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Research ArticleOriginal Research

A Randomized Trial of High-Value Change Using Practice Facilitation

LeAnn Michaels, Tracy Anastas, Elizabeth Needham Waddell, Lyle Fagnan and David A. Dorr
The Journal of the American Board of Family Medicine September 2017, 30 (5) 572-582; DOI: https://doi.org/10.3122/jabfm.2017.05.170013
LeAnn Michaels
From the Oregon Health & Science University, Portland, OR
BS
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Tracy Anastas
From the Oregon Health & Science University, Portland, OR
BA
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Elizabeth Needham Waddell
From the Oregon Health & Science University, Portland, OR
PhD
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Lyle Fagnan
From the Oregon Health & Science University, Portland, OR
MD
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David A. Dorr
From the Oregon Health & Science University, Portland, OR
MD, MS
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  • Article
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    Figure 1.

    Summed HVE selection and achievement by arm.

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    Table 1.

    Goals and Action Items

    Goal Selection and ProgressInterventionControl
    Average No. of goals selected per clinic (range)7.3 (7 to 8)7.5 (6 to 10)
        Goals that were HVEs (%)82.826.7
    Average months worked on individual HVE goal2.72.4
    Average months worked on other goal2.22.1
    Action ItemsInterventionControl
    Total action items115160
        % complete65.265.6
    Total action items for HVE goals10141
        % complete68.361.0
    Total action items for other goals680
        % complete42.967.2
    % Total acton items chosen by provider29.620.0
    % Total action items chosen by PF14.819.4
    %Total action items chosen by “other”55.660.6
    • View popup
    Table 2.

    High Value Element (HVE) Descriptions and Clinic Selection of HVEs

    HVE# Clinics SelectedLevel 1Level 2Level 3
    % Improvement Pre/Post*
    IC
    After-hours access00Offers access to in-person care at least 12 hours weekly outside traditional business hours.
    0%+25%
    Tracking 3rd next available appointments31Tracks 3rd next available appointments.Meets a benchmark on 3rd next available appointments.
    +25%+13%
    Tracking/responding to electronic requests10Able to receive and respond to electronic requests.Able to track electronic request response times.Provides a response to online or electronic queries within two business days.
    +17%+17%
    Reminders40Uses patient information, clinical data, and evidence-based guidelines to generate lists of patients who need reminders and to proactively remind patients/families/caregivers and clinicians of needed services.Tracks the number of eligible patients who were sent appropriate reminders.Sends appropriate reminders to at least 20% of all eligible patients.
    +75%+50%
    Clinical information exchange00Exchanges structured clinical information and tracks critical elements (e.g., hospitalizations).
    +50%0%
    Utilization followup42Follows up on patient hospitalizations and emergency department (ED) visits 30% of the time (when they have the information).Follows up on patient hospitalizations or ED visits 70% of the time (when they have the information).Follows up on patient hospitalizations and ED visits 70% of the time (when they have the information).
    +58%+8%
    Utilization prevention21Selects and reviews utilization measures and goals most relevant to their overall patient panel, or an at-risk patient population.Shows improvement or meets a benchmark in utilization metrics on measures closely linked to utilization.
    +13%+13%
    Performance data utilization21Uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.
    +25%0%
    Care coordination outreach01Care coordination outreach reaches 25% of high risk patients.Care coordination outreach reaches 50% of high-risk patients.
    +12%+25%
    Care plan utilization31Reports data on care plans provided to high-risk patients.Provides care plans to >25% of high risk patients.Provides care plans to >50% of high risk patients.
    +50%0%
    Advance directive utilization31Tracks offers of advance directives to patients over 65 years.Offers advance directives to at least 30% of patients over 65 years.Offers advance directives to at least 50% of patients over 65 years.
    +42%+8%
    Education and self-management resources20More than 10% of all unique patients are provided patient-specific education resources.More than 10% of all unique patients are provided patient-specific education resources and self-management services.
    +25%+25%
    • ↵* Improvement indicates average change in levels passed from baseline to quarter 4 of HVE reporting.

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    Table 3.

    Practice Characteristics of Intervention and Control Clinics

    ArmOrganizationLocationPatient PanelHigh-Risk Patients (%)MD, DOPA, NP
    InterventionSingle clinicUrban/ suburban11,6031840
    ControlMulticlinic groupUrban14,119871
    InterventionCommunity-based academic medical centerUrban13,12516102
    ControlAcademic medical centerUrban13,04021121
    InterventionSmall health systemRural7,257831
    ControlSmall health systemRural10,282953
    InterventionSmall health systemRural13,3213.270
    ControlSmall health systemRural1,2003013
    • View popup
    Table 4.

    Clinician and Staff Survey Results Before and After TOPMED Trial

    Survey/ScaleNInterventionControlDifference-in-Difference (Intervention − Control)P†
    PrePostDifferencePrePostDifference
    TDM Pre: N = 137; Post: N = 83Mean (95% CI)Mean (95% CI)Mean (95% CI)Mean (95% CI)
    Score22059.1 (57.3 to 60.8)62.0 (59.4 to 64.6)2.9659.9 (56.9 to 62.8)60.4 (58.3 to 62.6)0.592.38.312
    CSQ Pre: N = 210; Post: N = 104NMean (95% CI)Mean (95% CI)DifferenceMean (95% CI)Mean (95% CI)DifferenceDiff-in-DiffP
    Adaptive reserve2763.8 (3.7 to 3.9)3.8 (3.6 to 3.9)-0.013.7 (3.5 to 3.8)3.9 (3.7 to 4.1)0.21−0.21.139
    Community knowledge2853.8 (3.7 to 3.9)3.7 (3.6 to 3.9)-0.043.7 (3.5 to 3.8)4.0 (3.8 to 4.3)0.35−0.38*.030
    Health IT integration3093.8 (3.7 to 3.9)3.9 (3.8 to 4.0)0.103.8 (3.7 to 3.9)3.6 (3.4 to 3.8)-0.150.25.080
    Cultural sensitivity3134.1 (3.9 to 4.2)4.0 (3.9 to 4.2)-0.024.1 (3.9 to 4.2)4.2 (4.0 to 4.4)0.11−0.13.473
    Patient safety culture3123.5 (3.4 to 3.6)3.7 (3.5 to 3.8)0.163.4 (3.2 to 3.6)3.8 (3.6 to 4.1)0.42−0.26.139
    CPAT Pre: 119; Post: 101NMean (95% CI)Mean (95% CI)DifferenceMean (95% CI)Mean (95% CI)DifferenceDiff-in-DiffP
    Mission, meaningful purpose, goals2135.6 (5.2 to 5.9)6.0 (5.8 to 6.3)0.456.1 (5.9 to 6.3)5.9 (5.7 to 6.2)−0.160.61*.013
    General relationships2156.0 (5.6 to 6.3)6.1 (5.9 to 6.3)0.096.4 (6.3 to 6.5)6.2 (6.0 to 6.4)−0.260.35.127
    Team leadership2065.0 (4.6 to 5.3)5.7 (5.5 to 6.0)0.765.7 (5.6 to 5.9)5.7 (5.5 to 5.9)−0.080.85*<.001
    General role, responsibility, autonomy2045.0 (4.7 to 5.3)5.4 (5.2 to 5.6)0.425.5 (5.4 to 5.7)5.3 (5.1 to 5.5)−0.210.63*.002
    Communication and information exchange2155.2 (4.8 to 5.6)5.7 (5.5 to 6.0)0.525.8 (5.6 to 6.0)5.8 (5.5 to 6.0)−0.060.58*.036
    Community linkages and coordination of care2174.7 (4.4 to 5.1)5.4 (5.1 to 5.7)0.725.3 (5.0 to 5.5)5.4 (5.1 to 5.7)0.150.57.057
    Decision-making and conflict management2094.5 (4.3 to 4.7)4.3 (4.2 to 4.5)-0.214.3 (4.2 to 4.4)4.3 (4.2 to 4.5)0.02−0.23.153
    Patient involvement2115.7 (5.3 to 6.2)6.1 (5.8 to 6.3)0.336.2 (6.0 to 6.4)6.0 (5.8 to 6.2)−0.160.49.092
    • ↵* P < .05.

    • ↵† P value associated with interaction term in multivariable model: posttest = clinic + intervention group + time + intervention group × time.

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The Journal of the American Board of Family     Medicine: 30 (5)
The Journal of the American Board of Family Medicine
Vol. 30, Issue 5
September-October 2017
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A Randomized Trial of High-Value Change Using Practice Facilitation
LeAnn Michaels, Tracy Anastas, Elizabeth Needham Waddell, Lyle Fagnan, David A. Dorr
The Journal of the American Board of Family Medicine Sep 2017, 30 (5) 572-582; DOI: 10.3122/jabfm.2017.05.170013

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A Randomized Trial of High-Value Change Using Practice Facilitation
LeAnn Michaels, Tracy Anastas, Elizabeth Needham Waddell, Lyle Fagnan, David A. Dorr
The Journal of the American Board of Family Medicine Sep 2017, 30 (5) 572-582; DOI: 10.3122/jabfm.2017.05.170013
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