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Journal of Ambulatory Care Management

Tonya Hansel, Howard Osofsky, Jennifer Langhinrichsen-Rohling, Joy Osofsky, Timothy Rehner, Cory Wornell, Anthony Speier, Michelle Brazeal, Elizabeth Arthur, Glenn Rohrer
The Mental and Behavioral Health (MBH) Capacity Project had a mission shared among 4 states to support MBH sustainability along the Gulf Coast. Integration of mental health into undersourced primary health clinics was an important goal of the project. The findings from the collaborative evaluation demonstrate long-term outcomes including the following: community has greater capacity and sustainability for quality health care; better informed and connected communities; and individuals are more informed, connected, and resilient...
October 2018: Journal of Ambulatory Care Management
Joanna DʼAfflitti, Kristen Lee, Melissa Jacobs, Christine Pace, Jason Worcester, Sophia Thornton, Karen E Lasser
Team-based care may address burnout in primary care; few studies have examined the impact of nurse practitioner-physician (NP-MD) teams on provider burnout. This article describes a model of NP-MD care teams in an urban safety-net primary care practice. Average time to third next available appointment with a team provider (either NP or MD) decreased by nearly 20 days after implementation of the model. In total, 79% of MDs reported that the model was very or extremely helpful in reducing the burden of work between visits and 100% of NPs reported that they were very or extremely satisfied with their current job...
October 2018: Journal of Ambulatory Care Management
(no author information available yet)
No abstract text is available yet for this article.
October 2018: Journal of Ambulatory Care Management
Jean M Gunderson, Mark L Wieland, Onelis Quirindongo-Cedeno, Gladys B Asiedu, Jennifer L Ridgeway, Michael W OʼBrien, Tara M Nelson, Ron Buzard, Chad Campbell, Jane W Njeru
Community health workers (CHWs) bring their unique capacity as liaisons for patients, communities, and health care systems to health care teams. We describe the collaborative development of a community-based CHW program to address the social determinants of health that affect patients. This cosupervisory, generalist CHW model provides an innovative template for cocreation of patient-centered infrastructure and resourcing within an evolving and replicable holistic care continuum across patient ages, diagnoses, health care payers, and communities to promote health equity...
October 2018: Journal of Ambulatory Care Management
Sara L Ackerman, Nathaniel Gleason
Growing demand for specialty care has resulted in longer wait times for appointments, particularly at US academic referral centers. A proportion of specialty visits are for routine follow-up care of stable problems, and there is evidence that primary care providers are willing and able to take responsibility for a significant proportion of these patients. However, little is known about how to transition care back to a referring primary care clinician in a manner that is acceptable to everyone involved. In this article, we describe social, legal, and financial barriers to effective care transition and propose communication strategies to overcome them...
October 2018: Journal of Ambulatory Care Management
Caitlin G Allen, J Nell Brownstein, Maria Cole, Gail Hirsch, Susie Williamson, E Lee Rosenthal
Although community health workers (CHWs) continue to gain credibility and recognition in the health care and public health sectors, there is still a need to expand workforce identity and development efforts, including identifying best practices for assessing CHW skill proficiencies. During this qualitative study, we interviewed 32 CHWs, trainers, and supervisors to understand current practice, perspectives, and perceived importance in assessing CHW skills and guiding principles for CHW skill assessment. Results from these interviews can be used to inform CHW workforce development to enhance efforts among those who are actively building CHW programs or who are considering improvements in strategies to assess CHW skill proficiencies...
October 2018: Journal of Ambulatory Care Management
Edward H Wagner, Lisa LeRoy, Judith Schaefer, Michael Bailit, Katie Coleman, Chunliu Zhan, David Meyers
The Patient-Centered Medical Home (PCMH) now defines excellent primary care. Recent literature has begun to elucidate the components of PCMHs that improve care and reduce costs, but there is little empiric evidence that helps practices, payers, or policy makers understand how high-performing practices have improved outcomes. We report the findings from 38 such practices that fill this gap. We describe how they execute 8 functions that collectively meet patient needs. They include managing populations, providing self-management support coaching, providing integrated behavioral health care, and managing referrals...
October 2018: Journal of Ambulatory Care Management
Sarah Hudson Scholle, Suzanne Morton, Juell Homco, Kristin Rodriguez, Daren Anderson, Elizabeth Hahn, David Kendrick, David Bardach, Elizabeth Hart
Using patient-reported outcome measures (PROMs) in care planning has the potential to improve care, but information about routine implementation in settings serving disadvantaged groups is needed. Two primary care clinics serving populations predominantly eligible for Medicaid and diverse in race/ethnicity implemented the PROMIS-29 as part of clinical care planning. Of the target population with diabetes, 26% (n = 490) completed the PROMs; the proportion that set a goal based on the PROMs differed by site. This report describes factors influencing the PROMs process and the results of interviews with patients and members of the care team about PROMs' implementation and impact...
October 2018: Journal of Ambulatory Care Management
Jayasree Basu, Amresh Hanchate, Siran Koroukian
This study examines the patterns of 30-day hospital readmissions by race/ethnicity and multiple chronic conditions (MCC) burden among nonelderly adult patients. We used hospital discharge data of patients in the 18- to 64-year age group in 5 US states, California, Florida, Missouri, New York, and Tennessee, for 2009 from the Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) of the Agency for Healthcare Research and Quality, linked to contextual and provider data from the Health Resources and Services Administration...
October 2018: Journal of Ambulatory Care Management
Brigit Hatch, Ning Smith, Mary Ann McBurnie, Thu Quach, Kenneth H Mayer, Mary J Dunne, Erika Cottrell
The aim of this study was to assess the impact of the Affordable Care Act (ACA) on community health centers (CHCs). Using electronic health records from the Community Health Applied Research Network, we assessed new patient characteristics, office visit volume, and payer distribution among CHC patients before and after ACA implementation, 2011-2014 (n = 442 455). New patients post-ACA were younger, more likely to be female and have chronic health conditions, and utilized more primary care (P < .05 for each)...
October 2018: Journal of Ambulatory Care Management
Stephen L Davidow, Jignesh Sheth, Constance S Sixta, Linda Thomas-Hemak
More than 105 million referrals of Medicare beneficiaries to specialists occur annually. Different settings and electronic health records have made care coordination complex. PCPI (formerly American Medical Association-convened Physicians Consortium for Performance Improvement) and The Wright Center for Graduate Medical Education sponsored the Closing the Referral Loop pilot project. Twelve dyads of primary care and specialist physicians sought to improve ambulatory referrals by mapping the referral process, and using care compacts, metrics, and electronic health records...
October 2018: Journal of Ambulatory Care Management
Heriberto Eddie Cruz, Janie Gawrys, Donna Thompson, Jairo Mejia, Linda Rosul, Danielle Lazar
In 2012, Access Community Health Network, a Federally Qualified Health Center (FQHC) network with 36 health centers serving the greater Chicago area, embarked on a 3-year initiative to improve patient access. "Dramatic Performance Improvement" (DPI) included the adoption of modified open access scheduling and practice changes designed to improve capacity and the ability to balance supply and demand. This article describes DPI implementation, strategies, and associated outcomes, including a 20% decrease in no-show rate, a 33% drop in time to the third next available appointment (TNAA), a 37% decrease in cycle time, and a 13% increase in patient satisfaction...
July 2018: Journal of Ambulatory Care Management
Avi Dor, Qian Luo, Maya Tuchman Gerstein, Floyd Malveaux, Herman Mitchell, Anne Rossier Markus
We present an incremental cost-effectiveness analysis of an evidence-based childhood asthma intervention (Community Healthcare for Asthma Management and Prevention of Symptoms [CHAMPS]) to usual management of childhood asthma in community health centers. Data used in the analysis include household surveys, Medicaid insurance claims, and community health center expenditure reports. We combined our incremental cost-effectiveness analysis with a difference-in-differences multivariate regression framework. We found that CHAMPS reduced symptom days by 29...
July 2018: Journal of Ambulatory Care Management
Karen Baur, Tracey Smith, M Cecilia Wendler
Community-based programs deploying community health workers (CHWs) who collaborate with other entities are beginning to emerge as the US health system evolves. Although these programs have used various evaluation criteria to determine program success, little research has been completed to examine the experiences of program participants as they receive these services. The purpose of this qualitative descriptive study was to describe what it was like to experience the benefit of improved care coordination through a community-based program featuring CHWs, in collaboration with community-based interprofessional providers...
July 2018: Journal of Ambulatory Care Management
Matthew R Augustine, Karin M Nelson, Stephan D Fihn, Edwin S Wong
The patient-centered medical home (PCMH) expands access by providing care same-day, by phone, and after hours; however, little is known about which patients seek these services. We examined the association of patient, clinical, and local economic characteristics with the self-reported use of 5 routine and nonroutine ways to access primary care within the Veterans Health Administration. We identified sets of characteristics, including gender- and age-specific, racial and ethnic, and socioeconomic differences of how veterans report seeking primary care...
July 2018: Journal of Ambulatory Care Management
Rani Polak, David Pober, Avigail Morris, Rakefet Arieli, Margaret Moore, Elliot Berry, Mati Ziv
The Community Culinary Coaching Program is a community-based participatory program aimed at improving communal settlement residents' nutrition. The residents, central kitchens, preschools, and communal dining rooms were identified as areas for intervention. Evaluation included goals accomplishment assessed by food purchases by the central kitchens, and residents' feedback through focus groups. Purchasing included more vegetables (mean (standard error) percent change), (+7% (4); P = .32), fish (+115% (11); P < ...
July 2018: Journal of Ambulatory Care Management
Ronnie Hasson, Aliza H Stark, Naama Constantini, Rani Polak, Gina Verbov, Naomi Edelstein, Michel Lachmi, Rivka Cohen, Shuli Maoz, Nihaya Daoud, Hannah Soltz-Aharony, Chen Stein-Zamir
Healthy lifestyle programs are essential for meeting the challenge of noncommunicable diseases. The Public Health Nurses Promoting Healthy Lifestyles (PHeeL-PHiNe) program engaged nurses from family health clinics in Jerusalem District and included physical activity, healthy nutrition, and motivational skills. Questionnaires were completed at baseline, postintervention, and at 18 months. Results showed a marked effect on health practices. The proportion of nurses consuming a balanced diet and the use of food labels significantly increased and were maintained over time...
July 2018: Journal of Ambulatory Care Management
Latifa Mohammad Baynouna Al Ketbi, Mariam Mohammad Al Kwuiti, Hanan Abdulbaqi, Mouza Hamad Al Kwuiti, Shamma Al Alawi, Amal Al Zarouni, Fathyia Al Awadhi, Durra Al Bloushi, Amal Al Harbi, Bakr Saadon, Omar Al Jabri
This study describes the transformation of Abu Dhabi Ambulatory Healthcare Services into patient-centered medical homes (PCMH) in 3 pilot sites by applying the National Commission for Quality Assurance (NCQA) PCMH standards. The intervention was system redesign, population management, team building, and optimizing electronic medical records toward patient-centered care. The pilot centers outperformed non-pilot centers in clinical key performance indicators. Based on the NCQA 2011 PCMH criteria, the pilot achieved 84% compared with 42% at the start of the project...
July 2018: Journal of Ambulatory Care Management
(no author information available yet)
No abstract text is available yet for this article.
July 2018: Journal of Ambulatory Care Management
Gail R Wilensky
No abstract text is available yet for this article.
May 15, 2018: Journal of Ambulatory Care Management
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