Jortberg Bonnie T, Fernald Douglas H, Hessler Danielle M, Dickinson L Miriam, Wearner Robyn, Connelly Lauri, Holtrop Jodi Summers, Fisher Lawrence, Dickinson W Perry
From Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (BTJ, DHF, LMD, RW, LC, JSH, WPD); Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA (DMH, LF).
J Am Board Fam Med. 2019 May-Jun;32(3):329-340. doi: 10.3122/jabfm.2019.03.180124.
Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation.
Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n = 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation.
In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all < .05) at baseline. In the final multilevel model, specialty (FM vs mixed, = .0081), rural location ( = .0109), and higher percent Medicaid ( < .0001) were associated with greater SMS. Practices described key facilitators (alignment, motivation, a visible champion, supporting infrastructure, and functional quality improvement and care teams) and barriers (no shared vision, no visible champion, siloed infrastructure, competing programs, turnover, and time constraints) to improving SMS delivery.
Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices.
先进的初级保健模式强调以患者为中心的护理，包括自我管理支持（SMS）。本研究旨在促进将自我管理支持转化为初级保健实践，并报告可能影响自我管理支持实施的关键基线实践特征。
2013年12月至2017年3月，科罗拉多州和加利福尼亚州的36家医疗机构参与了该研究。机构管理人员填写了一份描述机构特征的《机构信息表》。临床医生和工作人员（n = 716）完成了《机构文化评估》和《以患者为中心的医疗之家（PCMH）监测》。计算描述性统计数据，以确定与文化、质量改进、以患者为中心的医疗之家水平和自我管理支持实施相关的实践特征。实地记录和关键信息提供者访谈提供了有关实践的背景细节。迭代定性分析确定了自我管理支持实施的重要促进因素、障碍和变革能力。
在双变量分析中，农村地区、糖尿病未得到控制的患者较少、医疗补助或未参保人群比例较高、服务不足的指定以及较高的“以患者为中心的医疗之家”水平与基线时报告的更高的患者自我管理支持实施率相关（均P <.05）。在最终的多层次模型中，专科类型（家庭医学与混合专科，P =.0081）、农村地区（P =.01）以及更高比例的医疗补助患者（P <.0001）与更高的自我管理支持相关。各机构描述了改善自我管理支持提供的关键促进因素（一致性、积极性、有影响力的倡导者、支持性基础设施以及功能性质量改进和护理团队）和障碍（缺乏共同愿景、没有有影响力的倡导者、孤立的基础设施、相互竞争的项目、人员流动和时间限制）。
对关键实践特征和背景给予仔细关注并采取行动，可能为改善初级保健实践中的自我管理支持的实践变革努力创造更有利的初始条件。
