PCMH Implementation Strategies: Implications for Cancer Survivor Care

PCMH 实施策略：对癌症幸存者护理的影响

• 批准号: 8633817
• 负责人: BENJAMIN F CRABTREE
• 金额: $ 65.15万
• 依托单位: RBHS-ROBERT WOOD JOHNSON MEDICAL SCHOOL
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-09-01 至 2017-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8633817
• 关键词: Acute; Adopted; Adoption; Adverse effects; Biological Response Modifier Therapy; Cancer Survivor; Caring; Case Study; Chronic; Chronic Disease; Communities; Complex; Counseling; Data; Diagnosis; Disease Management; Ethnography; Family; Future; Goals; Health behavior; Health system; Healthcare; Home environment; Individual; Intervention; Interview; Long-Term Care; Medical; Mental Health Services; Methods; Modeling; Neighborhoods; Patient-Centered Care; Patients; Phase; Population; Primary Health Care; Process; Quality of Care; Radiation; Research Design; Resources; Role; Safety; Sampling; Science; State Health Plans; Surveys; System; Time; United States; Vision; Visit; Writing; base; cancer therapy; chemotherapy; comparative; cost; follow-up; hormone therapy; improved; innovation; meetings; member; model design; patient oriented; primary care setting; public health relevance; success; theories

Successes in diagnosis and treatment of cancer have resulted in dramatic increases in the number of long- term cancer survivors. In fact, the past 20 years has seen dramatic shifts in patients receiving care in primary care practices like cancer survivors with complex, co-morbid conditions. Instead of most visits being for acute or single chronic conditions, the majority of visits are now for patients with complex conditions and needs. To meet the needs of complex patients like cancer survivors, primary care practices must radically reconfigure. The Patient-Centered Medical Home (PCMH) is purported to enhance quality and safety in primary care and is often part of health system reform efforts. While much is written about the PCMH, it is not clear that a PCMH enhances quality for complex patients like cancer survivors. In fact, PCMH attributes critical for meeting the needs of cancer survivors are the most challenging to implement: reorienting to a population perspective, developing collaborative teams, integrating healthcare neighborhoods and community resources, and changing roles/identities of clinicians and staff. Complexity science (CS) provides a theoretical basis for understanding how primary care practices implement innovations like the PCMH. As complex adaptive systems, practices self-organize according to dominant goals and co-evolve to take on configurations consistent with those goals. If a goal of achieving NCQA recognition dominates, practices self-organize to maximize this goal. Likewise, if caring for individuals, families, and communities dominates, practices self-organize to maximize this goal. In both cases, the result may be a PCMH, but CS suggests they might evolve to have very different capacities to care for cancer survivors. To identify and describe how PCMHs successfully implement the challenging attributes needed for cancer survivor care, we use a CS framework to conduct comparative case studies of practices that used different PCMH implementation strategies: some focused on NCQA Level 3 PCMH recognition and others focused on caring for individuals, families, and communities. We examine innovative primary care practices using a mixed- methods comparative case study design with practices selected from a national list of innovative practices. An initial sample of 10 practices (5 seeking level 3 NCQA recognition and 5 seeking to meet needs of individuals, families, and communities) will be selected for comparative purposes, with 10 replicative cases selected to confirm/disconfirm hypotheses. Data include validated surveys, costs of implementing and sustaining innovations, and ethnographic observations and interviews of practice members and patients. Results could have a profound impact on cancer survivor care and PCMH implementation strategies used throughout the US.

癌症诊断和治疗的成功导致长期癌症的数量急剧增加。 癌症的长期幸存者。事实上，在过去的20年里，接受初级护理的患者发生了戏剧性的变化 护理做法就像癌症幸存者患有复杂的并存疾病。与大多数急诊不同的是， 无论是单一的慢性疾病还是单一的慢性病，现在的就诊对象大多是病情和需求复杂的患者。至 为了满足像癌症幸存者这样复杂的患者的需求，初级保健实践必须从根本上重新配置。 以患者为中心的医疗之家(PCMH)旨在提高初级保健的质量和安全，并 通常是卫生系统改革努力的一部分。虽然关于PCMH的报道很多，但还不清楚PCMH 提高癌症幸存者等复杂患者的质量。事实上，PCMH的属性对于满足 癌症幸存者的需求是最难实现的：从人口角度重新定位， 发展协作团队，整合医疗社区和社区资源，并改变 临床医生和工作人员的角色/身份。 复杂性科学(CS)为理解初级保健实践如何实施提供了理论基础 像PCMH这样的创新。作为复杂的适应系统，实践按照主导目标进行自组织 并共同进化，以实现与这些目标一致的配置。如果实现NCQA认可的目标 支配、练习自我组织以最大化这一目标。同样，如果关心个人、家庭和 社区主导，实践自我组织，以最大化这一目标。在这两种情况下，结果都可能是 PCMH，但CS表示，它们可能进化成具有非常不同的能力来照顾癌症幸存者。 识别和描述PCMH如何成功地实现癌症所需的具有挑战性的属性 幸存者护理，我们使用CS框架对使用不同 PCMH实施战略：一些侧重于NCQA 3级PCMH认可，另一些侧重于 关爱个人、家庭和社区。我们使用混合的- 方法案例研究设计与从国家创新实践目录中选择的实践相比较。一个 10个实践的初始样本(5个寻求3级NCQA认可，5个寻求满足个人需求， (家庭和社区)将用于比较目的，选择10个可复制的案例 确认/不确认假设。数据包括经过验证的调查、实施和维持成本 创新，以及人种学观察和对执业成员和患者的采访。结果可能是 对美国各地使用的癌症幸存者护理和PCMH实施战略产生深远影响。