Cross Dori A, Nong Paige, Harris-Lemak Christy, Cohen Genna R, Linden Ariel, Adler-Milstein Julia
University of Minnesota School of Public Health, Division of Health Policy and Management, Minneapolis, MN, USA.
University of Michigan School of Medicine, Department of Learning Health Sciences, Ann Arbor, MI 48109, USA.
Healthc (Amst). 2019 Mar;7(1):30-37. doi: 10.1016/j.hjdsi.2018.08.004. Epub 2018 Sep 7.
Improving primary care for patients with chronic illness is critical to advancing healthcare quality and value. Yet, little is known about what strategies are successful in helping primary care practices deliver high-quality care for this population under value-based payment models.
Double-blind interviews in 14 primary care practices in the state of Michigan, stratified based on whether they did (n = 7) or did not (n = 7) demonstrate improvement in primary care outcomes for patients with at least one reported chronic disease between 2010 and 2013. All practices participate in a statewide pay-for-performance program run by a large commercial payer. Using an implementation science framework to identify leverage points for effecting organizational change, we sought to identify, describe and compare strategies among improving and non-improving practices across three domains: (1) organizational learning opportunities, (2) approaches to motivating staff, and (3) acquisition and use of resources.
We identified 10 strategies; 6 were "differentiating" - that is, more prevalent among improving practices. These differentiating strategies included: (1) participation in learning collaboratives, (2) accessing payer tools to monitor quality performance, (3) framing pay-for-performance as a practice transformation opportunity, (4) reinvesting earned incentive money in equitable, practice-centric improvement, (5) employing a care manager, and (6) using available technical support from local hospitals and provider organizations to support performance improvement. Implementation of these strategies varied based on organizational context and relative strengths.
Practices that succeeded in improving care for chronic disease patients pursued a mix of strategies that helped meet immediate care delivery needs while also creating new adaptive structures and processes to better respond to changing pressures and demands. These findings help inform payers and primary care practices seeking evidence-based strategies to foster a stronger delivery system for patients with significant healthcare needs.
改善慢性病患者的初级保健对于提高医疗质量和价值至关重要。然而，对于在基于价值的支付模式下，哪些策略能成功帮助初级保健机构为这一人群提供高质量护理，我们知之甚少。
对密歇根州的14家初级保健机构进行双盲访谈，根据它们在2010年至2013年间是否（n = 7）或未（n = 7）显示出至少有一种报告慢性病患者的初级保健结果有所改善进行分层。所有机构都参与了由一家大型商业支付方运营的全州按绩效付费计划。我们使用实施科学框架来确定影响组织变革的杠杆点，试图识别、描述和比较改善组和未改善组在三个领域的策略：（1）组织学习机会，（2）激励员工的方法，以及（3）资源的获取和使用。
我们确定了10种策略；其中6种是“差异化”策略，即在改善组中更普遍。这些差异化策略包括：（1）参与学习协作，（2）使用支付方工具监测质量绩效，（3）将按绩效付费视为实践转型机会，（4）将赚取的激励资金重新投入到公平的、以实践为中心的改进中，（5）聘请护理经理，以及（6）利用当地医院和医疗机构提供的现有技术支持来促进绩效提升。这些策略的实施因组织背景和相对优势而异。
成功改善慢性病患者护理的机构采用了一系列策略，这些策略有助于满足即时护理需求，同时还创建了新的适应性结构和流程，以更好地应对不断变化的压力和需求。这些发现有助于为寻求循证策略以建立更强大的医疗服务体系的支付方和初级保健机构提供参考，以满足有重大医疗需求患者的需求。
