netherlands and elsewhere collect meticulous high-quality data on cancer site, histology, and stage, several critical pieces of information that infl uence both choice of treatment and cancer outcomes are missing. In particular, there is no information about comorbidity or performance status. Consequently, it is exceedingly diffi cult, if not impossible, to determine whether the survival differences reported are due to differences in the quality of care or to underlying systematic differences in the characteristics of patients who seek care at general vs specialty hospitals. This potential for selection bias is the bugaboo of scores of articles on regionalization of specialty cancer care as well as the related voluminous literature on volume – outcome relationships in cancer surgery. In the analysis of Vernooij et al. (1), we note that patients treated at general hospitals were an average of 5 years older and were substantially less likely to undergo primary surgical reduction or to receive systemic chemotherapy than those treated at more specialized centers. It is of course not possible to know whether the patients who did not undergo debulking surgery and chemotherapy would have received these interventions had they gone to a specialty center or whether these interventions would have improved their outcomes. However, both the age of the patients and the treatment differences strongly indicate that Dutch ovarian cancer patients who seek care at specialized hospitals have different characteristics from those who seek care at general hospitals. This potential for confounding makes it impossible to know whether the superior outcomes at specialty centers are a result of the patients’ underlying attributes and disease severity or of the care they received. Therefore, this analysis in and of itself does not justify regionalization of ovarian cancer surgery in The Netherlands to specialty centers. Although there are many reasons that explain why the care may be superior in specialty centers, the survival differences are quite modest and there is considerable evidence of selection when it comes to hospital choice. The data presented hint that generalized hospitals in The Netherlands may treat the very old and infi rm, who do not undergo surgery at all, as well as patients with early-stage uncomplicated disease, who generalist gynecologists may be more comfortable managing. Such a heterogeneous mixture of patients would attenuate differences in survival outcomes between generalized and specialized centers. The optimal strategy to mitigate selection bias is randomization. If women could be randomly assigned to receive their care in particular hospitals and systematic differences in their outcomes were evident, then we would have convincing evidence about how to organize care. However, the practical obstacles to randomly

Developing Staff Nurse Shared Leadership Behavior in Professional Nursing Practice

Mutual trust between the Chief Nurse Executive (CNE) and a regional nursing staff enabled the creation of a shared vision of excellence in clinical outcomes in Aurora Health Care—Metro Region, an organized care delivery system in Eastern Wisconsin. Motivation, leadership skill development, and a res

The American organization of nurse executives research column

SummaryPatient safety is now in the forefront. Attention to patient safety opens up new opportunities to develop new and better systems for care delivery, and new approaches to ensure patient safety. Research to discover the most effective ways for organizing care delivery and to develop optimal models of nursing care provide the much-needed science on which to base decisions. The AONE Education, Research and Development Priorities provide a framework for this research agenda. The work of cohesive multidisciplinary teams of various professionals would be enhanced by research findings. In reality, there are multiple factors that contribute to error. Secking depth in understanding of what should be done to reduce error is a matter of professional accountability.

Primary nursing: a mode of care or a philosophy of nursing?

An examination of the literature surrounding primary nursing has shown that the term 'primary nursing' is used to mean different things by different authors. This results in a confusing situation where 'primary nursing' is considered by some to mean both a mode of organizing care delivery and a philosophy of nursing. In this paper I argue for a clear separation between the terms which refer to the set of ideas underpinning nursing and descriptions of modes of care. A case is made for using the term 'human centred nursing' to refer to nursing beliefs and 'primary nursing' to refer to the mode of nursing care delivery.