JOURNAL OF AMBULATORY CARE MANAGEMENT最新文献

Children with complex medical conditions (CCMC) face substantial health challenges, high health care utilization and costs, and an elevated risk of adverse events. CCMC families experience barriers to optimal care, including financial difficulties, unmet medical needs, a lack of care coordination, and limited access to mental health services. This paper explores key systemic challenges in delivering high-quality, cost-effective care to CCMC and proposes 3 targeted strategies to improve care delivery and reduce avoidable spending: (1) bridging clinical care by ensuring 24/7 access to clinicians familiar with the child's needs, (2) using technology such as telehealth, mobile apps, and referral platforms to improve care coordination and access, and (3) prioritizing mental health through partnering with family-centered behavioral health services. While comprehensive policy reforms remain essential, this paper highlights pragmatic solutions that health care systems, government services, and technology companies can implement collaboratively to address the unmet care demands, improve patient outcomes, and enhance cost efficiency.

Objective: Sustaining evidence-based interventions in health care delivery organizations are a well-known challenge. Failure to sustain evidence-based interventions wastes resources, diminishes access to high-quality care for patients and negatively affects quality outcomes, and leaves a residue of disillusionment among organizational members that hinder future efforts to implement other evidence-based interventions. The purpose of this study was to identify characteristics associated with sustainability capacity in a group of primary care clinics implementing the evidence-based heart health improvement program (HHIP).

Methods: We used mixed methods that included validated cross-sectional surveys and semi-structured interviews administered throughout 2023-2024 among 23 primary care clinics. Univariate and ordinary least squares regression models were used to describe the level of capacity across seven different dimensions of sustainability and their relationship with organizational characteristics. Quantitative relationships were considered statistically significant at P ≤ .05. A framework-guided analysis was applied to 6 interviews with clinic leaders and staff to identify thematic barriers to sustainability.

Results: Study participants reported relatively high levels of capacity to sustain the HHIP (range of 5.46-6.00, on a scale of 1-7), with the outcomes and effectiveness dimension rated highest and engaged staff rated lowest. The baseline level of organizational readiness to implement change was most consistently and positively related to sustainability capacity (5 of 7 dimensions). FQHCs (relative to non-FQHCs) and clinic leaders (relative to clinicians and clinic staff) were associated with higher ratings of 3 operationally focused dimensions of sustainability capacity (implementation and training, monitoring and evaluation, and outcomes and effectiveness).

Conclusions: Despite generally positive perceptions of clinic capacity to sustain the HHIP, our analysis highlights general opportunities to build capacity to sustain evidence-based practices in primary care settings (cultivate readiness to change among clinic members) and places where focused efforts may do the same (target organizational-cultural dimensions of sustainability capacity, non-FQHCs).

Community Health Centers (CHCs) provide care to 32.5 million low-income patients across high need areas, forming the largest primary care network in the US. CHCs consistently improve outcomes and lower costs, yet face growing financial stress. Rising demand, workforce shortages, and uncompensated care costs are stretching limited budgets at CHCs, while Medicaid payments and federal funding do not reflect the true cost of care. Many CHCs lack financial reserves to modernize or join new payment models. This article argues for long-term investments to maintain access to affordable and comprehensive primary care.

Community health workers (CHWs) play a vital role in advancing health equity, improving health outcomes, and addressing the social determinants of health. However, funding for CHW positions and supportive policy infrastructure to sustain a thriving CHW workforce remain elusive. This commentary provides a definition of CHW workforce sustainability and an overview of how a CHW-led national training and technical assistance center used a community organizing framework to build the capacity of CHWs and their allies to advance local sustainability efforts. The model includes four key objectives: (1) grow CHW leadership and policy capacity, (2) build strong relationships and partnerships, (3) establish supportive systems and policies, and (4) implement diverse financing mechanisms. It also offers a conceptual model to illustrate the steps CHWs can take to lead local efforts to advance CHW workforce sustainability.

Health systems are mandated to report on quality of care provided to older patients. However, reporting on quality of care remains challenging. The coordinating center for a practice-based research network collaborated with primary care practices to develop tools to facilitate data collection and reporting of age-friendly quality-of-care measures. Three practices informed design of the toolkit. Six additional practices (9 practices total) used the toolkit to report measurement data with technical assistance. All practices reported that quality-of-care assessment using the toolkit was feasible and acceptable. Providing tools and technical assistance are effective strategies for enabling primary care practices to report age-friendly quality metrics.

Objective: Community health centers (CHCs) are a vital safety net for under-resourced and medically underserved patients. As few studies have explored how they implemented broad-based organizational changes throughout the COVID-19 pandemic, we aimed to qualitatively examine CHCs' longitudinal, comprehensive pandemic response through the perspectives of staff, administrators, and researchers working in CHCs.

Methods: 25 clinic leaders, staff, and researchers from three CHC networks and two academic medical centers in Northern California and the Central Valley of California participated in 18 focus groups and interviews between April and October 2022. We used thematic content analysis to identify key themes.

Results: Key themes emerged for three pandemic phases: shutdown, pivot, and recovery. During the shutdown, CHCs paused non-urgent services and in-person outreach while facing increased strain on staff capacity. Although CHCs were traditionally siloed, the pivot phase yielded efforts to build trust through information dissemination, partnerships with other health care organizations, and unprecedented innovations in care delivery. During recovery, CHCs re-prioritized preventive care but continued to face poor access to specialty care and socioeconomic resources for their patients.

Conclusions: The COVID-19 pandemic magnified extant barriers within CHCs, including limitations in funding, staff capacity, and infrastructure for collaboration. CHC constituents highlight lessons learned through organization-wide adaptations and opportunities for the continuation and expansion of pandemic-related changes (e.g., investments in CHCs' workforce, care delivery infrastructure, and avenues for multidisciplinary collaboration) to better serve their communities in the post-COVID era.

Background: Emergency department (ED) crowding is a persistent issue in health care, resulting in increased mortality and medical errors. This challenge is particularly pronounced in underserved populations, where a higher prevalence of chronic conditions and ED utilization exacerbates gaps in care. To address this, system-level strategies, including the establishment of intermediate care clinics, are essential. This study evaluates the first three years of a nurse-led ambulatory intermediate care clinic (AICC) in the Southern US, focusing on its role in enhancing care continuity and operational challenges for expansion.

Methods: This study, conducted at the University of Alabama at Birmingham Medical Center in Birmingham, Alabama, the United States, used a convergent parallel mixed-methods design, analyzing quantitative data from 3137 AICC appointment records (May 2020-June 2023) and conducting qualitative interviews with AICC staff members. Quantitative data included patient demographics and appointment characteristics. Qualitative data were thematically analyzed to identify common themes around AICC benefits and challenges.

Results: Our quantitative analysis showed that the AICC managed an increasing number of patient visits with a stable appointment adherence rate. However, rising clinic-initiated cancellations indicated resource limitations. Qualitative findings provided further context for these quantitative trends. Patients from racial minority groups and those with Medicaid insurance had significantly higher odds of missing appointments. The results highlighted the AICC's value in preventing ED visits but also revealed challenges related to patient acuity level, resource allocation, scheduling complexities, and appointment adherence barriers.

Conclusions: Establishing a nurse-led AICC is feasible and beneficial in alleviating the care gap between primary and acute care and reducing ED crowding. Key considerations for sustainable success include determining patient acuity thresholds, streamlining same-day referral processes, and addressing capacity issues. These findings can guide health systems in implementing intermediate care clinics in ambulatory settings, particularly for those serving underserved communities.