Delivery Of Primary Care Services Research Articles

Factors That Influence Data Use to Improve Health Service Delivery in Low- and Middle-Income Countries.

Health service delivery indicators are designed to reveal how well health services meet a community's needs. Effective use of the data can enable targeted improvements in health service delivery. We conducted a systematic review to identify the factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income settings. We reviewed empirical studies published in 2005 or later that provided evidence on the use of health service delivery data at the primary care level in low- and middle-income countries. We searched Scopus, Medline, the Cochrane Library, and citations of included studies. We also searched the gray literature, using a separate strategy. We extracted information on study design, setting, study population, study objective, key findings, and any identified lessons learned. Twelve studies met the inclusion criteria. This small number of studies suggests there is insufficient evidence to draw reliable conclusions. However, a content analysis identified the following potentially influential factors, which we classified into 3 categories: governance (leadership, participatory monitoring, regular review of data); production of information (presentation of findings, data quality, qualitative data); and health information system resources (electronic health management information systems, organizational structure, training). Contextual factors and performance-based financing were also each found to have a role; however, discussing these as mediating factors may not be practical in terms of promoting data use. Scant evidence exists regarding factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income countries. However, the existing evidence highlights some factors that may have a role in improving data use. Further research may benefit from comparing data use factors across different types of program indicators or using our classification as a framework for field experiments.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Integrating eye health into policy: Evidence for health systems strengthening in KwaZulu-Natal

Background: Available evidence is that eye health care receives less attention compared to other allied health professions in public health services across South Africa, yet vision impairment is known to have significant social and economic consequences. Rural areas appear to be more affected, with KwaZulu-Natal (KZN) representing the second-most populous province in the country. The World Health Organization formulated a health systems framework which describes health systems in terms of six building blocks. This approach was applied in KZN, to assess the Department of Health’s capacity to provide comprehensive primary eye health services in KZN, South Africa. Aim: To determine the capacity for comprehensive primary eye care service delivery within the public health sector in KZN. Setting: All health disctrict in KwaZulu-Natal. Methods: An explorative-descriptive cross-sectional design, gathering both quantitative and qualitative data, was used. Data were collected utilising questionnaires, observation, and interviews. Results were analysed against the health systems framework. Results: A total of 28 optometrists responded to the survey, representing 60% of public health facilities that provide eye health care in KZN. The majority (53.6%) of optometrists were from district hospitals in rural areas. Facilities were generally inadequately equipped, with inefficiencies in service delivery including long waiting times and multi-tasking of clinicians. The absence of a financing model impacted the service at all levels. Conclusion: Policy development for eye health is necessary for KZN to deliver comprehensive eye health services. In particular, emphasis should be placed on the integration of eye health into primary health care and appropriate planning to foster accessibility and sustainability of services.

Utilization and Cost of an Employer-Sponsored Comprehensive Primary Care Delivery Model

Primary care is increasingly delivered at or near workplaces, yet utilization and cost of employer-sponsored primary care services remain unknown. To compare the health care utilization and cost of an employer-sponsored on-site, near-site, and virtual comprehensive primary care service delivery model with those of traditional community-based primary care. This population-based cohort study of 23 518 commercially insured employees and dependents of an engineering and manufacturing firm headquartered in southern California was performed from January 1, 2016, to July 1, 2019. A subset of the population with most (≥50%) primary care visits through employer-sponsored on-site, near-site, or virtual care clinics was matched to a subset not having most such visits through the employer-sponsored clinics using propensity score matching (n = 1983 each). In sensitivity analyses, employees were matched to dependents at neighboring firms that lacked access to the employer-sponsored primary care delivery model (additional n = 1680). Integrated primary care, mental health, and physical therapy delivered through on-site, near-site, and virtual clinics. Utilization (inpatient, outpatient, emergency department, pharmaceutical, radiology, and laboratory visits per 1000 member-months) and spending (2019 costs per member per month in US dollars) by service type. A total of 23 518 individuals (mean [SD] age, 27 [15] years; 14 604 [62.1%] male) were included in the full population sample and had been enrolled in the employer-sponsored health plan for a mean of 29 months (interquartile range, 14-48 months). Of eligible members, 5292 (22.5%) used the employer-sponsored services, with 2305 (9.8%) using them for most of their primary care. The mean (SD) cost of employer-sponsored service delivery was $87 ($32) per member month. Among the matched populations (mean [SD] age, 31 [11] years; 3349 [84.5%] male) of primary users vs control individuals, total spending was 45% lower per member per month (95% CI, 35%-55%; cost difference, -$167 per member per month; 95% CI, -$204 to -$130; P < .001) among users after adjustment. The lower spending was associated with lower spending on non-primary care services, such as emergency department (-33%; 95% CI, -44% to -22%) and hospital visits (-16%; 95% CI, -22% to -10%), despite higher spending on primary care (109%; 95% CI, 102%-116%) and mental health (20%; 95% CI, 13%-27%). The findings suggest that individuals who used the models' services for most of their primary care had lower total spending despite higher primary care spending, which may be associated with self-selection of lower-risk persons to the employer-sponsored services and/or with the use of comprehensive primary care.

A comparison of In-Person, Synchronous and Asynchronous Telepsychiatry: Skills/Competencies, Teamwork, and Administrative Workflow

Research is increasing on the use of asynchronous technologies like e-mail, text, e-consultation, and asynchronous telepsychiatry by primary care and specialist clinicians. Clinicians need measurable skills, knowledge, and attitudes for these technologies to ensure quality care outcomes. This narrative review used a literature search of Medline, American Psychological Association PsycNET, PsycINFO, Embase, Cochrane, and Web of Science, using subject headings and keywords along with a manual search of reference lists of articles published by December 2019. Articles were included if they discussed and compared asynchronous technologies (e.g., asynchronous telepsychiatry), synchronous telepsychiatric (video including telemental and telebehavioral health), and in-person care. The review compares approaches, effectiveness, skills, and outcomes of these three modes of service delivery in behavioral health and primary care, since those clinicians interface with these technologies. Few studies have evaluated the efficacy and effectiveness of asynchronous technologies in behavioral, or compared them directly to synchronous and in-person care. Publications comparing synchronous telepsychiatry, asynchronous telepsychiatry, and other asynchronous technologies to in-person care focus on the technology used, how to do it, workflow processes, and medico-legal issues, but there is less written about clinical issues like the therapeutic frame, communication, boundaries, and trust. No studies specifically discuss behaviors or competencies for asynchronous care, though telepsychiatric, telebehavioral health, social media, and mobile health competencies have relevant elements. Users of asynchronous technologies (i.e., patients, primary care teams, and psychiatrists) need to adjust clinical skills, work as team members, and integrate technological and administrative factors into workflow. Implications for clinicians, trainees, faculty, administrators, and institutions are discussed. Asynchronous technologies improve access, reduce costs, and compliment other care options. Health systems must appraise how to help individuals and interprofessional participants best interface with a wide range of technologies. This requires adjustments in clinical and administrative workflow. Research in measurable competency sets, implementation, and outcomes is needed.

Working conditions and interventions of health extension workers in the rural areas of South-Western Ethiopia

This study examined the working conditions and interventions of health extension workers in the two selected rural kebeles found in Sarbo District, South-Western Ethiopia. The qualitative research approach utilized owing to the nature of the study in which four health extension workers interviewed in-depth and key informant interviews used as methods. Data were analyzed and interpreted by using qualitative methods of data analysis with triangulation in the thematic method. The study indicated that low payment, poor transportations, unsafe working conditions, and less supportive top management were among the issues that impede interventions and working conditions of health extension workers in the study areas. Furthermore, it further leads to poor delivery of primary health care services. This calls for the designing of effective interventions to improve rural health care services by creating favorable working conditions for rural health extension workers.

Protocol for the process and feasibility evaluations of a new model of primary care service delivery for managing pain and function in patients with knee osteoarthritis (PARTNER) using a mixed methods approach

IntroductionThis protocol outlines the rationale, design and methods for the process and feasibility evaluations of the primary care management on knee pain and function in patients with knee osteoarthritis (PARTNER)...

Adolescent SBIRT implementation: Generalist vs. Specialist models of service delivery in primary care

BackgroundDrug, alcohol, and tobacco use among adolescents pose significant short- and long-term health consequences and are associated with more severe use as adults. Screening, brief intervention, and referral to treatment in primary care settings has the potential to deliver preventive interventions to a diverse range of adolescents, but optimal implementation of these services needs to be determined. The purpose of this study was to compare implementation of two different SBIRT service delivery models in primary care settings. MethodsThis cluster-randomized trial assigned 7 primary care clinics of a federally qualified health center to implement brief interventions (BI) using a Generalist model (4 sites), in which BIs were delivered by the primary care provider (PCP), or a Specialist model (3 sites), in which BIs were delivered by a behavioral health counselor (BHC) for adolescent patients ages 12–17 years. Implementation was tracked through the clinic's electronic health record, spanning 9639 clinic visits over 20 months. Multilevel logistic regression modeling was used to compare Generalist and Specialist strategies on penetration of BI for patients scoring ≥2 on the CRAFFT substance use screen, delivered by the PCP in the Generalist sites, and via warm hand-off to a BHC in the Specialist sites. ResultsApproximately 62% of adolescent patient visits were screened with the CRAFFT (with <4% screening positive with a CRAFFT score ≥ 2). The Generalist Condition had significantly higher self-reported penetration of BI delivery than the Specialist Condition (38% vs. 8%; Adjusted Odds Ratio = 6.53; p = .005). DiscussionDespite having co-located behavioral health services at all sites, a Specialist approach to providing BI was less effectively implemented than a Generalist approach in this FQHC. BI delivered by PCPs rather than by hand-off to a BHC may ensure greater penetration of these services in primary care settings. Both implementation models provided a framework for identifying and intervening with adolescent primary care patients whose substance use might have otherwise gone undetected.

Managing patients in care homes

Older people in care homes deserve the best health and social care we can offer. Their care needs are usually high and they are vulnerable either physically, cognitively or both. They are likely to have several long-term conditions and be in the last year or so of life. Although some may have families and friends supporting them with regular visits and advocacy, others may be more alone and socially isolated. Care homes are traditionally classed as either residential homes or nursing homes, with some being dual registered. The main difference is the presence of 24-hour on-site qualified nursing support in nursing homes. This means that, in general, the residents of nursing homes are more dependent and complex. This article will first describe how to approach the planning and delivery of primary care services to nursing homes, and then consider some of the most common problems and conditions. Much of this also applies to residential home residents.

The Vancouver Community Analytics Tool (VCAT): Software Enabling Operationalization of the Building Blocks of High-Performing Primary Care at Community Health Centers in British Columbia, Canada.

Community health centers (CHCs) in British Columbia, Canada, are using a data-driven approach to enable functions related to the design, organization, management, delivery, and evaluation of primary health care services for complex populations. Descriptive study leveraging case studies from 4 CHCs in Vancouver, Canada, to provide an overview and examples of the functions and outputs of the Vancouver Community Analytics Tool (VCAT). Quantitative data were derived from electronic medical record data and regional emergency department data. Data were analyzed and reported by the VCAT software. VCAT is a health system modeling, analytics, and reporting application suite that enables operationalization of the Ten Building Blocks of High-Performing Primary Care framework via 1) creation of a virtual patient record, 2) modeling and measurement of epidemiological profiles, 3) population management and quality improvement, 4) measurement and assessment of biopsychosocial complexity, 5) empanelment, and 6) design and optimization of team-based care. The software captures data on patient pathways and service operations for over 300 service sites, including community health centers, detox centers, and emergency departments. The software integrates data on service utilization and myriad other variables for over 750,000 individuals. Using case studies, the article describes how the software helps solve practical clinical, organizational, and performance issues facing CHCs. VCAT models, analyzes, and visualizes the complexity profiles and service utilization patterns of complex populations, thereby enabling system administrators and clinicians to improve system performance and quality of care. The software represents a significant advance for health services research and is transforming the organization, delivery, and evaluation of primary health care services.

Exploring the implementation and delivery of primary care services for transgender individuals in Ontario: case study protocol.

Historically transgender adults have experienced barriers in accessing primary care services. In Ontario, Canada, health care for transgender adults is accessed through primary care; however, a limited number of practitioners provide care, and patients are often waiting and/or traveling great distances to receive care. The purpose of this protocol is to understand how primary care is implemented and delivered for transgender adults. The paper presents how the case study method can be applied to explore implementation of health services delivery for the transgender population in primary care. Case study methodology will be used to explore this phenomenon in different primary care contexts. Normalization Process Theory is used as a guide. Three cases known to provide transgender primary care and represent different Ontario primary care models have been identified. Comparing transgender care implementation and delivery across different models is vital to understanding how care provision to this population can be supported. Qualitative interviews will be conducted. Participants will also complete the NoMAD (NOrmalization MeAsure Development) survey, a tool measuring implementation processes. The tool will be modified to explore the implementation of primary care services for transgender individuals. Documentary evidence will be collected. Cross-case synthesis will be completed to compare the cases. Findings will provide an Ontario perspective on the implementation and delivery of primary care for transgender adults in different primary care models. Results may be applicable to other primary care settings in Canada and other nations with similar systems. Barriers and facilitators in delivery and implementation will be identified. Providing an understanding and increasing awareness of the implementation and delivery of primary care may help to reduce the invisibility and disparities transgender individuals experience when accessing primary care services. Understanding delivery of care could allow care providers to implement primary care services for transgender individuals, improving access to health care for this vulnerable population.

Implementing Geographic Information Systems (GIS) into VHA Home Based Primary Care

The Veteran's Health Administration (VHA) Home Based Primary Care (HBPC) program provides comprehensive in-home primary care services to elderly Veterans with complex chronic medical conditions. Nurses have prominent roles in HBPC including as program leaders, primary care providers and nurses who make home visits. Delivery of primary care services to patients in their homes can be challenging due to travel distances, difficult terrain, traffic, and adverse weather. Mapmaking with geographic information systems (GIS) can support optimization of resource utilization, travel efficiency, program capacity, and management during normal operations, and patient safety during disasters. This paper reports on the feasibility, acceptability and outcomes of an initiative to implement GIS mapmaking in VHA HBPC programs. A mixed method evaluation assessed extent of adoption and identified facilitators and barriers to uptake. Results indicate that GIS mapping in VHA HBPC is feasible and can increase effectiveness and efficiency of VHA HBPC nurses.

INTERDISCIPLINARY CURRICULUM FOR THE CARE OF OLDER ADULTS: CREATING NETWORKS OF COLLABORATIVE LEARNERS

Serving older adults with multiple chronic conditions and variable social, emotional, or physical support effectively within the primary care setting requires an interdisciplinary approach to care. Our GWEP program has developed an interprofessional education center that educates and prepares students and professionals from social work, medicine, nursing, dentistry, pharmacy, and community health partners, to function within a transformed integrated patient-centered geriatric primary care and community-based service delivery system. Learners from multiple disciplines attend a face-to-face Interdisciplinary Case Management Experience (ICME) session lasting 2.5 hours. Sessions include learners from each discipline and, if possible, at least one community practitioner in small groups of 6–8 learners at each table facilitated by 1 faculty member. Approximately 1,200 learners have received the curriculum. To evaluate the program, Kirkpatrick’s Training Evaluation Model was used to determine if learners were satisfied with the content, skilled, and confident in their abilities to utilize the curriculum. Learners completed a satisfaction survey after taking each module, along with an interdisciplinary geriatric care knowledge test and self-efficacy test before and after taking each module to measure learning outcomes. Analysis showed that learners, irrespective of discipline, were satisfied with the program. All disciplines showed a significant increase from pre- to posttest for all 5 online modules achieving a mean post-knowledge score of 85% across all 5 online training modules. All disciplines experienced significant differences in their self-efficacy with working on interdisciplinary teams from pre to post ICME. Implications for future interprofessional curriculum will be discussed.

Empanelment: A foundational component of primary health care.

Empanelment is a foundational strategy for building or improving primary health care systems and a critical pathway for achieving effective universal health coverage. However, there is little international guidance for defining empanelment or understanding how to implement empanelment systems in low- and middle-income countries. To fill this gap, a multi-country collaborative within the Joint Learning Network for Universal Health Coverage developed this empanelment overview, proposing a people-centered definition of empanelment that reflects the responsibility to proactively deliver primary care services to all individuals in a target population. This document, building on existing literature on empanelment and representing input from 10 countries, establishes standard concepts of empanelment and describes why and how empanelment is used. Finally, it identifies key domains that may influence effective empanelment and that must be considered in deciding how empanelment can be implemented. This document is designed to be a useful resource for health policymakers, planners and decision-makers in ministries of health, as well as front line providers of primary care service delivery who are working to ensure quality people-centered primary care to everyone everywhere.

Geographical variation in preventable hospital admissions for dental conditions: An Australia-wide analysis.

To describe the characteristics of hospital admissions for dental conditions, by Australian Statistical Geography Standard remoteness area for the 5years 2010/2011 to 2014/2015. Retrospective analysis of preventable hospital admissions due to dental conditions. National data set provided by the Australian Institute of Health and Welfare. Every hospital admission for patients who were admitted for dental conditions over five financial years, from 2010/2011 to 2014/2015. The number (and rate per 1000 population) of hospital admissions due to dental conditions in each Australian Statistical Geography Standard remoteness area (major city, inner regional, outer regional, remote and very remote). There were 316937 hospital admissions for dental conditions over the 5-year period. The rate of potentially preventable dental hospital admissions ranged from an average of 2.5 per 1000 population in major cities to 3.2 in inner regional areas, 3.1 in outer regional areas, and 4.1 per 1000 in remote and very remote areas. The rate of admissions was highest among those aged 0-14years living in remote (9.0-10.0 per 1000) and very remote (9.8-12.5 per 1000) areas. Dental caries was the most common reason for admissions. There is an urgent need to address the social determinants of oral health in children aged 0-14years living in remote and very remote Australia. The delivery of mobile primary dental care services needs to be expanded in remote and very remote areas to prevent and treat dental caries.

Addressing Diabetes in Primary Care: Hybrid Effectiveness-Implementation Study of Lifestyle Redesign® Occupational Therapy.

Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy's feasibility and efficacy in primary care settings. To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)-occupational therapy (LR-OT) diabetes management intervention in a primary care clinic. Patients were randomized to be offered LR-OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods. Safety-net primary care clinic. Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18-75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%. Eight 1-hr individual sessions of LR-OT focused on diabetes management. Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR-OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations. Seventy-three patients were offered LR-OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation. LR-OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care. This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy's effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

Taking up the gauntlet: Pharmacist delivery of primary care services

Taking up the gauntlet: Pharmacist delivery of primary care services

Evidenced Based Policy Decisions &amp; Population Health: Policies, Disparities, and Data Integrity

The surfeit of health policy research in the health care literature is concomitant with the dearth in the public administration literature, although billions of public dollars are spent annually on healthcare. The purpose of this paper is to shed light on a critical flaw in our ability to accurately analyze the contributions of efficient and effective healthcare practitioners who hold the potential to substantially improve health care equity in the United States. Developing adequate primary care workforce capacity may depend on modernizing state regulatory policies. However, this decision must be based on clear evidence. Evidence related to service delivery and health outcomes for the US’ most vulnerable groups relies on the availability of valid, reliable, quality data. The Centers for Medicare and Medicaid database is the most logical and comprehensive data source. Yet, this intergovernmental and privatized program presents significant data obstacles. In seeking to analyze health policies using Medicaid data, significant data quality concerns emerged. Specifically, nurse practitioner and physician assistant services were under-represented in the datasets analyzed. This underestimates their true contributions to primary care and subsequently impairs our ability to analyze the true cost of primary care service delivery. Why is this important? In an era of healthcare transitions and changing reimbursement mechanisms, the ability to conduct valid investigations into Medicaid services is necessary to accurately inform regulatory and programmatic policy analysis and reform. Improvements in Medicaid data collection will contribute to improving data integrity, thus enabling better evidence based solutions for addressing crippling healthcare fiscal challenges. This study contributes three key findings, the adaptation of a model for data integrity in public administration, and concludes with making three recommendations for improving the utilization and reporting of critical evidence on which to base future health policy.

Variance Ranking Attributes Selection Techniques for Binary Classification Problem in Imbalance Data

Data are being generated and used to support all aspects of healthcare provision, from policy formation to the delivery of primary care services. Particularly, with the change of emphasis from curative to preventive medicine, the importance of data-based research such as data mining and machine learning has emphasized the issues of class distributions in datasets. In typical predictive modeling, the inability to effectively address a class imbalance in a real-life dataset is an important shortcoming of the existing machine learning algorithms. Most algorithms assume a balanced class in their design, resulting in poor performance in predicting the minority target class. Ironically, the minority target class is usually the focus in predicting processes. The misclassification of the minority target class has resulted in serious consequences in detecting chronic diseases and detecting fraud and intrusion where positive cases are erroneously predicted as not positive. This paper presents a new attribute selection technique called variance ranking for handling imbalance class problems in a dataset. The results obtained were compared to two well-known attribute selection techniques: the Pearson correlation and information gain technique. This paper uses a novel similarity measurement technique ranked order similarity-ROS to evaluate the variance ranking attribute selection compared to the Pearson correlations and information gain. Further validation was carried out using three binary classifications: logistic regression, support vector machine, and decision tree. The proposed variance ranking and ranked order similarity techniques showed better results than the benchmarks. The ROS technique provided an excellent means of grading and measuring the similarities where other similarity measurement techniques were inadequate or not applicable.

Team- and individual-level motivation in complex primary care system change: A realist evaluation of the Salud Mesoamerica Initiative in El Salvador

Background:We study the role of individual and team-level motivation in explaining large-scale primary care performance improvements in El Salvador, one of the top-performing countries in the Salud Mesoamerica Initiative.Methods:Case study with outlier sampling of high-performing, community health teams in El Salvador. Design includes scoping review of literature, document review, non-participant observation, and qualitative analysis of in-depth interviews following a realist case study protocol.Results:The interplay between program interventions and organizational, community and policy contexts trigger multi-level motivational mechanisms that operate in complex, dynamic fashion. Interventions like performance measurement and team-based, in-kind incentives foster motivation among individual members of high-performing teams, which may be moderated by working conditions, supervision practices, and by the stress exerted by the interventions themselves. Individuals report a strong sense of public service motivation and an overarching sense of commitment to the community they serve. At the interpersonal level, the linkage between performance measurement and in-kind incentives triggers a sense of collective efficacy and increases team motivation and improvement behaviors. The convening of learning forums and performance dialogue increases the stakes for high-performing teams, helps them make sense of performance data, and leads to performance information utilization for healthcare improvements. Closeness to communities creates strong emotional linkages among team members that further increases collective efficacy and social identity. Such changes in individuals, team, and organizational behaviors can contribute to improved delivery of primary care services and explain the gains in performance demonstrated by the program.Conclusions:This case suggests that primary care systems that rely on multi-disciplinary teams for the provision of care can benefit from performance measurement and management interventions that leverage individual and team-level motivation. Realist evaluation can help prioritize policy-relevant research and enhance the design and evaluation of large-scale performance reforms in primary care systems in low- and middle-income settings.