Impact of a Team-based Approach to Primary Care: A Natural Experiment in Primary Care Redesign

 该K 08 AHRQ以患者为中心的成果研究（PCOR）指导临床研究者奖的目的是建立Anita Misra-Hebert博士作为研究重新设计初级保健提供系统的自然实验的独立研究者。她的目标是发展实施科学定量和定性研究方法的高水平技能，重点是定义可能促进在不同实践环境中特定初级保健重新设计工作成功或失败的背景因素。Misra-Hebert博士将通过正式和非正式的教育方案以及在本项目期间与导师的密切合作，获得变革和组织振兴方案初级保健重新设计方面的实用专业知识。Kurt Stange博士，她的主要研究导师，是一位公认的初级保健实践重新设计背景因素研究专家。她的共同导师包括大卫阿隆博士，在实施科学研究方法的公认专家，迈克尔·罗斯伯格博士，定量研究方法的专家，特别是与大型数据集的观察性研究，和亚当Perzynski博士，社会学家和定性和定量研究方法的专家。Cleveland Clinic位于俄亥俄州的克利夫兰，是一家非营利性的多专业学术医疗中心，将临床和医院护理与研究和教育相结合，是美国最大和最受尊敬的医院之一。Cleveland Clinic是一个团体诊所。工作人员中的医生是领薪雇员，不是私人执业。实践的结构是为了补充小组实践模式。克利夫兰诊所的医学研究所正在领导整个机构的努力，以促进患者护理的价值为基础的护理举措。医学研究所基于价值的护理研究中心专门从事卫生服务和临床研究，涉及可以提高质量，降低成本或两者兼而有之的新型护理方法。该中心包括4名主要研究人员，护士，统计学家和研究助理，以及来自克利夫兰诊所的附属卫生服务研究人员。Misra-Hebert博士将在这种环境中得到充分支持，以进行研究，评估初级保健重新设计工作的最佳做法。克利夫兰诊所及其医学研究所支持Misra-Hebert博士的研究和开发的能力得到了克利夫兰临床与转化科学合作组织的极大增强，该组织为她的指导团队所代表的机构提供协作临床研究支持和基础设施。研究项目本研究的目的是提供证据的最佳实践，以团队为基础的初级保健与评估的背景因素，在实施初级保健重新设计的努力。随着医疗保健服务的复杂性增加，初级保健正在从单个临床医生向单个患者提供护理的护理模式转变为基于团队的护理模式。为了了解这些新模式是否真的提高了护理服务的价值，重要的是要衡量与患者相关的结果和那些特定的基于团队的护理。团队方法需要根据不同的背景因素进行优化。最初的项目将侧重于评估与特定团队重新设计工作相关的背景因素，与常规护理相比，该工作涉及医疗助理的增强作用，并将包括对患者和提供者经验的评估。本研究的具体目的如下：目的1：评估以病人为中心的临床护理质量的结果在团队为基础的护理医疗助理模式（TBC-MA）相比，通常的护理。目标2：确定有助于持续实施TBC-MA模式的背景因素（患者，提供者，实践）。目的3：评估TBC-MA模式与常规护理相比的患者和提供者经验。在职业发展奖的后期工作将包括基于团队的护理的纵向影响的研究，并重新设计实施，涉及非临床医生护理团队成员在改善初级保健患者的护理协调。

 DESCRIPTION (provided by applicant): The purpose of this K08 AHRQ Patient-Centered Outcomes Research (PCOR) Mentored Clinical Investigator Award is to establish Dr. Anita Misra-Hebert as an independent investigator studying natural experiments in redesigning primary care delivery systems. Her goal is to develop high-level skills in implementation science quantitative and qualitative research methods, with an emphasis on defining contextual factors that may promote success or failure of specific primary care redesign efforts in diverse practice settings. Dr. Misra-Hebert will gain practical expertise in PCOR primary care redesign through both formal and informal educational programs and through close work with her mentors during this project. Dr. Kurt Stange, her primary research mentor, is a recognized expert in the study of contextual factors in primary care practice redesign. Her co-mentors include Dr. David Aron, a recognized expert in implementation science research methods, Dr. Michael Rothberg, an expert in quantitative research methods, specifically related to observational studies with large datasets, and Dr. Adam Perzynski, a sociologist and an expert in qualitative and quantitative research methods. Environment Located in Cleveland, Ohio, Cleveland Clinic is a nonprofit, multispecialty academic medical center that integrates clinical and hospital care with research and education, and one of the largest and most respected hospitals in the country. Cleveland Clinic is structured as a group practice. The physicians on staff are salaried employees and are not in private practice. The practice is structured to complement the group practice model. The Medicine Institute at Cleveland Clinic is leading efforts across the institution to promote value-based care initiatives for patient care. The Medicine Institute Center for Value-Based Care Research specializes in health services and clinical research regarding novel approaches to care that can improve quality, reduce cost, or both. The Center includes 4 primary investigators, nurses, statisticians and research assistants, as well as affiliated health services researchers from across the Cleveland Clinic. Dr. Misra-Hebert will be fully supported in this environment to conduct research to evaluate best practices in primary care redesign efforts. The ability of the Cleveland Clinic and its Medicine Institute to support Dr. Misra-Hebert's research and development is greatly enhanced by the Cleveland Clinical & Translational Science Collaborative, which provides collaborative clinical research support and infrastructure across the institutions represented on her mentoring team. Research Project This goal of this study is to provide evidence of best practices for the delivery of team-based primary care with evaluation of contextual factors in the implementation of primary care redesign efforts. As the complexity of healthcare delivery increases, primary care is moving from a model of care delivery in which individual clinicians provide care to individual patients to team-based care models. To understand whether these new models have actually improved value in care delivery, it will be important to measure outcomes relevant to patients and those specific to team-based care. Team approaches will need to be optimized based on diverse contextual factors. The initial project will focus on the evaluation of contextual factors relevant to a specific team-based redesign effort involving an enhanced role of medical assistants compared to usual care and will include evaluation of patient and provider experience. The specific aims of the proposed research are as follows: Aim 1: To evaluate patient-centered clinical quality of care outcomes in the team-based care-medical assistant model (TBC-MA) compared to usual care. Aim 2: To identify contextual factors (patient, provider, practice) that contribute to the sustained implementation of the TBC-MA model. Aim 3: To assess patient and provider experience in the TBC-MA model compared to usual care. Later work during the career development award will include study of the longitudinal effects of team-based care, and redesign implementation that involves non-clinician care team members in improving care coordination for primary care patients.