Forman Jane H, Robinson Claire H, Krein Sarah L
VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, UM North Campus Research Complex, 2800 Plymouth Road, Building 16, 3rd floor, Ann Arbor, MI, 48109-2800, USA.
Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
BMC Health Serv Res. 2019 Mar 4;19(1):145. doi: 10.1186/s12913-019-3943-2.
An important goal of the patient-centered medical home is increasing timely access for urgent needs, while maintaining continuity. In academic primary care clinics, meeting this goal, along with training medical residents and associated professionals, is challenging.
The aim of this study was to understand how academic primary care clinics provide continuity to patients requesting same-day access and identify factors that may affect site-level success. We conducted qualitative interviews from December 2013-October 2014 with primary care leadership involved with residency programs at 19 Veterans Health Administration academically-affiliated medical centers. Interview recordings were transcribed verbatim. To analyze the data, we created comprehensive, structured transcript summaries for each site. Site summaries were then entered into NVivo 10 software and coded by main categories to facilitate within-case and cross-case analyses. Themes and patterns across sites were identified using matrix analysis.
Interviewees found it challenging to provide continuity for same-day in-person visits. Most sites took a team-based approach to ensure continuity and provide coverage for same-day access, notably using NPs, PAs, and RNs in their coverage algorithms. Further, they reported several adaptations that increased multiple types of continuity for walk-in patients, urgent care between in-person visits, and follow-up care. While this study focused on longitudinal continuity, both by individual PCPs or by a team of professionals, informational continuity and continuity of supervision, as well as, to a lesser extent, relational and management continuity, were also addressed in our interviews. Finally, most interviewees reported clinic intention to provide patient-centered, team-based care and a robust educational experience for trainees, and endeavored to structure their clinics in ways that align these two missions.
In contending with the tension between providing continuity and educating new clinicians, clinics have re-conceptualized continuity as team-based, creating alternative strategies to same-day visits with a usual provider, coupled with communication strategies. Understanding the effect of these strategies on different types of continuity as well as patient experience and outcomes are key next steps in the further development and dissemination of effective models for improving continuity and the transition to team-based care in the academic clinic setting.
以患者为中心的医疗之家的一个重要目标是在保持连续性的同时，增加对紧急需求的及时就诊机会。在学术性初级保健诊所中，实现这一目标以及培训住院医师和相关专业人员具有挑战性。
本研究的目的是了解学术性初级保健诊所如何为要求当日就诊的患者提供连续性，并确定可能影响机构层面成功的因素。我们在2013年12月至2014年10月期间，对19个退伍军人健康管理局学术附属医疗中心参与住院医师培训项目的初级保健负责人进行了定性访谈。访谈录音逐字转录。为了分析数据，我们为每个机构创建了全面、结构化的转录摘要。然后将机构摘要输入NVivo 10软件，并按主要类别进行编码，以促进案例内和跨案例分析。使用矩阵分析确定各机构之间的主题和模式。
受访者发现为当日面对面就诊提供连续性具有挑战性。大多数机构采用基于团队的方法来确保连续性，并为当日就诊提供覆盖，特别是在其覆盖算法中使用执业护士、医师助理和注册护士。此外，他们报告了几种调整措施，这些措施增加了多种类型的连续性，包括为非预约患者提供的连续性、面对面就诊之间的紧急护理以及后续护理。虽然本研究侧重于由个体初级保健医生或专业团队提供的纵向连续性，但我们的访谈中也涉及了信息连续性和监督连续性，以及在较小程度上的关系连续性和管理连续性。最后，大多数受访者报告称，诊所有意提供以患者为中心的、基于团队的护理，并为实习生提供丰富的教育体验，并努力以协调这两个使命的方式构建其诊所。
在应对提供连续性和教育新临床医生之间的紧张关系时，诊所已将连续性重新概念化为基于团队的，创造了与常规提供者进行当日就诊的替代策略，以及沟通策略。了解这些策略对不同类型连续性以及患者体验和结果的影响，是进一步开发和推广有效模型以改善学术诊所环境中的连续性和向基于团队的护理过渡的关键下一步。
