Delivery Of Primary Care Services Research Articles

Effects of a Medical Home Program for Children with Special Health Care Needs on Parental Perceptions of Care in an Ethnically Diverse Patient Population

The Pediatric Medical Home Program at UCLA enrolled 41 patients in a primary care model focused on providing intensive care coordination for medically complex, ethnically diverse children with special health care needs (CSHCN) in our Pediatric Resident Continuity clinic. We sought to determine the effect of our program on parental satisfaction, and to compare differences in parental satisfaction between English and Spanish speaking patients. The Medical Home Family Index, developed by the Center for Medical Home Improvement, was administered to a total of 22 participating parents, in the family's primary language by a native speaker, at various times after enrollment in the program. Survey data and language effects were analyzed. The 36 standardized mean scores for the 15 Spanish speaking families were significantly higher (8.5 points higher) than the mean scores from the seven English speaking families (p = 0.003). Although no statistically significant differences were noted in individual questions between Spanish and English speakers, a trend towards more positive responses by Spanish speakers was noted in questions regarding physician-patient communication (p = 0.054) and family-centeredness (p = 0.053). Our results suggest that a primary care model focused on providing intensive care coordination produces positive parental perceptions of the organization and delivery of primary care services in a medically complex population of CSHCN. The main finding of the study is that utilizing the AAP's approach to the medical home model, emphasizing family-centered and culturally competent care, can produce higher satisfaction scores in Spanish speaking parents when compared to English speaking parents.

Using information and communication technologies to consult with patients in Victorian primary care: the views of general practitioners

Information and communication technologies such as email, text messaging and video messaging are commonly used by the general population. However, international research has shown that they are not used routinely by GPs to communicate or consult with patients. Investigating Victorian GPs' perceptions of doing so is timely given Australia's new National Broadband Network, which may facilitate web-based modes of doctor-patient interaction. This study therefore aimed to explore Victorian GPs' experiences of, and attitudes toward, using information and communication technologies to consult with patients. Qualitative telephone interviews were carried out with a maximum variation sample of 36GPs from across Victoria. GPs reported a range of perspectives on using new consultation technologies within their practice. Common concerns included medico-legal and remuneration issues and perceived patient information technology literacy. Policy makers should incorporate GPs' perspectives into primary care service delivery planning to promote the effective use of information and communication technologies in improving accessibility and quality of general practice care.

Facilitating Pediatric Patient-Provider Communications Using Wireless Technology in Children and Adolescents With Sickle Cell Disease

IntroductionUse of wireless devices has the potential to transform delivery of primary care services for persons with sickle cell disease (SCD). The study examined text message communications between patients and an advanced practice registered nurse (APRN) and the different primary care activities that emerged with use of wireless technology. MethodsPatients (N = 37; mean age 13.9 ± 1.8 years; 45.9% male and 54.1% female) engaged in intermittent text conversations with the APRN as part of the Wireless Pain Intervention Program. Content analyses were used to analyze the content of text message exchanges between patients and the APRN. ResultsThe primary care needs that emerged were related to pain and symptom management and sickle cell crisis prevention. Two primary care categories (collaborating and coaching), four primary care subcategories (screening, referring, informing, and supporting), and 16 primary care activities were evident in text conversations. DiscussionThe use of wireless technology may facilitate screening, prompt management of pain and symptoms, prevention or reduction of SCD-related complications, more efficient referral for treatments, timely patient education, and psychosocial support in children and adolescents with SCD.

Integrated model of primary and secondary eye care for underserved rural areas: The L V Prasad Eye Institute experience

Blindness is a major global public health problem and recent estimates from World Health Organization (WHO) showed that in India there were 62 million visually impaired, of whom 8 million are blind. The Andhra Pradesh Eye Disease Study (APEDS) provided a comprehensive estimate for prevalence and causes of blindness for the state of Andhra Pradesh (AP). It also highlighted that uptake of services was also an issue, predominantly among lower socio-economic groups, women, and rural populations. On the basis of this analysis, L V Prasad Eye Institute (LVPEI) developed a pyramidal model of eye care delivery. This article describes the LVPEI eye care delivery model. The article discusses infrastructure development, human resource development, and service delivery (including prevention and promotion) in the context of primary and secondary care service delivery in rural areas. The article also alludes to opportunities for research at these levels of service delivery and the amenability of the evidence generated at these levels of the LVPEI eye health pyramid for advocacy and policy planning. In addition, management issues related to the sustainability of service delivery in rural areas are discussed. The article highlights the key factors required for the success of the LVPEI rural service delivery model and discusses challenges that need to be overcome to replicate the model. The article concludes by noting the potential to convert these challenges into opportunities by integrating certain aspects of the existing healthcare system into the model. Examples include screening of diabetes and diabetic retinopathy in order to promote higher community participation. The results of such integration can serve as evidence for advocacy and policy.

Primary Care Reform: Can Quebec’s Family Medicine Group Model Benefit from the Experience of Ontario’s Family Health Teams?

Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care.

The place of information and communication technology-mediated consultations in primary care: GPs' perspectives

New information and communication technologies such as email and text messaging have been shown to be useful in some aspects of primary care service delivery. Little is known about Scottish GPs' attitudes towards the adoption of these technologies as routine consultation tools. To explore GPs' perceptions of the potential place of new non-face-to-face consultation technologies in the routine delivery of primary care; to explore GPs' perceived barriers to the introduction of these technologies and to identify the processes by which GPs feel that new consultation technologies could be incorporated into routine primary care. Qualitative interview study: 20 in-depth semi-structured interviews carried out with maximum variation sample of GPs across Scotland. Whilst the face-to-face consultation was seen as central to much of the clinical and diagnostic work of primary care, many GPs were conditionally willing to consider using new technologies in the future, particularly to carry out administrative or less complex tasks and therefore maximize practice efficiency and patient convenience. Key considerations were access to appropriate training, IT support and medico-legal guidance. GPs are conditionally willing to use new consultation media if clinically appropriate and if medico-legal and technical support is available.

Where is the community in the primary health care revolution in Rivers State?

Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port HarcourtCorrespondence to: Dr Best Ordinioha, Department of Community Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. (E-mail:ruralhealthforum@yahoo.com) Phone number +2348037075300I want to use the opportunity offered by the wide readership of your journal, especially in Rivers State, and the rest of Nigeria, to comment on the involvement of the Rivers State Government in the delivery of primary health care services in the State. This is probably the first of this kind of letter to be sent to the journal for publication, but I believe it should be encouraged to promote scientific discourse amongst the readers of the journal.The present administration of Rivers State, under the leadership of Governor Chibuike Amaechi came into office following a Supreme Court judgment. He promised, on being sworn in, to use the resources of the oil-rich State for the welfare of the people, and not for the gratification of a few political godfathers.Health care delivery is one of the welfare programmes given priority attention by the administration. Primary health care in particular, though the statutory responsibility of the local government councils, was taken over, because of its acknowledged role in the quest for health for all. In a record time, 160 primary health care centres were built through out the state, at over a hundred million naira each, and doctors were recruited to provide services at the health centres

Influencing Health Equity: Role of the Effective Consumer Scale in Measuring Skills and Abilities in a Middle Income Country

The 2008 World Health Report emphasizes the need for patient-centered primary care service delivery models in which patients are equal partners in the planning and management of their health. It is argued that this involvement will lead to improved management of disease, improved health outcomes and patient satisfaction, better informed decision-making, increased compliance with healthcare decisions, and better resource utilization. This article investigates the domains captured by the Effective Consumer Scale (EC-17) in relation to vulnerable population groups that experience health inequity. Particular focus is paid to the domain of health literacy as an area fundamental to patients' involvement in managing their condition and negotiating the healthcare system. In examining the possible influence of Outcome Measures in Rheumatology Clinical Trials (OMERACT) on health equity, we used the recent translation and validation of the EC-17 scale into Spanish and tested Argentina as an example. Future plans to use the EC-17 with vulnerable groups include formal collaboration and needs assessment with the community to tailor an intervention to meet its needs in a culturally relevant manner. Some systematic reviews have questioned whether interventions to improve effective consumer skills are appropriate in vulnerable populations. We propose that these populations may have the most to gain from such interventions since they might be expected to have relatively lower skills and health literacy than other groups.

Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years' Evaluation in Afghanistan

In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008. Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0-100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3-84.5, p<0.0001); provider satisfaction (65.4-79.2, p<0.01); capacity for service provision (47.4-76.4, p<0.0001); quality of services (40.5-67.4, p<0.0001); and overall vision for pro-poor and pro-female health services (52.0-52.6). The financial domain also showed improvement until 2007 (84.4-95.7, p<0.01), after which user fees were eliminated. By 2008, all provinces achieved the upper benchmark of national median set in 2004. The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts. Please see later in the article for the Editors' Summary.

The impact of direct provision accommodation for asylum seekers on organisation and delivery of local primary care and social care services: a case study.

BackgroundMany western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre) for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue.MethodsIn 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied.ResultsThere was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for.ConclusionsDirect provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations.

Comparison of Brief and Standard Interventions for Drug and Alcohol Dependence: Considerations for Primary Care Service Delivery

Although brief intervention (BI) is an empirically validated treatment modality for alcohol dependence, it has generally failed to gain wide acceptance in practice. Most studies have focused exclusively on individuals with alcohol problems, and little is known about the effectiveness for patients with other drug problems. The objective of this study was to examine the effectiveness of BI compared to standard therapy for drug and alcohol dependence in an outpatient treatment program. The study was conducted at the Addictions Unit of the McGill University Health Centre in Montreal. The trial compared 72 patients randomly assigned at intake to an individual 5-session brief intervention (BI) or a 6-month conventional treatment (CT) consisting of individual and group therapy. At 6 months' follow-up, the BI (N = 19) and CT (N = 20) groups were compared in terms of substance use, psychological, health, and occupational outcomes. There were approximately equivalent changes in both treatment groups compared to intake. Under the conditions of the present trial, CT did not show superiority over BI, providing additional support for the notion that BI can be an effective first step in the treatment of alcohol and drug dependence in a variety of health care settings.

Health systems strengthening in conflict situations

Many people in Africa live in fragile states where conflicts are common. These countries are under pressure to deliver health services within their limited capacity. This paper looks at ways of strengthening health systems in conflict and post-conflict situations at a time when many African countries are emerging from conflict. The paper concludes that health systems strengthening in post-conflict situations should focus on the delivery of primary health care services using existing human resources for health, community structures, NGOs and mobile clinics while pursuing renovation of health facilities and human resources for health development in the medium and long term.

Comparative Efficiency Assessment of Primary Care Service Delivery Models Using Data Envelopment Analysis

This paper compares the relative productive efficiencies of four models of primary care service delivery using the data envelopment analysis method on 130 primary care practices in Ontario, Canada. A quality-controlled measure of output and two input scenarios are employed: one with full-time-equivalent labour inputs and the other with total expenditures. Regression analysis controls for the mix of patients in the practice population. Overall, we find that community health centres fare the worst when it comes to relative efficiency scores.

Comparative Efficiency Assessment of Primary Care Service Delivery Models Using Data Envelopment Analysis

Comparative Efficiency Assessment of Primary Care Service Delivery Models Using Data Envelopment Analysis

Are We Preparing the Integrators?

A colleague challenged me recently to consider the relationship between the aims of pharmacy education and the concepts articulated by Donald Berwick and colleagues in the 2007 Health Affairs article entitled “The Triple Aim: Care, Health, and Cost.” Dr. Berwick has recently assumed the role of Administrator of the Centers for Medicare and Medicaid Services (CMS) in the Department of Health and Human Services. CMS currently covers as many as 100 million lives and the agency's policies often influence coverage decisions in other public and private insurance programs. CMS has substantial jurisdiction for implementation of key provisions of the March 2010 health care reform legislation. The perspectives of Dr. Berwick on health safety and quality are well known to pharmacists and other clinicians working to improve health care. The Institute for Healthcare Improvement (www.ihi.org) has led numerous efforts to improve the safety and quality of care of patients, especially in the institutional environment, for over 30 years. IHI hosts the Open School, affording educators and students significant resources for teaching and learning the tools and strategies for quality improvement in health care. Rapid cycle improvement, learning collaboratives, and benchmarking against meaningful measures of quality are hallmarks of IHI's work under its founding president, Dr. Berwick. The triple aim outlined in Berwick's writing includes: improving the individual experience of care; improving the health of populations; and reducing health care per capita costs. Consider the match between these aims and the competencies outlined by AACP's Center for the Advancement of Pharmaceutical Education (CAPE), now embedded in current accreditation standards, to educate student pharmacists: to deliver pharmaceutical care to individuals, contribute to public health at the population level, and design and manage effective systems of care. These same constructs are part of the vision for pharmacy practice in 2015 as articulated by the Joint Commission of Pharmacy Practitioners. Pharmacists' full engagement in activities that ensure the most optimal outcomes from the use of medications is a requirement for achievement of “the triple aim.” The alignment of goals is quite remarkable. Berwick and colleagues define the role of an “integrator” as key to achieving the triple aim for health care. While their intent was that the integrator was a health delivery organization that would “produce or contract for individual care and population-based interventions that are evidence-based and highly reliable,” reading their article, I could not help but think of our graduates in the role of an integrator in the delivery system. An integrator: creates partnerships with individuals and families, redesigns primary care, provides population health management, aligns financial incentives for quality care, and offers macro-system integration of health services. As outlined by Smith and coauthors in their May 2010 Health Affairs article,1 “Why Pharmacists Belong in the Medical Home,” individual and population health for those suffering 1 or more chronic illness can be vastly improved with care coordination enhanced by pharmacists' involvement. Improved patient engagement and pharmacists' monitoring and triage for evidence-based primary and specialty care leads to better clinical and economic outcomes in community and ambulatory care settings, specialty clinics, and institutional care delivery. A systematic review by Dr. Chisholm-Burns and colleagues provides a new examination of this evidence.2 The Commonwealth Fund recently profiled a number of projects involving pharmacists' integration in new models of primary care in its newsletter Quality Matters.3 Over the next several years, 30 million newly insured patients will enter the health care system. Many of them will not only be sicker as a result of not having insurance, they also will need to learn how to access the health system to use their new insurance. Our primary care delivery systems will be totally overwhelmed and leaders must identify strategies that ensure that patients are integrated into the most appropriate care systems delivering evidence-based treatments efficiently and effectively. Given the centrality of medication use for prevention and acute and chronic health management, pharmacists must contribute significantly to expanded access to primary care service delivery. Indeed, I believe we are educating an integrator for future care delivery systems.

Impact of community-based interventions on maternal and neonatal health indicators: Results from a community randomized trial in rural Balochistan, Pakistan

BackgroundPakistan has high maternal mortality, particularly in the rural areas. The delay in decision making to seek medical care during obstetric emergencies remains a significant factor in maternal mortality.MethodsWe present results from an experimental study in rural Pakistan. Village clusters were randomly assigned to intervention and control arms (16 clusters each). In the intervention clusters, women were provided information on safe motherhood through pictorial booklets and audiocassettes; traditional birth attendants were trained in clean delivery and recognition of obstetric and newborn complications; and emergency transportation systems were set up. In eight of the 16 intervention clusters, husbands also received specially designed education materials on safe motherhood and family planning. Pre- and post-intervention surveys on selected maternal and neonatal health indicators were conducted in all 32 clusters. A district-wide survey was conducted two years after project completion to measure any residual impact of the interventions.ResultsPregnant women in intervention clusters received prenatal care and prophylactic iron therapy more frequently than pregnant women in control clusters. Providing safe motherhood education to husbands resulted in further improvement of some indicators. There was a small but significant increase in percent of hospital deliveries but no impact on the use of skilled birth attendants. Perinatal mortality reduced significantly in clusters where only wives received information and education in safe motherhood. The survey to assess residual impact showed similar results.ConclusionsWe conclude that providing safe motherhood education increased the probability of pregnant women having prenatal care and utilization of health services for obstetric complications.

Patient satisfaction with mobile clinic services in a remote rural area of Saudi Arabia

Mobile clinics have been established in Saudi Arabia to facilitate the equitable delivery of primary health care services in remote and rural areas. A descriptive cross-sectional study was conducted to investigate the perceived quality of services provided to villages in the Al-Laith region. The majority of the 176 clients interviewed were satisfied with the working hours and health staff. However, 35.8% viewed the location as unsatisfactory and 20.5% were dissatisfied with the clinic schedule. Overall satisfaction was very high, although the mobile clinics were not viewed as substitutes for primary health care centres. Public awareness of the service needs to be improved and better access and quality of services are important for optimal service provision.

A potential model for primary care mental health services in Ireland.

A high demand for the inclusion of psychosocial interventions for primary care mental health presentations has become more apparent in recent years. Current policies have proposed models of care highlighting principles required for a quality service. However, implementation has been slow to date. This article aims to inform the current debate relating to primary care service delivery models for mental health presentations and to contribute towards future planning initiatives. A narrative review of a range of policies and selected articles relevant to primary care mental health in an Irish context. The search produced four distinct themes: current service provision in Ireland; stakeholders' views; psychological care options; and potential service structures. Thereafter, a potential service delivery model is proposed. This formulated model employs a combination of elements from the reviewed themes to provide a clinically- and cost-effective, equitable and accessible service driven by service user and carer input. Although this review was selective in nature, the proposed potential model can complement future research agendas for more favourable primary care practice in Ireland. Recommendations are made for the planning of services including policy implementation procedures, training and communication.

Incorporating public health more closely into local governance of health care delivery: lessons from the Québec experience.

In 2004, the Quebec government undertook a major reorganization of its health care system by integrating public health more formally into local governance structures. In all, 95 new organizations - Health and Social Services Centres (CSSS)--were created and given a population-based responsibility. This mandate required that CSSSs broaden their range of services by adopting a population-based plan and integrating public health into their activities. To accomplish this, they needed to link public health and health care issues more formally within a single governance structure. The aim of this article is to identify and analyze various activities undertaken by CSSS managers to fulfill their population-based responsibility. We conducted a longitudinal case study of two CSSSs (2005-2008). Our analyses are based on real-time observations of 144 meetings of decision-makers/managers and professionals at the regional and local levels, 46 interviews with managers, as well as secondary data. CSSSs focused on five areas of population-based responsibility: primary health care, specialized services, vulnerable groups, health promotion and social services. Over time, the activities developed by CSSSs in relation to these five areas reflected an increasingly population-based perspective on the delivery of health care services. Service planning in the two cases under study is now based on a broader view of the health care continuum, and managers invest more time and resources in preventive interventions. Our study provides key information on the process of integrating a population-based perspective and preventive approaches in the planning and delivery of primary care services.

Incorporating Public Health More Closely Into Local Governance of Health Care Delivery: Lessons From the Québec Experience

Background and Objective: In 2004, the Quebec government undertook a major reorganization of its health care system by integrating public health more formally into local governance structures. In all, 95 new organizations – Health and Social Services Centres (CSSS) – were created and given a population-based responsibility. This mandate required that CSSSs broaden their range of services by adopting a population-based plan and integrating public health into their activities. To accomplish this, they needed to link public health and health care issues more formally within a single governance structure. The aim of this article is to identify and analyze various activities undertaken by CSSS managers to fulfill their population-based responsibility. Methods: We conducted a longitudinal case study of two CSSSs (2005-2008). Our analyses are based on real-time observations of 144 meetings of decision-makers/managers and professionals at the regional and local levels, 46 interviews with managers, as well as secondary data. Results: CSSSs focused on five areas of population-based responsibility: primary health care, specialized services, vulnerable groups, health promotion and social services. Over time, the activities developed by CSSSs in relation to these five areas reflected an increasingly population-based perspective on the delivery of health care services. Conclusion: Service planning in the two cases under study is now based on a broader view of the health care continuum, and managers invest more time and resources in preventive interventions. Our study provides key information on the process of integrating a population-based perspective and preventive approaches in the planning and delivery of primary care services. Key words: Population-based responsibility; public health; health care; Quebec