实现以患者为中心的医疗之家内强化门诊项目的关键要素：文献回顾与定性分析。
Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: A literature review and qualitative analysis.
机构信息
Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, United States; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, United States.
Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, United States; Division of General Medical Disciplines, Stanford University, Stanford, CA, United States.
出版信息
Healthc (Amst). 2016 Mar;4(1):22-9. doi: 10.1016/j.hjdsi.2015.12.005. Epub 2015 Dec 29.
BACKGROUND
Intensive outpatient programs aim to transform care while conserving resources for high-need, high-cost patients, but little is known about factors that influence their implementation within patient-centered medical homes (PCMHs).
METHODS
In this mixed-methods study, we reviewed the literature to identify factors affecting intensive outpatient program implementation, then used semi-structured interviews to determine how these factors influenced the implementation of an intensive outpatient program within the Veterans Affairs' (VA) PCMH. Interviewees included facility leadership and clinical staff who were involved in a pilot Intensive Management Patient Aligned Care Team (ImPACT) intervention for high-need, high-cost VA PCMH patents. We classified implementation factors in the literature review and qualitative analysis using the Consolidated Framework for Implementation Research (CFIR).
RESULTS
The literature review (n=9 studies) and analyses of interviews (n=15) revealed key implementation factors in three CFIR domains. First, the Inner Setting (i.e., the organizational and PCMH environment), mostly enabled implementation through a culture of innovation, good networks and communication, and positive tension for change. Second, Characteristics of Individuals, including creativity, flexibility, and interpersonal skills, allowed program staff to augment existing PCMH services. Finally, certain Intervention Characteristics (e.g., adaptability) enabled implementation, while others (e.g., complexity) generated implementation barriers.
CONCLUSIONS
Resources and structural features common to PCMHs can facilitate implementation of intensive outpatient programs, but program success is also dependent on staff creativity and flexibility, and intervention adaptations to meet patient and organizational needs.
IMPLICATIONS
Established PCMHs likely provide resources and environments that permit accelerated implementation of intensive outpatient programs.
LEVEL OF EVIDENCE
V.
背景
强化门诊项目旨在改变医疗服务模式，同时为高需求、高费用患者节省资源，但对于影响其在以患者为中心的医疗之家（PCMH）内实施的因素知之甚少。
方法
在这项混合方法研究中，我们回顾了文献，以确定影响强化门诊项目实施的因素，然后使用半结构化访谈来确定这些因素如何影响退伍军人事务部（VA）PCMH 中强化门诊项目的实施。受访者包括参与针对 VA PCMH 高需求、高费用患者的强化管理患者对齐护理团队（ImPACT）试点计划的设施领导和临床工作人员。我们使用实施研究综合框架（CFIR）对文献综述和定性分析中的实施因素进行分类。
结果
文献综述（n=9 项研究）和访谈分析（n=15）揭示了三个 CFIR 领域中的关键实施因素。首先，内部环境（即组织和 PCMH 环境）主要通过创新文化、良好的网络和沟通以及对变革的积极紧张感来促进实施。其次，个体特征，包括创造力、灵活性和人际交往能力，使项目工作人员能够增强现有的 PCMH 服务。最后，某些干预特征（例如适应性）使实施成为可能，而其他特征（例如复杂性）则产生了实施障碍。
结论
PCMH 共有的资源和结构特征可以促进强化门诊项目的实施，但项目的成功还取决于工作人员的创造力和灵活性，以及干预措施适应患者和组织需求的能力。
意义
已建立的 PCMH 可能提供资源和环境，从而加速强化门诊项目的实施。
证据水平
V。
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