Abstract Session F4: Organization of Care and Chronic Disease - - PDF document

Abstract Session F4: Organization of Care and Chronic Disease Management Moderator: Karin M. Nelson, MD, MSHS

PATIENT-CENTERED MEDICAL HOME IMPLEMENTATION AND PROVIDER JOB TURNOVER Philip W. Sylling1; Edwin Wong1,4; Chuan-Fen Liu1,4; Susan Hernandez1,4; Adam Batten1; Christian Helfrich1,4; Karin M. Nelson1,2; Stephan D. Fihn3,5; Paul Hebert1,4. 1VA Puget Sound Healthcare System, Seattle, WA; 2VA Puget Sound Healthcare System, Seattle, WA; 3University of Washington, Seattle, WA; 4University of Washington, Seattle, WA; 5Veterans Health Administration, Seattle, WA. (Tracking ID #1938371) BACKGROUND: The aim of this study was to examine the relationship between the implementation of a patient-centered medical home (PCMH) model and primary care provider (PCP) job turnover. The Veterans Health Administration (VHA) began implementing a PCMH through its Patient Aligned Care Team (PACT) initiative in April 2010. Although elements of PACT have been individually associated with greater PCP job satisfaction, the magnitude of organizational change required by PACT's restructuring of primary care may result in higher provider turnover, at least in the short-term. Existing literature has not specifically examined the effect of PCMH on PCP turnover. METHODS: We applied an interrupted time series model using VHA administrative data. PCP turnover was defined by providers' dropping out of the primary care workforce for two or more consecutive quarters. We constructed discrete-time longitudinal data from PCPs employed by the VHA anytime from 2003 to 2012 with the unit of analysis at the PCP-quarter level. PCPs included physicians, nurse practitioners, and physician

• assistants. We estimated the association between PACT and provider turnover using logistic regression and

adjusted for seasonality and secular trend, provider and job characteristics, and the local area unemployment

• rate. For adjusted analysis, we calculated average marginal effects (AMEs), which reflected the change in PCP

turnover probability associated with unit increases in the explanatory variables. To examine differential effects

• f PACT across providers, we interacted a PACT indicator variable with PCP demographics.

RESULTS: The unadjusted quarterly rate of PCP turnover was 3.06% prior to PACT and 3.38% after PACT. In adjusted analysis, PACT was associated with higher provider turnover (AME=0.004, p=0.004). The association between PACT and PCP turnover was significantly different across age groups and experience

• levels. PACT was associated with a -0.0008 (p=0.711), 0.0046 (p=0.011), and 0.0069 (p=0.002) percentage

point increase in turnover probability for providers under age 45, age 45 to 55, and over age 55, respectively. Compared to PCPs with 5 years of experience (AME=0.0019, p=0.239), the estimated effect of PACT on turnover was higher for PCPs with 20 years of experience (AME=0.0106, p<0.001). Provider type was also associated with baseline provider turnover. Nurse practitioners (AME=0.0055, p<0.001) and physician assistants (AME=0.0084, p<0.001) had higher baseline turnover than physicians. CONCLUSIONS: PCMH implementation in VHA primary care required providers to adopt a team-based model of care as well as utilize new patient-centered forms of care delivery. This transition represented substantial organizational change which may have increased job stress among some providers. Our results suggest that PCMH implementation was associated with higher initial provider job turnover, particularly among

• lder and more experienced providers. From a policy perspective, health system decision makers should

consider the potential short-term impact of increased PCP turnover when implementing PCMH models, which could adversely impact quality of patient care delivery. Also, health systems implementing PCMH may maximize resources by focusing retention efforts on older and more experienced providers.

IMPACT OF LOSS OF INTERPERSONAL CONTINUITY ON PATIENT EXPERIENCE OF CARE AND AMBULATORY QUALITY OF CARE Ashok Reddy1,4; David A. Asch2,3; Anne Canamucio2; Rachel M. Werner2,3. 1University of Pennsylvania, Philadelphia, PA; 2VISN 4 Center for Evaluation of PACT, Philadelphia, PA; 3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; 4Robert Wood Johnson Clinical Scholar Program, University of Pennsylvania, Philadelphia, PA. (Tracking ID #1938406) BACKGROUND: Continuity remains a core tenet of primary care. Several studies link a more continuous PCP-patient relationship with higher patient satisfaction, higher preventive service use, and lower hospitalizations rates. Continuity is often defined as having three components: interpersonal (having a continuous personal physician-patient relationship), longitudinal (having a medical home in which patients receive the majority of their care), and informational (having a patient's medical records available at the time a doctor sees the patient). While prior work demonstrates the importance of continuity on patient care outcomes, it is uncertain which component of continuity matters most. Our study focuses on isolating the impact of interpersonal continuity in the setting of stable informational and longitudinal continuity. In the setting of the Veterans Health Administration (VHA), we conduct an analysis of patients who experienced a loss of the interpersonal relationship (primary care provider turnover) but continue to receive care at the VHA (stable longitudinal and informational continuity). We then measure the impact of turnover on patient care experience and ambulatory quality of care. METHODS: We included all patients enrolled in primary care at the Veterans Health Administration (VHA) between 2010 and 2012 who were also included in one of two national datasets used to measure our outcome variables: the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) and the External Peer Review Program (EPRP; used to measure ambulatory quality of care). Both datasets include a random sample of veterans receiving outpatient care in the VHA. We measured primary care provider (PCP) turnover in the two years prior to measuring patient experience and quality of care using VHA primary care encounter data. A linear probability model was used to test whether PCP turnover was associated with changes in patient experience of care and ambulatory quality of care, adjusting for patient-level covariates (age, gender, race, income and DCG risk score) and clinic-level fixed effects, and clustering standard errors at clinic level. RESULTS: Our analyses include SHEP responses from 639,011 patients (9% of who experience PCP turnover) and EPRP data from 361,627 patients (10% experiencing PCP turnover). A majority of respondents reported positive experiences of care in 3 out of 5 domains: How well doctor/nurse communicate (53%), rating of personal doctor/nurse (71%), and overall rating of VHA healthcare (59%). In addition, patients had high rates of completion of testing for retinal preventive care (90%), control of hypertension (79%) and colon cancer screening (82%). In our primary analysis, PCP turnover was associated with a decrease in all 5 domains of patient care experience. For example, PCP turnover was associated with a 3.7 percentage point (p<0.05) lower response in how well a patient communicates with his or her provider. However, we found no association between PCP turnover and ambulatory quality of care measures. CONCLUSIONS: With increasing primary care turnover, interpersonal continuity in medical care continues to

• diminish. Our study shows that loss of interpersonal continuity is a common experience and is associated with a

small but significantly worse patient experience of care. However, this loss of interpersonal continuity does not impact the quality of preventive services for common ambulatory conditions. These findings demonstrate that health care systems with robust informational and longitudinal continuity could mitigate the impact of a loss of any one provider on a person's healthcare.

THE IMPACT OF PATIENT-CENTERED MEDICAL HOME TRANSFORMATION WITHIN VETERANS HEALTH ADMINISTRATION ON PATIENT EXPERIENCE OF CARE Ashok Reddy1,4; Anne Canamucio2; Rachel M. Werner2,3. 1University of Pennsylvania, Philadelphia, PA;

2VISN 4 Center for Evaluation of PACT, Philadelphia, PA; 3Leonard Davis Institute of Health Economics,

University of Pennsylvania, Philadelphia, PA; 4Robert Wood Johnson Clinical Scholar Program, University of Pennsylvania, Philadelphia, PA. (Tracking ID #1938552) BACKGROUND: The patient-centered medical home (PCMH) is an innovative primary care health delivery model that places an emphasis on delivering ‘patient-centered' healthcare. However, there is little known regarding whether medical home transformation improves patients' experience of care. In 2010, the Veterans Health Administration (VHA) began implementing its own medical home model, termed Patient Aligned Care Teams (PACT), across all primary care clinics nationwide. Our study takes place in one mid-Atlantic region of the Veterans Health Administration (VISN 4), which includes 56 primary care sites providing care for over 300,000 veterans. We evaluate the impact of adoption of the medical home model on patience experience of care. METHODS: Patients were selected from the VHA quality improvement assessment program, the Survey of Healthcare Experiences of Patients (SHEP). For our study cohort, we identify patient survey respondents between July 2010 and October 2012. Our primary outcomes include 5 composite measures of patient care experience: how well doctors/nurses communicate, rating of personal doctor/nurse, getting needed care, overall rating of VA healthcare, and getting care quickly. We examine the effect of PACT implementation on these

• utcomes using two sources of variation—the timing and the effectiveness of PACT implementation across

study sites. To do so, we first obtained the date when each primary care provider (PCP) became a PACT

• provider. Second, based on qualitative site-level interviews, we developed two types of site-level measures of

PACT effectiveness: 1) nine indicators for structural changes supporting the PACT model and 2) a scale variable measuring the quality of PACT implementation. For our analysis we use a repeated cross-sectional design to evaluate the impact of the medical home transformation on patient experience of care. We conduct patient-level analyses, with patients clustered within PCPs and sites of care to test whether changes in health care delivery in the VHA under the PACT transformation led to changes in patient experience of care. Our linear probability models are adjusted for age, sex, race, income, and risk-based DCG scores and include PCP- level fixed effects. RESULTS: Our analyses include SHEP responses from 28,041 patients who were associated with 568

• physicians. The median age of respondents was 68 and most were male (96%) who self-identified as white

(91%). A majority of respondents had a positive experience of care in 3 domains: how well doctor/nurse communicate (59%), rating of personal doctor/nurse (77%), and overall rating of the VHA (65%). Over the study period the percentage of PCPs who were part of the PACT increased from 8.2% in the first time period to 81.1% in the last time period. Similarly, we observe an increase the implementation of PACT structural changes and the quality of that implementation. For example, the use of high-risk registries increased from 6.9% in the first time period to 64.2% in the last. In our primary analysis, we found no association between medical home transformation and patient experience of care using any of the three measures of PACT implementation. For example, patients assigned to a PACT provider had a 0.51% (p=0.66) higher response in how well they communicate with their provider compared to patients not assigned to a PACT provider and to patients in the pre-PACT period. CONCLUSIONS: While the medical home model is increasingly adopted, in part to improve patient experience of care, we did not see an improvement in patient care experience in the VHA.

HEALTHCARE FRAGMENTATION IN A MAJOR U.S. CITY Lisa M. Kern1; Zachary Grinspan1; Jason Shapiro2; Rainu Kaushal1. 1Weill Cornell Medical College, New York, NY; 2Mount Sinai School of Medicine, New York, NY. (Tracking ID #1939540) BACKGROUND: American healthcare is fragmented, with patients routinely seeking care from multiple providers in different practices and health systems. Healthcare fragmentation is thought to be particularly common in cities with multiple academic medical centers. Healthcare fragmentation is important, because it can lead to fragmentation of clinical information (that is, clinical information that is needed by healthcare providers but which is missing at the point of care because of gaps in communication across providers). Previous studies have estimated that such gaps occur frequently, with relevant clinical information missing in 1 of every 7 ambulatory visits, potentially contributing to adverse events and readmissions. The degree to which healthcare fragmentation is contributing to this problem of information fragmentation has not been measured. In the absence of data on the amount of healthcare fragmentation, healthcare providers and policy makers may underestimate the actual degree of fragmentation and may, thus, underestimate the value of interventions designed to address it. Our aim was to derive a quantitative estimate of the amount of healthcare fragmentation in New York City. METHODS: We conducted a longitudinal study using data from 2010 and 2011. We obtained the data from a health information exchange (HIE) organization previously called the New York Clinical Information Exchange (NYCLIX); it subsequently merged with another HIE organization and is now part of Healthix. We selected data from NYCLIX because it had detailed information on individual patient encounters with health care. The NYCLIX data included emergency department (ED) and inpatient visits for patients who sought care at 6 hospitals in Manhattan: Beth Israel Medical Center, Mount Sinai Medical Center, New York-Presbyterian Hospital, New York University Medical Center, Roosevelt Hospital, and St. Luke's Hospital. For each patient who sought ED or inpatient care at one of the 6 hospitals, we determined whether that patient had been seen in a different hospital in the previous 12 months. This analysis allowed the specific 12-month window to vary from patient to patient, fixing time zero as the date of that patient's encounter in 2011. The purpose of this analysis was to calculate the rate of encounters for which a patient's clinical information could be missing if data were not exchanged across providers. RESULTS: We identified 566,907 patients who were seen in the ED or inpatient settings in the 6 participating hospitals in 2011. We found that each of the 6 hospitals shared patients with every other hospital. For the entire group of patients, we found that there were 74,196 ED visits for which clinical information could have been missing, because the patient had been seen elsewhere in the previous 12 months. This is equivalent to 10.0% of ED visits having potentially missing clinical information. Similarly, we found that there were 31,967 inpatient admissions for which clinical information could have been missing, because the patient had been seen elsewhere in the previous 12 months. This is equivalent to 9.1% of inpatient admissions having potentially missing clinical information. The risk of potentially missing clinical data varied slightly by institution, but all institutions were affected. Depending on the institution, between 6.8% and 16.9% of ED visits had clinical data potentially missing. Similarly, between 6.6% and 26.5% of inpatient admissions had clinical data potentially missing, depending on the institution. CONCLUSIONS: Healthcare fragmentation in New York City is extensive. All 6 participating hospitals were affected by healthcare fragmentation, with each hospital having its patients seen at each of the other 5 hospitals in a single year. It was very common for patients to seek care at the ED or inpatient setting of one hospital and have had previous care within the past 12 months at another hospital; this affected 10% of all ED visits and 9%

• f all inpatient admissions. This puts both patients and hospitals in a risky situation, in which relevant clinical

information may be missing at the point of care. Interventions designed to decrease healthcare fragmentation are

• needed. In addition, interventions such as electronic health information exchange are needed, as they can

potentially facilitate the efficient sharing of clinical data across providers and minimize the impact of healthcare fragmentation.

ROLES DESIRED BY CAREGIVERS OF PATIENTS WITH HEART FAILURE: IMPLICATIONS FOR CLINICIANS Robert Burke1,2; Jacqueline Jones3; David Bekelman4,2. 1Denver VA Medical Center, Denver, CO; 2University

• f Colorado, Denver, CO; 3University of Colorado, Denver, CO; 4Denver VA Medical Center, Denver, CO.

(Tracking ID #1940148) BACKGROUND: Heart failure (HF) often results in significant burden to patients, their caregivers, and the health care system. A significant contributor to the morbidity and mortality associated with HF is poor adherence to self-management of the disease. Caregivers play a major role in HF management. However, few studies have assessed the roles caregivers desire in interacting with the person they care for and the health care

• system. Understanding these desired roles is important because doing so may lessen caregiver burden, improve

the ability of patients and caregivers to manage their illness at home, and improve the efficacy of the clinicians caring for these patients leading to improved outcomes. METHODS: Two interviewers with experience in qualitative methods conducted in-depth, semistructured, 60- to 90-minute interviews with 33 diverse patients with New York Heart Association class II to IV HF (confirmed by a cardiologist) and 20 of their family caregivers. The interviews explored specific domains including symptoms, psychosocial issues, decision-making, and the future of illness. Caregivers were identified by asking patients, "Can you think of the one person beside a healthcare provider who helps you the most with your heart condition?'' We used the method of constant comparison derived from grounded theory for analysis, using participant triangulation (comparing perspectives of both patients and caregivers) to identify roles caregivers desired and those they perceived were assigned to them. RESULTS: Caregivers desire different roles than the ones they perceive are assigned to them by the health care system and the person they care for. First, many caregivers express a desire for a role working on behalf of the health care system to carry out HF care at home, but desire more information to be able to do so. Second, most caregivers want a role that is valued when interacting with the health care system, and want to be invited to participate in interactions between the person they care for and the health care system. Third, the majority of caregivers wish for a role moderating communication between the person they care for and the health care system as they frequently observe poor bidirectional communication. Fourth, many caregivers desire a more passive role in communicating at home than the one they feel is assigned to them, and would welcome help discussing difficult topics with the person they care for. CONCLUSIONS: This study has several important implications for clinicians caring for patients with HF who have supporting caregivers. First, many caregivers, when included in the care plan and supported with relevant information, are eager to facilitate home care for patients with HF. Second, clinicians should solicit the input of caregivers, as many caregivers feel they have important insights that may not be identified otherwise. Third, clinicians should ask patients with HF if they have a caregiver and arrange visits so the caregiver can attend. Fourth, clinicians should inquire about whether the caregiver and patient with HF are communicating about difficult topics, including goals of care, burden, and psychological adjustment to the illness, and offer help to surmount barriers in communication. These changes are may result in more accurate assessment of patients with HF, improved management of the disease at home, and improved quality of life for the patient and caregiver.