PCMH Implementation Strategies: Implications for Cancer Survivor Care

描述：癌症诊断和治疗的成功已经导致长期癌症幸存者的数量急剧增加。事实上，在过去20年中，在初级保健实践中接受治疗的患者，如患有复杂合并症的癌症幸存者，发生了巨大变化。现在大多数就诊的病人都有复杂的病情和需求，而不是大多数的急性或单一的慢性疾病。为了满足癌症幸存者等复杂患者的需求，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性，通常是卫生系统改革努力的一部分。虽然有很多关于PCMH的文章，但PCMH是否能提高癌症幸存者等复杂患者的质量尚不清楚。事实上，对满足癌症幸存者需求至关重要的PCMH属性是最难实施的：重新定位于人口视角，发展协作团队，整合医疗保健社区和社区资源，以及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PCMH等创新提供了理论基础。作为复杂的自适应系统，实践根据主导目标进行自我组织，并共同进化以采取与这些目标一致的配置。如果实现NCQA认可的目标占主导地位，实践自组织以最大化这一目标。同样地，如果关心个人、家庭和社区占主导地位，实践自我组织以最大限度地实现这一目标。在这两种情况下，结果都可能是PCMH，但CS认为它们可能进化成具有非常不同的照顾癌症幸存者的能力。为了确定和描述PCMH如何成功地实施癌症幸存者护理所需的具有挑战性的属性，我们使用CS框架对使用不同PCMH实施策略的实践进行比较案例研究：一些侧重于NCQA 3级PCMH认可，另一些侧重于照顾个人、家庭和社区。我们使用混合方法比较案例研究设计和从国家创新实践列表中选择的实践来检验创新的初级保健实践。将选择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、家庭和社区的需求）进行比较，并选择10个复制案例来证实/否定假设。数据包括经过验证的调查、实施和维持创新的成本、人种学观察和对实践成员和患者的访谈。结果可能对整个美国使用的癌症幸存者护理和PCMH实施策略产生深远影响。

DESCRIPTION: 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.