Publications by authors named "Larry A Green"

125 Publications

Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond.

J Am Board Fam Med 2021 Feb;34(Suppl):S203-S209

From the Robert Graham Center for Policy Studies in Primary Care, American Academy of Family Physicians, Washington, DC (JMW); Health Systems and Population Health Sciences, University of Houston, College of Medicine, TX (WL); Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo (KG); Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, General Medical Sciences and Sociology, and Case Comprehensive Cancer Center Case, Western Reserve University Cleveland, OH (KS); Farley Health Policy Center, University of Colorado School of Medicine Aurora, CO (LAG, LSH); Center for Professionalism and Value in Health Care, American Board of Family Medicine, Washington, DC (RP, AB); Departments of Family & Community Medicine and Population Health Sciences Lozano Long School of Medicine, University of Texas Health, San Antonio (CRJ); Larry A. Green Center for the Advancement of Primary Health Care for the Public Good, Virginia Commonwealth University, Richmond (KS, RSG); Cuyahoga County Board of Health, Parma, OH (HG); Department of Family Medicine, Oregon Health and Science University, Portland (JD); American Board of Family Medicine (JCP); Center for Community Health Integration, Case Western Reserve University, Cleveland, OH (KS, RSG).

The Coronavirus disease 2019 (COVID-19) pandemic has laid bare the dis-integrated health care system in the United States. Decades of inattention and dwindling support for public health, coupled with declining access to primary care medical services have left many vulnerable communities without adequate COVID-19 response and recovery capacity. "Health is a Community Affair" is a 1966 effort to build and deploy local communities of solution that align public health, primary care, and community organizations to identify health care problem sheds, and activate local asset sheds. After decades of independent effort, the COVID-19 pandemic offers an opportunity to reunite and align the shared goals of public health and primary care. Imagine how different things might look if we had widely implemented the recommendations from the 1966 report? The ideas and concepts laid out in "Health is a Community Affair" still offer a COVID-19 response and recovery approach. By bringing public health and primary care together in community now, a future that includes a shared vision and combined effort may emerge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3122/jabfm.2021.S1.200458DOI Listing
February 2021

Colorado's continuing journey to integrated care: Progress!

Fam Syst Health 2020 09;38(3):323-326

Department of Family Medicine, University of Colorado School of Medicine.

This commentary discusses the journey to integrated behavioral health and primary care in the state of Colorado. The authors discuss integrated care, and the lessons learned by early adopters can help those just getting started. They argue integration is possible in practice settings of all types despite the barriers that exist - but these barriers must continue to be broken down for further scaling and long-term sustainability. While adequate payment, workforce, and data-sharing infrastructure and policy are necessary for scaling and sustainability, they are not sufficient: practice transformation support is crucial for a change this fundamental. Finally, scaling and sustaining integration takes a village; diverse stakeholders across sectors, including payers, clinicians, patients, public health, philanthropy, and policymakers, all have a role to play. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1037/fsh0000526DOI Listing
September 2020

Conditions Influencing Collaboration Among the Primary Care Disciplines as They Prepare the Future Primary Care Physician Workforce.

Fam Med 2020 06 16;52(6):398-407. Epub 2020 Mar 16.

Oregon Health and Science University, Portland, OR.

Background And Objectives: Much can be gained by the three primary care disciplines collaborating on efforts to transform residency training toward interprofessional collaborative practice. We describe findings from a study designed to align primary care disciplines toward implementing interprofessional education.

Methods: In this mixed methods study, we included faculty, residents and other interprofessional learners in family medicine, internal medicine, and pediatrics from nine institutions across the United States. We administered a web-based survey in April/May of 2018 and used qualitative analyses of field notes to study resident exposure to team-based care during training, estimates of career choice in programs that are innovating, and supportive and challenging conditions that influence collaboration among the three disciplines. Complete data capture was attained for 96.3% of participants.

Results: Among family medicine resident graduates, an estimated 87.1% chose to go into primary care compared to 12.4% of internal medicine, and 36.5% of pediatric resident graduates. Qualitative themes found to positively influence cross-disciplinary collaboration included relationship development, communication of shared goals, alignment with health system/other institutional initiatives, and professional identity as primary care physicians. Challenges included expressed concerns by participants that by working together, the disciplines would experience a loss of identity and would be indistinguishable from one another. Another qualitative finding was that overwhelming stressors plague primary care training programs in the current health care climate-a great concern. These include competing demands, disruptive transitions, and lack of resources.

Conclusions: Uniting the primary care disciplines toward educational and clinical transformation toward interprofessional collaborative practice is challenging to accomplish.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.22454/FamMed.2020.741660DOI Listing
June 2020

Proportional Erosion of the Primary Care Physician Workforce Has Continued Since 2010.

Am Fam Physician 2019 08;100(4):211-212

View Article and Find Full Text PDF

Download full-text PDF

Source
August 2019

The Next Generation of Connectivity in Family Medicine Research.

Ann Fam Med 2019 07;17(4):291-292

Department of Family Medicine, School of Medicine, University of Colorado Denver, Aurora, Colorado.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1370/afm.2426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827652PMC
July 2019

Le futur rôle du médecin personnel au Canada: Opinions des résidents, du corps professoral et des médecins communautaires en médecine familiale.

Can Fam Physician 2018 12;64(12):e514-e516

Professeur et titulaire de la Chaire Epperson Zorn pour l'innovation en médecine familiale et en soins primaires à la Faculté de médecine de l'Université du Colorado à Aurora.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371879PMC
December 2018

Future role of the personal physician in Canada: Opinions of family medicine residents, faculty members, and community family physicians.

Can Fam Physician 2018 12;64(12):883-885

Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado School of Medicine in Aurora.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371865PMC
December 2018

Redesigning Residency Training: Summary Findings From the Preparing the Personal Physician for Practice (P4) Project.

Fam Med 2018 07;50(7):503-517

University of Colorado.

Background And Objectives: The Preparing the Personal Physician for Practice (P4) project (2007 to 2014) involved a comparative case study of experiments conducted by 14 selected family medicine programs designed to evaluate new models of residency education that aligned with the patient-centered medical home (PCMH). Changes in length, structure, content, and location of training were studied.

Methods: We conducted both a critical review of P4 published Evaluation Center and site-specific papers and a qualitative narrative analysis of process reports compiled throughout the project. We mapped key findings from P4 to results obtained from a survey of program directors on their top 10 "need to know" areas in family medicine education.

Results: Collectively, 830 unique residents took part in P4, which explored 80 hypotheses regarding 44 innovations. To date, 39 papers have resulted from P4 work, with the P4 Evaluation Center producing 17 manuscripts and faculty at individual sites producing 22 manuscripts. P4 investigators delivered 21 presentations and faculty from P4 participating programs delivered 133 presentations at national meetings. For brevity, we present findings derived from the analyses of project findings according to the following categories: (1) how residency training aligned with PCMH; (2) educational redesign and assessment; (3) methods of financing new residency experiences; (4) length of training; (5) scope of practice; and (6) setting standards for conducting multisite educational research.

Conclusions: The P4 project was a successful model for multisite graduate medical education research. Insights gained from the P4 project could help family medicine educators with future residency program redesign.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.22454/FamMed.2018.829131DOI Listing
July 2018

A qualitative study of patient experiences of care in integrated behavioral health and primary care settings: more similar than different.

Transl Behav Med 2018 09;8(5):649-659

Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.

Integrated behavioral health and primary care is a patient-centered approach designed to address a person's physical, emotional, and social healthcare needs. Increasingly, practices are integrating care to help achieve the Quadruple Aim, yet no studies have examined, using qualitative methods, patients' experiences of care in integrated settings. The purpose of this study was to examine patients' experiences of care in community-based settings integrating behavioral health and primary care. This is a qualitative study of 24 patients receiving care across five practices participating in Advancing Care Together (ACT). ACT was a 4-year demonstration project (2010-2014) of primary care and community mental health centers (CMHCs) integrating care. We conducted in-depth interviews in 2014 and a multidisciplinary team analyzed data using an inductive qualitative descriptive approach. Nineteen patients described receiving integrated care. Both primary care and CMHC patients felt cared for when the full spectrum of their needs, including physical, emotional, and social circumstances, were addressed. Patients perceived personal, interpersonal, and organizational benefits from integrated care. Interactions with integrated team members helped patients develop and/or improve coping skills; patients shared lessons learned with family and friends. Service proximity, provider continuity and trust, and a number of free initial behavioral health appointments supported patient access to, and engagement with, integrated care. In contrast, patients' prior experience, provider "mismatch," clinician turnover, and restrictive insurance coverage presented barriers in accessing and sustaining care. Patients in both primary care and CMHCs perceived similar benefits from integrated care related to personal growth, improved quality, and access to care. Policy makers and practice leadership should attend to proximity, continuity, trust, and cost/coverage as factors that can impede or facilitate engagement with integrated care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/tbm/ibx001DOI Listing
September 2018

Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension.

Health Aff (Millwood) 2018 02;37(2):222-230

Deborah J. Cohen is a professor and vice chair of research in the Department of Family Medicine at Oregon Health & Science University.

Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1377/hlthaff.2017.1100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805471PMC
February 2018

Will people have personal physicians anymore? Dr Ian McWhinney Lecture, 2017.

Authors:
Larry A Green

Can Fam Physician 2017 12;63(12):909-912

Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado School of Medicine.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729133PMC
December 2017

Impact of Residency Training Redesign on Residents' Clinical Knowledge.

Fam Med 2017 Oct;49(9):693-698

Department of Family Medicine, Oregon Health & Science University.

Background And Objectives: The In-training Examination (ITE) is a frequently used method to evaluate family medicine residents' clinical knowledge. We compared family medicine ITE scores among residents who trained in the 14 programs that participated in the Preparing the Personal Physician for Practice (P4) Project to national averages over time, and according to educational innovations.

Methods: The ITE scores of 802 consenting P4 residents who trained in 2007 through 2011 were obtained from the American Board of Family Medicine. The primary analysis involved comparing scores within each academic year (2007 through 2011), according to program year (PGY) for P4 residents to all residents nationally. A secondary analysis compared ITE scores among residents in programs that experimented with length of training and compared scores among residents in programs that offered individualized education options with those that did not.

Results: Release of ITE scores was consented to by 95.5% of residents for this study. Scores of P4 residents were higher compared to national scores in each year. For example, in 2011, the mean P4 score for PGY1 was 401.2, compared to the national average of 386. For PGY2, the mean P4 score was 443.1, compared to the national average of 427, and for PGY3, the mean P4 score was 477.0, compared to the national PGY3 score of 456. Scores of residents in programs that experimented with length of training were similar to those in programs that did not. Scores were also similar between residents in programs with and without individualized education options.

Conclusions: Family medicine residency programs undergoing substantial educational changes, including experiments in length of training and individualized education, did not appear to experience a negative effect on resident's clinical knowledge, as measured by ITE scores. Further research is needed to study the effect of a wide range of residency training innovations on ITE scores over time.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2017

Scope of Practice Among Recent Family Medicine Residency Graduates.

Fam Med 2017 Sep;49(8):607-617

Department of Family Medicine, Oregon Health & Science University.

Background And Objectives: The scope of practice among primary care providers varies, and studies have shown that family physicians' scope may be shrinking. We studied the scope of practice among graduates of residencies associated with Preparing the Personal Physician for Practice (P4) and how length of training and individualized education innovations may influence scope.

Methods: We surveyed graduates 18 months after residency between 2008 and 2014. The survey measured self-reported practice characteristics, scope of practice and career satisfaction. We assessed scope using individual practice components (25 clinical activities, 30 procedures) and a scaled score (P4-SOP) that measured breadth of practice scope. We conducted subgroup analyses according to exposure to innovations over the project period and exposure to specific innovations.

Results: No significant differences were found in mean P4-SOP scores between the Pre and Full P4 groups. Compared to national data, P4 graduates reported higher rates for vaginal deliveries (19.3% vs 9.2%), adult inpatient care (48.5% vs 33.7%) and nursing home care (25.4 vs 11.7%) in practice. Graduates exposed to innovations that lengthened training, compared to standard training length, were more likely to include adult hospital care (58.2% vs 38.5%, P=0.002), adult ICU care (30.6% vs 19.2%, P=0.047) and newborn resuscitation (25.6% vs 14%, P=0.028) in their practice and performed 19/30 procedures at higher rates. Graduates of programs with individualized training innovations reported no significant differences in scope compared to graduates without this innovation.

Conclusions: Graduates of residencies engaged in significant educational redesign report a broad scope of practice. Innovations around the length of training may broaden scope and individualized education appears not to constrict scope.
View Article and Find Full Text PDF

Download full-text PDF

Source
September 2017

Perspectives of an Early Adopter of Family Medicine as a Discipline and a Cause.

Authors:
Larry A Green

Fam Med 2017 Apr;49(4):261-264

Department of Family Medicine, University of Colorado School of Medicine.

View Article and Find Full Text PDF

Download full-text PDF

Source
April 2017

Outcomes of Integrated Behavioral Health with Primary Care.

J Am Board Fam Med 2017 Mar-Apr;30(2):130-139

From the Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, Dallas, TX (BAB, KKJ); the Department of Family Medicine, Oregon Health and Science University, Portland (DJC, MD, RG, KG); and the Department of Family Medicine, University of Colorado School of Medicine, Denver (LMD, FVdG, BFM, LAG).

Background: Integrating behavioral health and primary care is beneficial to patients and health systems. However, for integration to be widely adopted, studies demonstrating its benefits in community practices are needed. The objective of this study was to evaluate effect of integrated care, adapted to local contexts, on depression severity and patients' experience of care.

Methods: This study used a convergent mixed-methods design, merging findings from a quasi-experimental study with patient interviews conducted as part of Advancing Care Together, a community demonstration project that created an innovation incubator for practices implementing evidence-based integration strategies. The study included 475 patients with a 9-item Patient Health Questionnaire (PHQ-9) score ≥10 at baseline, from 5 practices.

Results: Statistically significant reductions in mean PHQ-9 scores were observed in all practices, ranging from 2.72 to 6.46 points. Clinically, 50% of patients had a ≥5-point reduction in PHQ-9 score and 32% had a ≥50% reduction. This finding was corroborated by patient interviews that demonstrated positive experiences with behavioral health clinicians and acquiring new skills to cope with adverse situations at work and home.

Conclusions: Integrating behavioral health and primary care, when adapted to fit into community practices, reduced depression severity and enhanced patients' experience of care. Integration is a worthwhile investment; clinical leaders, policymakers, and payers should support integration in their communities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3122/jabfm.2017.02.160234DOI Listing
December 2017

Varied Rates of Implementation of Patient-Centered Medical Home Features and Residents' Perceptions of Their Importance Based on Practice Experience.

Fam Med 2017 Mar;49(3):183-192

Department of Family Medicine, Oregon Health & Science University.

Background And Objectives: Little is known about how the patient-centered medical home (PCMH) is being implemented in residency practices. We describe both the trends in implementation of PCMH features and the influence that working with PCMH features has on resident attitudes toward their importance in 14 family medicine residencies associated with the P4 Project.

Methods: We assessed 24 residency continuity clinics annually between 2007-2011 on presence or absence of PCMH features. Annual resident surveys (n=690) assessed perceptions of importance of PCMH features using a 4-point scale (not at all important to very important). We used generalized estimating equations logistic regression to assess trends and ordinal-response proportional odds regression models to determine if resident ratings of importance were associated with working with those features during training.

Results: Implementation of electronic health record (EHR) features increased significantly from 2007-2011, such as email communication with patients (33% to 67%), preventive services registries (23% to 64%), chronic disease registries (63% to 82%), and population-based quality assurance (46% to 79%). Team-based care was the only process of care feature to change significantly (54% to 93%). Residents with any exposure to EHR-based features had higher odds of rating the features more important compared to those with no exposure. We observed consistently lower odds of the resident rating process of care features as more important with any exposure compared to no exposure.

Conclusions: Residencies engaged in educational transformation were more successful in implementing EHR-based PCMH features, and exposure during training appears to positively influence resident ratings of importance, while exposure to process of care features are slower to implement with less influence on importance ratings.
View Article and Find Full Text PDF

Download full-text PDF

Source
March 2017

From Our Practices to Yours: Key Messages for the Journey to Integrated Behavioral Health.

J Am Board Fam Med 2017 01;30(1):25-34

From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (SBG, LAG); Department of Family Medicine and Community Health, University of Minnesota School of Medicine, Minneapolis, MN (CJP).

Background: The historic, cultural separation of primary care and behavioral health has caused the spread of integrated care to lag behind other practice transformation efforts. The Advancing Care Together study was a 3-year evaluation of how practices implemented integrated care in their local contexts; at its culmination, practice leaders ("innovators") identified lessons learned to pass on to others.

Methods: Individual feedback from innovators, key messages created by workgroups of innovators and the study team, and a synthesis of key messages from a facilitated discussion were analyzed for themes via immersion/crystallization.

Results: Five key themes were captured: (1) frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care; (2) initialize: define relationships and protocols up-front, understanding they will evolve; (3) build inclusive, empowered teams to provide the foundation for integration; (4) develop a change management strategy of continuous evaluation and course-correction; and (5) use targeted data collection pertinent to integrated care to drive improvement and impart accountability.

Conclusion: Innovators integrating primary care and behavioral health discerned key messages from their practical experience that they felt were worth sharing with others. Their messages present insight into the challenges unique to integrating care beyond other practice transformation efforts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3122/jabfm.2017.01.160100DOI Listing
January 2017

How to write a health policy brief.

Fam Syst Health 2017 Mar 1;35(1):21-24. Epub 2016 Dec 1.

Department of Family Medicine, Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine.

Although many health care professionals are interested in health policy, relatively few have training in how to utilize their clinical experience and scientific knowledge to impact policy. Developing a policy brief is one approach that health professionals may use to draw attention to important evidence that relates to policy. This article offers guidance on how to write a policy brief by outlining 4 steps: (a) define the problem, (b) state the policy, (c) make your case, and (d) discuss the impact. The steps and tips offer a starting point for health care professionals interested in health policy and translating research or clinical experience to impact policy. (PsycINFO Database Record
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1037/fsh0000238DOI Listing
March 2017

Implementation of behavioral health interventions in real world scenarios: Managing complex change.

Fam Syst Health 2017 03 28;35(1):36-45. Epub 2016 Nov 28.

Department of Family Medicine, Oregon Health & Science University.

Introduction: A practice embarks on a radical reformulation of how care is designed and delivered when it decides to integrate medical and behavioral health care for its patients and success depends on managing complex change in a complex system. We examined the ways change is managed when integrating behavioral health and medical care.

Method: Observational cross-case comparative study of 19 primary care and community mental health practices. We collected mixed methods data through practice surveys, observation, and semistructured interviews. We analyzed data using a data-driven, emergent approach.

Results: The change management strategies that leadership employed to manage the changes of integrating behavioral health and medical care included: (a) advocating for a mission and vision focused on integrated care; (b) fostering collaboration, with a focus on population care and a team-based approaches; (c) attending to learning, which includes viewing the change process as continuous, and creating a culture that promoted reflection and continual improvement; (d) using data to manage change, and (e) developing approaches to finance integration.

Discussion: This paper reports the change management strategies employed by practice leaders making changes to integrate care, as observed by independent investigators. We offer an empirically based set of actionable recommendations that are relevant to a range of leaders (policymakers, medical directors) and practice members who wish to effectively manage the complex changes associated with integrated primary care. (PsycINFO Database Record
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1037/fsh0000239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315783PMC
March 2017

Association Between Patient- Centered Medical Home Features and Satisfaction With Family Medicine Residency Training in the US.

Fam Med 2016 Nov;48(10):784-794

Department of Family Medicine, Oregon Health & Science University.

Background And Objectives: Primary care residencies are undergoing dramatic changes because of changing health care systems and evolving demands for updated training models. We examined the relationships between residents' exposures to patient-centered medical home (PCMH) features in their assigned continuity clinics and their satisfaction with training.

Methods: Longitudinal surveys were collected annually from residents evaluating satisfaction with training using a 5-point Likert-type scale (1=very unsatisfied to 5=very satisfied) from 2007 through 2011, and the presence or absence of PCMH features were collected from 24 continuity clinics during the same time period. Odds ratios on residents' overall satisfaction were compared according to whether they had no exposure to PCMH features, some exposure (1-2 years), or full exposure (all 3 or more years).

Results: Fourteen programs and 690 unique residents provided data to this study. Resident satisfaction with training was highest with full exposure for integrated case management compared to no exposure, which occurred in 2010 (OR=2.85, 95% CI=1.40, 5.80). Resident satisfaction was consistently statistically lower with any or full exposure (versus none) to expanded clinic hours in 2007 and 2009 (eg, OR for some exposure in 2009 was 0.31 95% CI=0.19, 0.51, and OR for full exposure 0.28 95% CI=0.16, 0.49). Resident satisfaction for many electronic health record (EHR)-based features tended to be significantly lower with any exposure (some or full) versus no exposure over the study period. For example, the odds ratio for resident satisfaction was significantly lower with any exposure to electronic health records in continuity practice in 2008, 2009, and 2010 (OR for some exposure in 2008 was 0.36; 95% CI=0.19, 0.70, with comparable results in 2009, 2010).

Conclusions: Resident satisfaction with training was inconsistently correlated with exposure to features of PCMH. No correlation between PCMH exposure and resident satisfaction was sustained over time.
View Article and Find Full Text PDF

Download full-text PDF

Source
November 2016

Return-For Good This Time-to Practicing in the Context of Families and Communities.

Ann Fam Med 2016 09;14(5):402-3

Department of Family Medicine, University of Colorado, Denver, Colorado.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1370/afm.1983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394380PMC
September 2016

Donald Iverson, PhD DSc(Hon) (1946-2016).

Support Care Cancer 2016 09;24(9):3679-80

University of Toronto, Toronto, ON, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00520-016-3355-3DOI Listing
September 2016

Reimagining Our Relationships with Patients: A Perspective from the Keystone IV Conference.

J Am Board Fam Med 2016 Jul-Aug;29 Suppl 1:S1-S11

From the Department of Family Medicine, University of Colorado, Denver (LAG); The American Board of Family Medicine, Lexington, KY (JCP).

Substantial efforts to redesign health care delivery are underway in the United States, including primary care, without attention to what has historically been known as "the personal physician." The American Board of Family Medicine Foundation convened the Keystone IV Conference to reflect on the nature of personal doctoring and particularly what promises personal physicians might appropriately make and keep with their patients, going forward in new systems of care. This commentary describes the conference and its participants and provides an overview of manuscripts prepared by attendees that together comprise a written record of the conference. The authors conclude that a properly prepared and positioned personal physician practicing within a modernized primary care platform is a critical means of achieving better health and health care that is affordable, revitalizing the health professions workforce, and restoring population health in the United States. There is urgency to join with patients and colleagues to create the conditions under which people can have a personal physician of their choosing who knows them well, will stick with them as they wish, and be accountable for their receiving care that is appropriate for them as unique persons, with particular goals, preferences, and capabilities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3122/jabfm.2016.S1.160152DOI Listing
December 2017

Maurice Wood: an appreciation.

Authors:
Larry A Green

Br J Gen Pract 2016 May;66(646):262

Professor of Family Medicine, Epperson Zorn Chair for Innovation in Family Medicine and Primary Care, University of Colorado School of Medicine, Colorado, US.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3399/bjgp16X685057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4838433PMC
May 2016

A Model for Catalyzing Educational and Clinical Transformation in Primary Care: Outcomes From a Partnership Among Family Medicine, Internal Medicine, and Pediatrics.

Acad Med 2016 09;91(9):1293-304

M.P. Eiff is professor and vice chair, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. L.A. Green is professor of family medicine, Epperson-Zorn Chair for Innovation in Family Medicine and Primary Care, University of Colorado, Denver, Colorado. E. Holmboe is senior vice president, Milestone Development and Evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois. F.S. McDonald is senior vice president, Academic and Medical Affairs, American Board of Internal Medicine, Philadelphia, Pennsylvania. K. Klink is director, Medical & Dental Education, Department of Veterans Affairs Office of Academic Affiliations, Washington, DC. D.G. Smith is director, Graduate Medical Education, Abington Memorial Hospital, Abington, Pennsylvania, and clinical associate professor of medicine, Temple University School of Medicine, Philadelphia, Pennsylvania. C. Carraccio is vice president, Competency-Based Assessment Program, American Board of Pediatrics, Chapel Hill, North Carolina. R. Harding is research assistant, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. E. Dexter is biostatistician, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. M. Marino is assistant professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. S. Jones is program director, Virginia Commonwealth University-Fairfax Residency Program, Fairfax, Virginia. K. Caverzagie is associate dean for educational strategy, University of Nebraska School of Medicine, Omaha, Nebraska. M. Mustapha is assistant professor, Department of Internal Medicine and Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota. P.A. Carney is professor of family medicine, School of Medicine, and professor of public health, School of Public Health, Oregon Health & Science University, Portland, Oregon.

Purpose: To report findings from a national effort initiated by three primary care certifying boards to catalyze change in primary care training.

Method: In this mixed-method pilot study (2012-2014), 36 faculty in 12 primary care residencies (family medicine, internal medicine, pediatrics) from four institutions participated in a professional development program designed to prepare faculty to accelerate change in primary care residency training by uniting them in a common mission to create effective ambulatory clinical learning environments. Surveys administered at baseline and 12 months after initial training measured changes in faculty members' confidence and skills, continuity clinics, and residency training programs. Feasibility evaluation involved assessing participation. The authors compared quantitative data using Wilcoxon signed-rank and Bhapkar tests. Observational field notes underwent narrative analysis.

Results: Most participants attended two in-person training sessions (92% and 72%, respectively). Between baseline and 12 months, faculty members' confidence in leadership improved significantly for 15/19 (79%) variables assessed; their self-assessed skills improved significantly for 21/22 (95%) competencies. Two medical home domains ("Continuity of Care," "Support/Care Coordination") improved significantly (P < .05) between the two time periods. Analyses of qualitative data revealed that interdisciplinary learning communities formed during the program and served to catalyze transformational change.

Conclusions: Results suggest that improvements in faculty perceptions of confidence and skills occurred and that the creation of interdisciplinary learning communities catalyzed transformation. Lengthening the intervention period, engaging other professions involved in training the primary care workforce, and a more discriminating evaluation design are needed to scale this model nationally.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ACM.0000000000001167DOI Listing
September 2016

A New Foundation for the Delivery and Financing of American Health Care.

Fam Med 2015 Sep;47(8):612-9

Department of Family Medicine, Oregon Health & Science University.

Background And Objectives: For the past decade, primary care practices across America have worked to implement a practice model called the Patient-Centered Medical Home (PCMH) to revitalize practice, better support clinicians and patients, improve efficiency, and facilitate growth in primary care capacity. In spite of substantial progress, this work has not been matched by sufficient change in the payment system to allow these goals to be accomplished. Nevertheless, improving the quality and availability of primary care remains essential to achieving the goals of the Triple Aim (better health care, better population health, and containment of health care costs). For this to occur, the PCMH model of care must be further refined, and the payment system for primary care must be completely restructured. The need for these changes is urgent. In October 2014, the discipline of family medicine announced a comprehensive strategic plan called Family Medicine for America's Health (FMAHealth). FMAHealth proposes to expand the PCMH care model by fully integrating our nation's behavioral/mental health, public health, and primary care systems to create a new foundation for American health care. Accomplishing these ambitious goals will require a broad coalition of private and public interests across the health care disciplines as well as patients, communities, government, and businesses. These changes require additional infrastructure that existing financing systems do not adequately support, so comprehensive payment reform is essential for large-scale dissemination and sustainability of this model. The new payment model must reward value rather than volume of service and must provide a secure financial foundation for practices designed to care for patients and communities at affordable costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
September 2015

Envisioning a New Health Care System for America.

Fam Med 2015 Sep;47(8):598-603

American Board of Family Medicine, Lexington, KY.

Background And Objectives: Between August 2013 and April 2014, eight family medicine organizations convened to develop a strategic plan and communication strategy for how our discipline might partner with patients and communities to build a new foundation for American health care. An outline of this initiative, Family Medicine for America's Health (FMAHealth), was formally announced to the public in October 2014. The purpose of this paper and the five papers to follow is to describe the guiding principles of FMAHealth in greater detail. FMAHealth is taking place at a pivotal point in the history of American health care, when the deficiencies of our overly expensive, underperforming health care delivery system are becoming more apparent than ever. By forming strategic partnerships to implement this initiative, family medicine seeks to define a new approach to health system leadership, care delivery, education, and research. This will require substantial reorientation of existing priorities and reimbursement systems, which are focused on delivering services, instead of on improving health. Family medicine is committed to engaging and empowering patients, their families and communities, and other health care professionals to establish a more equitable, effective, and efficient delivery system--a system in which health is the primary design element and the "Triple Aim" is the guiding principle.
View Article and Find Full Text PDF

Download full-text PDF

Source
September 2015

The American Board of Family Medicine Foundation Inaugurates the G. Gayle Stephens Keystone Conference Series.

J Am Board Fam Med 2015 Jul-Aug;28(4):538-9

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3122/jabfm.2015.04.150156DOI Listing
April 2016

Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program.

J Am Board Fam Med 2015 Sep-Oct;28 Suppl 1:S86-97

From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).

Purpose: Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions.

Methods: Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention.

Results: Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions.

Conclusions: ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim-oriented reimbursement and purchasing mechanisms are likely needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3122/jabfm.2015.S1.150052DOI Listing
June 2016

Understanding Care Integration from the Ground Up: Five Organizing Constructs that Shape Integrated Practices.

J Am Board Fam Med 2015 Sep-Oct;28 Suppl 1:S7-20

From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).

Purpose: To provide empirical evidence on key organizing constructs shaping practical, real-world integration of behavior health and primary care to comprehensively address patients' medical, emotional, and behavioral health needs.

Methods: In a comparative case study using an immersion-crystallization approach, a multidisciplinary team analyzed data from observations of practice operations, interviews, and surveys of practice members, and implementation diaries. Practices were drawn from 2 studies of practices attempting to integrate behavioral health and primary care: Advancing Care Together, a demonstration project of 11 practices located in Colorado, and the Integration Workforce Study, a study of 8 practices across the United States.

Results: We identified 5 key organizing constructs influencing integration of primary care and behavioral health: 1) Integration REACH (the extent to which the integration program was delivered to the identified target population), 2) establishment of continuum of care pathways addressing the location of care across the range of patient's severity of illness, 3) approach to patient transitions: referrals or warm handoffs, 4) location of the integration workforce, and 5) participants' mental model for integration. These constructs intertwine within an organization's historic and social context to produce locally adapted approaches to integrating care. Contextual factors, particularly practice type, influenced whether specialty mental health and substance use services were colocated within an organization.

Conclusion: Interaction among 5 organizing constructs and practice context produces diverse expressions of integrated care. These constructs provide a framework for understanding how primary care and behavioral health services can be integrated in routine practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3122/jabfm.2015.S1.150050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304938PMC
June 2016