Impact of Primary Care Clinician Interdependence and Coordination on Quality of Care Delivered to Complex Older Patients with Diabetes

初级保健临床医生相互依赖和协调对复杂老年糖尿病患者护理质量的影响

• 批准号: 9908029
• 负责人: Christine M Everett
• 金额: $ 12.23万
• 依托单位: DUKE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-08-01 至 2022-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9908029
• 关键词: Address; Aging; Americas; Area; Caring; Case Manager; Chronic Disease; Clinic; Clinical; Clinical Pathways; Clinical Research; Communication; Complement; Complex; Coupled; Data; Development; Diabetes Mellitus; Disease Management; Elderly; Electronic Health Record; Foundations; Goals; Growth; Health; Health Policy; Health Professional; Health Services; Health Services Research; Intervention; Intervention Trial; Interview; Knowledge; Lipids; Measures; Mediating; Mediation; Medical; Medical Care Team; Medical Records; Mentors; Mentorship; Methods; Modeling; North Carolina; Nurse Practitioners; Outcome; Patient Care; Patient-Focused Outcomes; Patients; Physician Assistants; Physicians; Population; Positioning Attribute; Prevalence; Primary Care Physician; Primary Health Care; Psychology; Quality of Care; Regression Analysis; Research; Research Methodology; Research Personnel; Research Training; Role; Sampling; Services; Specialist; Surveys; Testing; Training; Universities; Work; aging population; base; care coordination; care delivery; career development; comparative effectiveness study; design; electronic data; experience; human old age (65+); implementation science; improved; meetings; multiple chronic conditions; older patient; phase 1 study; pre-clinical; skills; social; success; successful intervention; theories

ABSTRACT A shortage of primary care physicians makes it difficult to deliver quality diabetes care to America’s aging population. A frequently recommended approach to compensate for escalating primary care physician shortages, while still meeting the chronic illness care needs of an aging population, is to incorporate physician assistants (PAs) and nurse practitioners (NPs) into primary care teams. While a number of team models incorporating PA&NPs have delivered quality care to patients with chronic illnesses such as diabetes, data is limited regarding which clinician team approaches are most effective. Identifying effective approaches to incorporating PA&NPs into primary care teams that care for older patients will require identification of effective PA&NP roles, as well as features of PA&NP and physician interaction (interdependence and coordination) that can improve patient outcomes. Interdependence between primary care PA&NPs and physicians occurs when they provide care to, or “share” common patients. Managing shared patients between clinicians requires coordination. Coordination can be accomplished through multiple methods including routines (ex: clinical pathways), boundary spanners (ex: case managers), team meetings (ex: huddles), and relational coordination (i.e., communication and relationships) and is believed to be a key mechanism by which clinician teams will improve patient outcomes, particularly for older, complex patients with multiple chronic conditions. Focus has been placed on improving patient outcomes by coordinating care between settings, such as between specialists and primary care. To our knowledge, however, no studies have evaluated the impact of interdependence and/or coordination within primary care on patient diabetes outcomes such as glycemic and lipid control or development of patient treatment goals. My long-term goal is to improve chronic illness care for older complex patients through identification and implementation of effective primary care teams. In order to develop and evaluate team interventions, it is critical to address the medical and social aspects of team-based care delivery. Designing and evaluating interventions that address both aspects of team care require a range of knowledge and skills, including expertise in mixed methods research approaches, organizational theory, and implementation science. The objective of this application is to determine if PA&NP and physician interaction (interdependence and coordination) on teams impacts outcomes for older patients with diabetes. My health policy background, clinical experience as a PA, and formal quantitative research training will provide the foundation for the proposed project. I will pursue career development in mixed methods, and implementation science and organizational theory at both Duke University and the University of North Carolina Chapel Hill (UNC). The specific aims of the proposed project are to describe the methods of coordination utilized between PA&NPs and physicians on primary care teams (Aim 1), to evaluate the relationship between the interdependence of PA&NPs and physicians on primary care teams and outcomes (glycemic and lipid control as well as patient treatment goals) for older patients with diabetes (Aim 2), and to determine if methods of coordination mediate the relationship between PA&NP role, interdependence and outcomes for older patients with diabetes (Aim 3). To achieve these aims, I propose a mixed methods approach. I will collaborate with Duke Primary Care to conduct interviews and surveys with health care professionals from Duke’s clinics regarding the full range of coordination mechanisms used within their teams and practices (Aim 1). This information will be combined with data derived from electronic health records for medically complex patients over the age of 65 with diabetes in order to match PA&NP and physician interactions (Aim 2) with patient outcomes (Aim 3). Synthesis of Aims 1-3 will inform development of a primary care team-based intervention involving clinician interdependence and coordination for an R01 proposal aimed at improving chronic disease management in complex older patients with diabetes. This proposal sets forth essential development steps that are analogous to preclinical/phase 1 studies that are pivotal to guide later successful intervention trials. Skills gained in organizational psychology, mixed methods and implementation science will complement my prior clinical and research training to position me for success as an independent health services researcher with the skills to design and implement health care teams that improve chronic disease management for complex older patients.

摘要 初级保健医生的短缺使得很难向美国的糖尿病患者提供高质量的糖尿病护理。 人口老龄化一种经常推荐的方法，以补偿不断升级的初级保健医生 在满足老龄化人口慢性病护理需求的同时， 助理（PA）和执业护士（NP）到初级保健团队。虽然一些团队模型 合并PA和NP为糖尿病等慢性病患者提供了优质护理，数据 关于哪种临床医生团队方法最有效的限制。确定有效办法， 将PA和NP纳入照顾老年患者的初级保健团队将需要识别有效的 PA和NP角色，以及PA和NP与医生互动的特征（相互依存和协调）， 可以改善患者的预后。 初级保健PA和NP与医生之间的相互依赖发生在他们向以下人员提供护理时，或 “分享”共同的病人。管理临床医生之间共享的患者需要协调。协调 可以通过多种方法完成，包括常规（例如：临床路径）、边界空间 (ex：个案经理）、团队会议（例如：秘密会议）和关系协调（即，沟通和 关系）并且被认为是临床医生团队将改善患者结果的关键机制， 特别是对于患有多种慢性病的老年复杂患者。重点放在改善 通过协调不同机构之间的护理，例如专家和初级护理之间的护理，改善患者的预后。到 然而，据我们所知，没有研究评估了内部相互依存和/或协调的影响。 对患者糖尿病结局的初级护理，如血糖和血脂控制或患者的发展 治疗目标。 我的长期目标是通过识别， 并建立有效的初级保健团队。为了制定和评估团队干预措施， 关键是要解决医疗和社会方面的团队为基础的护理提供。设计和评估 针对团队护理两个方面的干预措施需要一系列知识和技能，包括 在混合方法研究方法，组织理论和实施科学的专业知识。的 本申请的目的是确定PA&NP和医生的相互作用（相互依赖性和 协调）影响老年糖尿病患者的结果。我的健康政策背景， 作为PA的临床经验和正式的定量研究培训将为 拟议项目。我将追求职业发展的混合方法，并实施科学和 组织理论在杜克大学和北卡罗来纳州查佩尔山大学（北卡罗来纳州）。 拟议项目的具体目标是描述在以下方面使用的协调方法： PA& NP和初级保健团队的医生（目标1），以评估 PA& NP和医生对初级保健团队和结果（血糖和血脂控制）的相互依赖性 以及患者治疗目标），并确定是否有方法 协调调节PA和NP角色之间的关系，相互依赖性和老年患者的结果 患有糖尿病（目标3）。为了实现这些目标，我提出了一个混合方法的方法。我将与 杜克初级保健与来自杜克诊所的医疗保健专业人员进行访谈和调查 关于在其团队和实践中使用的各种协调机制（目标1）。这 信息将与来自医学复杂患者的电子健康记录的数据相结合 65岁以上的糖尿病患者，以匹配PA&NP和医生互动（目标2）与患者 （目标3）。 目标1-3的综合将为基于初级保健团队的干预措施的制定提供信息， 临床医生的相互依赖和协调，以改善慢性病的R 01提案 复杂的老年糖尿病患者的管理。该提案提出了基本的发展步骤 类似于临床前/1期研究，这些研究对指导后来成功的干预试验至关重要。 在组织心理学，混合方法和实施科学获得的技能将补充我的 之前的临床和研究培训，使我能够成功地成为一名独立的卫生服务研究人员 具有设计和实施医疗保健团队的技能，可以改善慢性病管理， 复杂的老年患者。

项目成果

Teaming up in primary care: Membership boundaries, interdependence, and coordination.

• DOI: 10.1097/01.jaa.0000805840.00477.58
• 发表时间: 2022-02-01
• 期刊: JAAPA-JOURNAL OF THE AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS
• 影响因子: 1.1
• 作者: Everett, Christine M.;Docherty, Sharron L.;Matheson, Elaine;Morgan, Perri A.;Price, Ashley;Christy, Jacob;Michener, Lloyd;Smith, Valerie A.;Anderson, John B., Jr.;Viera, Anthony;Jackson, George L.
• 通讯作者: Jackson, George L.

Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study.

• DOI: 10.1136/bmjoq-2022-002229
• 发表时间: 2023-06
• 期刊: BMJ open quality
• 影响因子: 1.4