PCMH Implementation Strategies: Implications for Cancer Survivor Care

描述：癌症诊断和治疗的成功导致长期癌症幸存者的数量急剧增加。事实上，在过去的20年里，在初级保健实践中接受护理的患者发生了巨大的变化，比如患有复杂的共病的癌症幸存者。大多数就诊不是针对急性或单一慢性疾病，现在大多数就诊是针对具有复杂疾病和需求的患者。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。以病人为中心的医疗之家（PCMH）旨在提高初级保健的质量和安全，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，但尚不清楚PCMH是否能提高癌症幸存者等复杂患者的质量。事实上，PCMH属性对于满足癌症幸存者的需求至关重要，是最具挑战性的实施：重新定位到人口的角度，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，实践根据主导目标自组织，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，实践自组织以最大限度地实现这一目标。同样，如果照顾个人，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，结果可能是PCMH，但CS表明它们可能进化为具有非常不同的照顾癌症幸存者的能力。为了识别和描述PCMH如何成功地实现癌症幸存者护理所需的挑战性属性，我们使用CS框架进行比较案例研究的做法，使用不同的PCMH实施策略：一些侧重于NCQA 3级PCMH的认可和其他人专注于照顾个人，家庭和社区。我们研究创新的初级保健做法，采用混合方法比较案例研究设计与做法，从国家名单中选择的创新做法。将选择10种做法的初始样本（5种寻求NCQA三级认可，5种寻求满足个人、家庭和社区的需求）进行比较，并选择10种重复案例来证实/否定假设。数据包括有效的调查，实施和维持创新的成本，以及人种学观察和采访的实践成员和病人。结果可能会产生深远的影响癌症幸存者护理和PCMH实施策略在美国各地使用。

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.