Article Figures & Data
Figures
- Figure 1.
Summed HVE selection and achievement by arm.
Tables
Goal Selection and Progress Intervention Control Average No. of goals selected per clinic (range) 7.3 (7 to 8) 7.5 (6 to 10) Goals that were HVEs (%) 82.8 26.7 Average months worked on individual HVE goal 2.7 2.4 Average months worked on other goal 2.2 2.1 Action Items Intervention Control Total action items 115 160 % complete 65.2 65.6 Total action items for HVE goals 101 41 % complete 68.3 61.0 Total action items for other goals 6 80 % complete 42.9 67.2 % Total acton items chosen by provider 29.6 20.0 % Total action items chosen by PF 14.8 19.4 %Total action items chosen by “other” 55.6 60.6 HVE # Clinics Selected Level 1 Level 2 Level 3 % Improvement Pre/Post* I C After-hours access 0 0 Offers access to in-person care at least 12 hours weekly outside traditional business hours. 0% +25% Tracking 3rd next available appointments 3 1 Tracks 3rd next available appointments. Meets a benchmark on 3rd next available appointments. +25% +13% Tracking/responding to electronic requests 1 0 Able 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% Reminders 4 0 Uses 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 exchange 0 0 Exchanges structured clinical information and tracks critical elements (e.g., hospitalizations). +50% 0% Utilization followup 4 2 Follows 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 prevention 2 1 Selects 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 utilization 2 1 Uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience. +25% 0% Care coordination outreach 0 1 Care coordination outreach reaches 25% of high risk patients. Care coordination outreach reaches 50% of high-risk patients. +12% +25% Care plan utilization 3 1 Reports 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 utilization 3 1 Tracks 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 resources 2 0 More 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.
Arm Organization Location Patient Panel High-Risk Patients (%) MD, DO PA, NP Intervention Single clinic Urban/ suburban 11,603 18 4 0 Control Multiclinic group Urban 14,119 8 7 1 Intervention Community-based academic medical center Urban 13,125 16 10 2 Control Academic medical center Urban 13,040 21 12 1 Intervention Small health system Rural 7,257 8 3 1 Control Small health system Rural 10,282 9 5 3 Intervention Small health system Rural 13,321 3.2 7 0 Control Small health system Rural 1,200 30 1 3 Survey/Scale N Intervention Control Difference-in-Difference (Intervention − Control) P† Pre Post Difference Pre Post Difference TDM Pre: N = 137; Post: N = 83 Mean (95% CI) Mean (95% CI) Mean (95% CI) Mean (95% CI) Score 220 59.1 (57.3 to 60.8) 62.0 (59.4 to 64.6) 2.96 59.9 (56.9 to 62.8) 60.4 (58.3 to 62.6) 0.59 2.38 .312 CSQ Pre: N = 210; Post: N = 104 N Mean (95% CI) Mean (95% CI) Difference Mean (95% CI) Mean (95% CI) Difference Diff-in-Diff P Adaptive reserve 276 3.8 (3.7 to 3.9) 3.8 (3.6 to 3.9) -0.01 3.7 (3.5 to 3.8) 3.9 (3.7 to 4.1) 0.21 −0.21 .139 Community knowledge 285 3.8 (3.7 to 3.9) 3.7 (3.6 to 3.9) -0.04 3.7 (3.5 to 3.8) 4.0 (3.8 to 4.3) 0.35 −0.38* .030 Health IT integration 309 3.8 (3.7 to 3.9) 3.9 (3.8 to 4.0) 0.10 3.8 (3.7 to 3.9) 3.6 (3.4 to 3.8) -0.15 0.25 .080 Cultural sensitivity 313 4.1 (3.9 to 4.2) 4.0 (3.9 to 4.2) -0.02 4.1 (3.9 to 4.2) 4.2 (4.0 to 4.4) 0.11 −0.13 .473 Patient safety culture 312 3.5 (3.4 to 3.6) 3.7 (3.5 to 3.8) 0.16 3.4 (3.2 to 3.6) 3.8 (3.6 to 4.1) 0.42 −0.26 .139 CPAT Pre: 119; Post: 101 N Mean (95% CI) Mean (95% CI) Difference Mean (95% CI) Mean (95% CI) Difference Diff-in-Diff P Mission, meaningful purpose, goals 213 5.6 (5.2 to 5.9) 6.0 (5.8 to 6.3) 0.45 6.1 (5.9 to 6.3) 5.9 (5.7 to 6.2) −0.16 0.61* .013 General relationships 215 6.0 (5.6 to 6.3) 6.1 (5.9 to 6.3) 0.09 6.4 (6.3 to 6.5) 6.2 (6.0 to 6.4) −0.26 0.35 .127 Team leadership 206 5.0 (4.6 to 5.3) 5.7 (5.5 to 6.0) 0.76 5.7 (5.6 to 5.9) 5.7 (5.5 to 5.9) −0.08 0.85* <.001 General role, responsibility, autonomy 204 5.0 (4.7 to 5.3) 5.4 (5.2 to 5.6) 0.42 5.5 (5.4 to 5.7) 5.3 (5.1 to 5.5) −0.21 0.63* .002 Communication and information exchange 215 5.2 (4.8 to 5.6) 5.7 (5.5 to 6.0) 0.52 5.8 (5.6 to 6.0) 5.8 (5.5 to 6.0) −0.06 0.58* .036 Community linkages and coordination of care 217 4.7 (4.4 to 5.1) 5.4 (5.1 to 5.7) 0.72 5.3 (5.0 to 5.5) 5.4 (5.1 to 5.7) 0.15 0.57 .057 Decision-making and conflict management 209 4.5 (4.3 to 4.7) 4.3 (4.2 to 4.5) -0.21 4.3 (4.2 to 4.4) 4.3 (4.2 to 4.5) 0.02 −0.23 .153 Patient involvement 211 5.7 (5.3 to 6.2) 6.1 (5.8 to 6.3) 0.33 6.2 (6.0 to 6.4) 6.0 (5.8 to 6.2) −0.16 0.49 .092
