Patient-Centered Population Health Improvement

Research in the areas surrounding and related to care models, design, workflow, and more.

Engage: Offering Game-Changing Software for Patient-Centric Care

1. On primary care characteristics and population oriented health care. Aimed at assessing and identifying organizational conditions for providing structured chronic care across different healthcare systems, this study examined the room for improvement that exists on a global basis. Although the original assertion was support—that a proactive, structured, and population-orientated approach is needed— it was noted that further research should focus on relations between practice characteristics, organizational workflow/features, including health system and primary care orientation, and outcomes. Read it here

2. On cancer pain management. Examining such factors as general health, vitality, and mental health, evidence was found in this study that coaching may be a useful strategy to help patients decrease attitudinal barriers toward cancer pain management and to better manage their cancer pain. Read it here.

By using motivational interviewing techniques, advanced practice oncology nurses can help patients develop an appropriate plan of care to decrease pain and other symptoms.

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3. On behavioral change driving wellness. With the patient being seen as the real expert in his/her own wellness, this study assumes that the majority of health risks and diseases are lifestyle-related. Accordingly, behavioral change must be the key to prevention and management of these risks. The study shows the efficacy of a wellness toolbox applied to the multiple, behavior-originated health risks patients have. Read it here.  

4. On integrated care for the elderly. This study suggested that integrated care programs may be a cost effective approach to reduce admission to institutions and functional decline in older people. This was compared against a traditional and fragmented model of community care, in which the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs. Read it here

In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs...

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5. On digital health management. This study examines mobile health and cloud computing to achieve personal health management and successful patient empowerment. Read it here.  

6. On disease management. With the heightened risk of people with mental illness contracting/transmitting HIV being seen as public health issue, this project demonstrated the effectiveness of community-based APNs in delivering a tailored intervention to improve outcomes of individuals with HIV and co-occurring serious mental illnesses. Persons with these co-occurring conditions can be successfully treated; with appropriate supportive services, their viral loads can be reduced.  Read it here

Engage: Changing How We Seamlessly Treat Chronic Disease/Illness Across the Care Continuum

7. On evidence-based models for chronic care. 2002: With late-life depression often being chronic or recurrent, this study examined treatments that included key components of evidence-based models for chronic illness care. A collaborative care model was found to not only be feasible, but to be significantly more effective than usual care for depression in a wide range of primary care practices. Read it here.

[The] collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.

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8. On self-management programs for chronic disease. This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease in a group of chronic disease patients.

Treatment subjects demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. With fewer hospitalizations and days in the hospital, the study suggested feasible and beneficial benefits, beyond usual care, in terms of improved health behaviors and health status due to the patient-centric program. Read it here

9. On efficacy of patient-centric approaches. Heart disease, chronic respiratory diseases, cancer and diabetes are the most common chronic diseases today. This paper asserts that in such cases, we need more than patient engagement to help to control of the disease in combination with health organization’s efforts.

The paper suggests a patient-centric approach where activities support the patients' self-management activities, making them feel confident and motivated. This article presents a model for supporting ubiquitous chronic care management, whose goal is to help the integration between patient and community resources. Read it here

10. On support for patient care. Cardiovascular risk management received by patients shows large variation across various countries. This study found evidence that direct support for both patients and clinicians seemed most influential on key components of CVRM in coronary heart disease patients. Read it here.

11. On team-based care for care quality. Examining the financial and clinical impact of team-based treatment for Medicaid enrollees with diabetes, this study concluded that team-based care (redesign of care delivery at the practitioner level using evidence-based guidelines, multidisciplinary treatment teams, decision support systems, and planned visits, etc.) had the potential to improve quality of care. Read it here.

12. On care coordination's effect on clinical excellence. This study examined the ability of care coordination programs to reduce hospitalizations and Medicare expenditures, and improved quality of care for chronically ill Medicare beneficiaries. The study suggested that viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can in fact improve aspects of care. Read it here

Engage: Optimized Workflow Design Combined with Team-Based Care Leverages Physicians Fully

13. On teamwork's effect on optimal value for patients. Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project.

This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. Teamwork was deemed as critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Interventions aimed at improving teamwork consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture. Read it here.

14. On patient engagement technology during care transitions. 2008: Patient-centered technology can be used to transition facilities from institution centric to patient-centric entities, and to promote disease management and wellness. This white paper examines challenges relates to design, workflow, reimbursement and usability. Read it here.

The need exists for valid & reliable instruments that can measure patient empowerment or shared decision making...For clinicians the challenge is to design patient education & counseling initiatives that will take advantage of the shift to patient-centered approach.

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15. On team-based care and the PCMH. Team-based care is one of the key components of the patient-centered medical home. Studies have consistently demonstrated that teams involving pharmacists or nurses in patient management can significantly improve blood pressure control.  Existing cost analyses have found favorable costs for team-based care when considering the potential to reduce morbidity and mortality. Read it here

16. On leadership and collaboration in dynamic clinical care teams. This American College of Physicians Position Paper, titled “Principles Supporting Dynamic Clinical Care Teams,” asserts that teams that deliver care require a new way of thinking about clinical responsibilities and leadership. “In this new model, groups of physicians, nurses, physician assistants, clinical pharmacists, social workers, and other health professionals establish new lines of collaboration, communication, and cooperation to better serve patient needs.”

This involves one that recognizes that different clinicians will assume principal responsibility for specific elements of a patient's care as the patient's needs dictate, while the team as a whole must ensure that all elements of care are coordinated for the patient's benefit. Read it here

Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams, well-functioning teams will assign responsibilities to advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.