Research ArticleOriginal Research

Primary Care Practices' Implementation of Patient-Team Partnership: Findings from EvidenceNOW Southwest

Tristen L. Hall, Kyle E. Knierim, Donald E. Nease, Elizabeth W. Staton, Carolina Nkouaga, L. Miriam Dickinson, Robert L. Rhyne and W. Perry Dickinson
The Journal of the American Board of Family Medicine July 2019, 32 (4) 490-504; DOI: https://doi.org/10.3122/jabfm.2019.04.180361

References

  1. 1.↵
    1. Hook ML
    . Partnering with patients–a concept ready for action. J Adv Nurs 2006;56:133–43.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Holman H,
    2. Lorig K
    . Patients as partners in managing chronic disease: partnership is a prerequisite for effective and efficient health care. BMJ 320:526, 2000.
    OpenUrlFREE Full Text
  3. 3.↵
    1. Bodenheimer T,
    2. Lorig K,
    3. Holman H,
    4. Grumbach K
    . Patient self-management of chronic disease in primary care. JAMA 2002;288:2469–75.
    OpenUrlCrossRefPubMedWeb of Science
  4. 4.↵
    1. Bodenheimer T,
    2. Ghorob A,
    3. Willard-Grace R,
    4. Grumbach K
    . The 10 building blocks of high-performing primary care. Ann Fam Med 2014;12:166–71.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Etz RS,
    2. Cohen DJ,
    3. Woolf SH,
    4. et al
    . Bridging primary care practices and communities to promote healthy behaviors. Am J Prev Med 2008;35:S390–397.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Alter DA,
    2. Stukel T,
    3. Chong A,
    4. Henry D
    . Lesson from Canada's Universal Care: socially disadvantaged patients use more health services, still have poorer health. Health Aff (Millwood) 2011;30:274–83.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    1. Rasanathan K,
    2. Montesinos EV,
    3. Matheson D,
    4. Etienne C,
    5. Evans T
    . Primary health care and the social determinants of health: essential and complementary approaches for reducing inequities in health. J Epidemiol Community Health 2011;65:656–60.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Saba GW,
    2. Wong ST,
    3. Schillinger D,
    4. et al
    . Shared decision making and the experience of partnership in primary care. Ann Fam Med 2006;4:54–62.
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Godolphin W
    . Shared decision-making. Healthc Q 2009;12:e186–90.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Sessums LL,
    2. McHugh SJ,
    3. Rajkumar R
    . Medicare's vision for advanced primary care: new directions for care delivery and payment. JAMA 2016;315:2665–6.
    OpenUrlCrossRefPubMed
  11. 11.↵
    National Committee for Quality Assurance. Standards and Guidelines for NCQA's Patient-Centered Medical Home (PCMH) 2011. Washington, D.C.: National Committee for Quality Assurance; 2011.
  12. 12.↵
    1. Davis K,
    2. Schoenbaum SC,
    3. Audet A-M
    . A 2020 vision of patient-centered primary care. J Gen Intern Med 2005;20:953–7.
    OpenUrlCrossRefPubMedWeb of Science
  13. 13.↵
    1. Frosch DL,
    2. May SG,
    3. Rendle KA,
    4. Tietbohl C,
    5. Elwyn G
    . Authoritarian physicians and patients' fear of being labeled ‘difficult’ among key obstacles to shared decision making. Health Aff (Millwood) 2012;31:1030–8.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Légaré F,
    2. Ratté S,
    3. Gravel K,
    4. Graham ID
    . Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns 2008;73:526–35.
    OpenUrlCrossRefPubMedWeb of Science
  15. 15.↵
    1. Légaré F,
    2. O'Connor AM,
    3. Graham ID,
    4. et al
    . Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice. Patient Educ Couns 2006;63:380–90.
    OpenUrlCrossRefPubMedWeb of Science
  16. 16.↵
    1. Furukawa MF,
    2. King J,
    3. Patel V,
    4. Hsiao C-J,
    5. Adler-Milstein J,
    6. Jha AK
    . Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Aff (Millwood) 2014;33:1672–9.
    OpenUrlAbstract/FREE Full Text
  17. 17.↵
    1. Audet A-M,
    2. Davis K,
    3. Schoenbaum SC
    . Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med 2006;166:754–9.
    OpenUrlCrossRefPubMedWeb of Science
  18. 18.↵
    1. Barello S,
    2. Graffigna G,
    3. Vegni E
    . Patient engagement as an emerging challenge for healthcare services: mapping the literature. Nurs Res Pract 2012;2012:905934.
    OpenUrlPubMed
  19. 19.↵
    1. Braveman P,
    2. Gottlieb L
    . The social determinants of health: it's time to consider the causes of the causes. Public Health Rep 2014;129:19–31.
    OpenUrlCrossRefPubMed
  20. 20.↵
    World Health Organization. Our cities, our health, our future: acting on social determinants for health equity in urban settings. Report to the WHO Commission on Social Determinants of Health from the Knowledge Network on Urban Settings. Geneva, Switzerland: World Health Organization; 2008.
  21. 21.↵
    1. Adler NE,
    2. Stead WW
    . Patients in context—EHR capture of social and behavioral determinants of health. N Engl J Med 2015;372:698–701.
    OpenUrlCrossRefPubMed
  22. 22.↵
    1. Gottlieb L,
    2. Sandel M,
    3. Adler NE
    . Collecting and applying data on social determinants of health in health care settings. JAMA Intern Med 2013;173:1017–20.
    OpenUrl
  23. 23.↵
    1. Holtrop JS,
    2. Dosh SA,
    3. Torres T,
    4. Thum YM
    . The community health educator referral liaison (CHERL): a primary care practice role for promoting healthy behaviors. Am J Prev Med 2008;35:S365–S372.
    OpenUrlCrossRefPubMed
  24. 24.↵
    1. Bodenheimer T,
    2. Wagner EH,
    3. Grumbach K
    . Improving primary care for patients with chronic illness. JAMA 2002;288:1775–9.
    OpenUrlCrossRefPubMedWeb of Science
  25. 25.↵
    1. Williams DR,
    2. Costa MV,
    3. Odunlami AO,
    4. Mohammed SA
    . Moving upstream: how interventions that address the social determinants of health can improve health and reduce disparities. J Public Health Manag Pract 2008;14:S8.
    OpenUrlCrossRefPubMed
  26. 26.↵
    1. Sandel M,
    2. Hansen M,
    3. Kahn R,
    4. et al
    . Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Aff (Millwood) 2010;29:1697–705.
    OpenUrlAbstract/FREE Full Text
  27. 27.↵
    1. Cohen E,
    2. Fullerton DF,
    3. Retkin R,
    4. et al
    . Medical-legal partnership: collaborating with lawyers to identify and address health disparities. J Gen Intern Med 2010;25:136–9.
    OpenUrlCrossRef
  28. 28.↵
    1. Nutting PA,
    2. Crabtree BF,
    3. Miller WL,
    4. Stange KC,
    5. Stewart E,
    6. Jaén C
    . Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood) 2011;30:439–45.
    OpenUrlAbstract/FREE Full Text
  29. 29.↵
    1. Frieden TR,
    2. Berwick DM
    . The “Million Hearts” initiative—preventing heart attacks and strokes. N Engl J Med 2011;365:e27.
    OpenUrlCrossRefPubMed
  30. 30.↵
    Agency for Healthcare Research and Quality. EvidenceNOW: bridging research & practice in primary care [Fact Sheet]. Available from: https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/about/evidence-now-fact-sheet.pdf. Published 2017. Accessed February 27, 2019.
  31. 31.↵
    1. Baskerville NB,
    2. Liddy C,
    3. Hogg W
    . Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012;10:63–74.
    OpenUrlAbstract/FREE Full Text
  32. 32.↵
    1. English AF,
    2. Dickinson LM,
    3. Zittleman L,
    4. et al
    . A community engagement method to design patient engagement materials for cardiovascular health. Ann Fam Med 2018;16:S58–S64.
    OpenUrlAbstract/FREE Full Text
  33. 33.↵
    1. Cohen DJ,
    2. Balasubramanian BA,
    3. Gordon L,
    4. et al
    . A national evaluation of a dissemination and implementation initiative to enhance primary care practice capacity and improve cardiovascular disease care: the ESCALATES study protocol. Implement Sci 2016;11:86.
    OpenUrl
  34. 34.↵
    Practice Innovation Program Colorado. Medical home practice monitor. Available from: http://resourcehub.practiceinnovationco.org/2017/02/03/medical-home-practice-monitor/. Accessed April 27, 2018.
  35. 35.↵
    1. Solberg LI,
    2. Asche SE,
    3. Margolis KL,
    4. Whitebird RR
    . Measuring an organization's ability to manage change: the change process capability questionnaire and its use for improving depression care. Am J Med Qual 2008;23:193–200.
    OpenUrlCrossRefPubMedWeb of Science
  36. 36.↵
    1. Harris PA,
    2. Taylor R,
    3. Thielke R,
    4. Payne J,
    5. Gonzalez N,
    6. Conde JG
    . Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81.
    OpenUrlCrossRefPubMedWeb of Science
  37. 37.↵
    1. Okun S,
    2. Schoenbaum S,
    3. Andrews D,
    4. et al
    . Patients and health care teams forging effective partnerships. Washington D.C.: Institute of Medicine; 2014.
  38. 38.↵
    1. Cromartie J
    . Rural-urban commuting area codes. October 12, 2016 ed. Washington, DC: United States Department of Agriculture, Economic Research Service; 2016.
  39. 39.↵
    1. Morrill R,
    2. Cromartie J,
    3. Hart G
    . Metropolitan, urban, and rural commuting areas: toward a better depiction of the United States settlement system. Urban Geogr 1999;20:727–48.
    OpenUrlCrossRefWeb of Science
  40. 40.↵
    1. Hosmer D,
    2. Lemeshow S,
    3. Sturdivant R
    . Model-building strategies and methods for logistic regression. In: Applied logistic regression. New York, NY: Wiley Interscience Publication; 2000.
  41. 41.↵
    1. Kogan MD,
    2. Schuster MA,
    3. Stella MY,
    4. et al
    . Routine assessment of family and community health risks: parent views and what they receive. Pediatrics 2004;113:1934–1943.
    OpenUrlPubMedWeb of Science
  42. 42.↵
    1. Garg A,
    2. Toy S,
    3. Tripodis Y,
    4. Silverstein M,
    5. Freeman E
    . Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015:135:e296–304.
    OpenUrlAbstract/FREE Full Text
  43. 43.↵
    1. DeVoe JE,
    2. Bazemore AW,
    3. Cottrell EK,
    4. et al
    . Perspectives in primary care: a conceptual framework and path for integrating social determinants of health into primary care practice. Ann Fam Med 2016;14:104–8.
    OpenUrlFREE Full Text
  44. 44.↵
    1. Green LA,
    2. Fryer GE Jr..,
    3. Yawn BP,
    4. Lanier D,
    5. Dovey SM
    . The ecology of medical care revisited. N Engl J Med 2001;344:2021–5.
    OpenUrlCrossRefPubMedWeb of Science
  45. 45.↵
    1. Kaufman A
    . Theory vs practice: should primary care practice take on social determinants of health now? Yes. Ann Fam Med 2016;14:100–1.
    OpenUrlFREE Full Text
  46. 46.↵
    1. Solberg LI
    . Theory vs practice: should primary care practice take on social determinants of health now? No. Ann Fam Med 2016;14:102–3.
    OpenUrlFREE Full Text
  47. 47.↵
    1. Garg A,
    2. Boynton-Jarrett R,
    3. Dworkin PH
    . Avoiding the unintended consequences of screening for social determinants of health. JAMA 2016;316:813–4.
    OpenUrlPubMed
  48. 48.↵
    1. Lorig KR,
    2. Holman HR
    . Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med 2003;26:1–7.
    OpenUrlCrossRefPubMedWeb of Science
  49. 49.↵
    1. Bosworth HB,
    2. Powers BJ,
    3. Oddone EZ
    . Patient self-management support: novel strategies in hypertension and heart disease. Cardiol Clin 2010;28:655–63.
    OpenUrlCrossRefPubMed
  50. 50.↵
    1. Kushel MB,
    2. Gupta R,
    3. Gee L,
    4. Haas JS
    . Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med 2006;21:71–7.
    OpenUrlCrossRefPubMedWeb of Science
  51. 51.↵
    1. Burgard SA,
    2. Seefeldt KS,
    3. Zelner S
    . Housing instability and health: findings from the Michigan Recession and Recovery Study. Soc Sci Med 2012;75:2215–24.
    OpenUrlCrossRefPubMed
  52. 52.↵
    1. Larson NI,
    2. Story MT
    . Food insecurity and weight status among US children and families: a review of the literature. Am J Prev Med 2011;40:166–73.
    OpenUrlCrossRefPubMed
  53. 53.↵
    1. Alvarez C,
    2. Lantz P,
    3. Sharac J,
    4. Shin P
    . Food insecurity, food assistance and health status in the US community health center population. J Health Care Poor Underserved 2015;26:82–91.
    OpenUrl
  54. 54.↵
    Health Resources and Services Administration. Medically underserved areas and populations (MUA/Ps). Available at: https://bhw.hrsa.gov/shortage-designation/muap. Published 2016. Accessed February 27, 2019.
  55. 55.↵
    1. Bodenheimer T,
    2. Wagner EH,
    3. Grumbach K
    . Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA 2002;288:1909–14.
    OpenUrlCrossRefPubMedWeb of Science
  56. 56.↵
    1. Coleman K,
    2. Austin BT,
    3. Brach C,
    4. Wagner EH
    . Evidence on the chronic care model in the new millennium. Health Aff (Millwood) 2009;28:75–85.
    OpenUrlAbstract/FREE Full Text
  57. 57.↵
    1. Nutting PA,
    2. Miller WL,
    3. Crabtree BF,
    4. Jaen CR,
    5. Stewart EE,
    6. Stange KC
    . Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med 2009;7:254–60.
    OpenUrlAbstract/FREE Full Text
  58. 58.↵
    1. Stange KC,
    2. Nutting PA,
    3. Miller WL,
    4. et al
    . Defining and measuring the patient-centered medical home. J Gen Intern Med 2010;25:601–12.
    OpenUrlCrossRefPubMedWeb of Science
  59. 59.↵
    1. Alley DE,
    2. Asomugha CN,
    3. Conway PH,
    4. Sanghavi DM
    . Accountable health communities—addressing social needs through Medicare and Medicaid. N Engl J Med 2016;374:8–11.
    OpenUrlCrossRefPubMed
  60. 60.↵
    1. Fraze T,
    2. Lewis VA,
    3. Rodriguez HP,
    4. Fisher ES
    . Housing, transportation, and food: how ACOs seek to improve population health by addressing nonmedical needs of patients. Health Aff (Millwood) 2016;35:2109–15.
    OpenUrlAbstract/FREE Full Text
  61. 61.↵
    1. Han E,
    2. Scholle SH,
    3. Morton S,
    4. Bechtel C,
    5. Kessler R
    . Survey shows that fewer than a third of patient-centered medical home practices engage patients in quality improvement. Health Aff (Millwood) 2013;32:368–75.
    OpenUrlAbstract/FREE Full Text
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