Medical Assistant–Based Care Management for High-Risk Patients in Small Primary Care Practices

2016 ◽  
Vol 164 (5) ◽  
pp. 323 ◽  
Author(s):  
Tobias Freund ◽  
Frank Peters-Klimm ◽  
Cynthia M. Boyd ◽  
Cornelia Mahler ◽  
Jochen Gensichen ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Care Management ◽  
Medical Assistant ◽  
High Risk Patients ◽  
Small Primary ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices

scholarly journals The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Katrien Danhieux ◽  
Veerle Buffel ◽  
Anthony Pairon ◽  
Asma Benkheil ◽  
Roy Remmen ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Qualitative Study ◽  
Chronic Care ◽  
Self Management ◽  
Management Support ◽  
High Risk Patients ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices

Abstract Background The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for next waves of the pandemic. Methods A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. Twenty-one people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM). Results Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated. Conclusion Our findings show a disruption of the delivery of chronic care in the Belgium prim care context. In such contexts, the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during next waves of the epidemic.

scholarly journals Perceived Susceptibility to Chronic Kidney Disease among High-risk Patients Seen in Primary Care Practices

2009 ◽  
Vol 24 (10) ◽  
pp. 1123-1129 ◽  
Author(s):  
L. Ebony Boulware ◽  
Kathryn A. Carson ◽  
Misty U. Troll ◽  
Neil R. Powe ◽  
Lisa A. Cooper
Keyword(s):  
Primary Care ◽  
Chronic Kidney Disease ◽  
High Risk ◽  
Kidney Disease ◽  
Perceived Susceptibility ◽  
High Risk Patients ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices

scholarly journals The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium

2021 ◽  
Author(s):  
Katrien Danhieux ◽  
Veerle Buffel ◽  
Anthony Pairon ◽  
Asma Benkheil ◽  
Roy Remmen ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Qualitative Study ◽  
Chronic Care ◽  
Self Management ◽  
Management Support ◽  
High Risk Patients ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices

Abstract Background. The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for next waves of the pandemic.Methods. A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. 21 people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM).Results. Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated.Conclusion: Our findings show a disruption of the delivery of chronic care in the Belgium prim care context. In such contexts, the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during next waves of the epidemic.

scholarly journals The Impact of COVID-19 on Chronic Care: A Qualitative Study Among Primary Care Practices in Belgium

2020 ◽  
Author(s):  
Katrien Danhieux ◽  
Veerle Buffel ◽  
Anthony Pairon ◽  
Asma Benkheil ◽  
Roy Remmen ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Qualitative Study ◽  
Chronic Care ◽  
Self Management ◽  
Management Support ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices ◽  
Second Wave

Abstract Background. The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for a second wave or flare-ups of the pandemic.Methods. A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. 21 people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM).Results. Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated.Conclusion: Our findings show the delivery of chronic care as disrupted. It indicates that the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during a second wave or in flare-ups.

scholarly journals Care coordination and provider stress in primary care management of high-risk patients

2017 ◽  
Vol 33 (1) ◽  
pp. 65-71 ◽  
Author(s):  
Adeyemi Okunogbe ◽  
Lisa S. Meredith ◽  
Evelyn T. Chang ◽  
Alissa Simon ◽  
Susan E. Stockdale ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Care Coordination ◽  
Care Management ◽  
High Risk Patients ◽  
Risk Patients ◽  
Primary Care Management

Improving harm reduction with a naloxone intervention in primary care to prescribe and educate a support person

2021 ◽  
Vol 17 (2) ◽  
pp. 109-113
Author(s):  
Julienne K. Kirk, PharmD, CDE, BCPS ◽  
Matthew Q. Tran, PharmD ◽  
Samantha Pelc, PharmD ◽  
Katherine G. Moore, PharmD, BCPS, BCACP
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Family Medicine ◽  
Quality Improvement Intervention ◽  
Opioid Overdose ◽  
Naloxone Administration ◽  
Support Person ◽  
High Risk Patients ◽  
Increased Risk ◽  
Risk Patients

Objective: To determine whether a pharmacist-led intervention would increase the number of naloxone prescriptions and naloxone administration education in a primary care family medicine setting.Design: Prospective quality improvement intervention in an academic family medicine clinic.Methods: We surveyed providers about naloxone knowledge, prescribing habits, and prescribing barriers. We identified patients on chronic opioid therapy, through electronic health records for the year 2019. Overdose risk categories based upon morphine milligram equivalent doses and concomitant benzodiazepine use were used to determine patients who met criteria for naloxone. Pharmacists phoned qualified patients to discuss overdose risk and naloxone benefits. Patients who accepted naloxone prescriptions used their local pharmacy through a department-approved standing order set.Results: From the survey results, there were 47 of 54 provider responses, and the majority noted that they do not routinely prescribe naloxone in high-risk patients. The predominant barriers were lack of time during visit and naloxone administration education. The population of patients from chart review included 93 high-risk patients with a mean age of 58 years. During the time of intervention, 71 patients remained eligible for naloxone coprescribing. Of the patients contacted, 29 (40 percent) accepted the intervention prescription, and subsequently, 22 picked up their prescription from the pharmacy. Sixteen received counseling with a support person. Twelve patients had naloxone already at home, and two received counseling with a support person.Conclusion: The naloxone prescribing intervention is achievable. The results of this intervention support identifying patients at increased risk of opioid overdose and offer education of a support person for naloxone in a large academic family medicine clinic.

Using mHealth tools to improve access, coverage and treatment of uninsured people with high cardiovascular disease risk in Argentina: a study protocol for a pragmatic cluster randomised trial

2018 ◽  
Vol 4 (3) ◽  
pp. 135-141 ◽  
Author(s):  
Shafika Abrahams-Gessel ◽  
Andrea Beratarrechea ◽  
Vilma Irazola ◽  
Laura Gutierrez ◽  
Daniela Moyano ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Primary Care ◽  
High Risk ◽  
Randomised Trial ◽  
Text Messages ◽  
Cluster Randomised Trial ◽  
Cvd Risk ◽  
High Risk Patients ◽  
Cluster Randomised ◽  
Risk Patients

IntroductionCardiovascular disease (CVD) accounts for approximately one-third of Argentina’s deaths. Despite government provision of free primary care health services to the uninsured population, with a focus on non-communicable diseases, screening and management of those with high CVD risk at primary care clinics (PCCs) remain low.Methods and analysisThis pragmatic cluster randomised trial will take place in two provinces of Argentina and will recruit 740 participants. Eight PCCs will be randomised to either the intervention or current practice arm. Community health workers (CHWs) in the intervention arm will be trained to use a set of integrated mHealth tools (a validated risk screening tool mobile application; electronic scheduling system using wireless access to PCCs; and educational text messages) to screen for CVD and to schedule appointments with primary care providers for persons with high CVD risk (≥10%). The primary aims of this study are to determine if the use of mHealth tools will (1) increase attendance of first appointments scheduled by CHWs for persons determined to have high risk for CVD during screening and, (2) lead to an increase in follow-up visits at PCCs by high risk patients. Secondary outcomes include assessing the proportion of high-risk patients receiving appropriate medications and a cost-effective analysis of the intervention.Ethics and disseminationThis study has been approved by the Institutional Review Boards at Partners/Brigham and Women’s Hospital (USA) and the Hospital Italiano de Buenos Aires (Argentina). The open-source software for the mHealth tools will be made publicly available at the end of the study.Trial registration numberNCT02913339.

scholarly journals Uptake and detection rate of a stepwise cardiometabolic disease detection program in primary care—a cohort study

2019 ◽  
Vol 30 (3) ◽  
pp. 402-407
Author(s):  
Daphne M Stol ◽  
Monika Hollander ◽  
Ilse F Badenbroek ◽  
Mark M J Nielen ◽  
François G Schellevis ◽  
...  
Keyword(s):  
Risk Factors ◽  
Primary Care ◽  
Cohort Study ◽  
High Risk ◽  
Newly Diagnosed ◽  
Additional Risk ◽  
High Risk Patients ◽  
Detection Program ◽  
Risk Patients

Abstract Background Early detection and treatment of cardiometabolic diseases (CMD) in high-risk patients is a promising preventive strategy to anticipate the increasing burden of CMD. The Dutch guideline ‘the prevention consultation’ provides a framework for stepwise CMD risk assessment and detection in primary care. The aim of this study was to assess the outcome of this program in terms of newly diagnosed CMD. Methods A cohort study among 30 934 patients, aged 45–70 years without known CMD or CMD risk factors, who were invited for the CMD detection program within 37 general practices. Patients filled out a CMD risk score (step 1), were referred for additional risk profiling in case of high risk (step 2) and received lifestyle advice and (pharmacological) treatment if indicated (step 3). During 1-year follow-up newly diagnosed CMD, prescriptions and abnormal diagnostic tests were assessed. Results Twelve thousand seven hundred and thirty-eight patients filled out the risk score of which 865, 6665 and 5208 had a low, intermediate and high CMD risk, respectively. One thousand seven hundred and fifty-five high-risk patients consulted the general practitioner, in 346 of whom a new CMD was diagnosed. In an additional 422 patients a new prescription and/or abnormal diagnostic test were found. Conclusions Implementation of the CMD detection program resulted in a new CMD diagnosis in one-fifth of high-risk patients who attended the practice for completion of their risk profile. However, the potential yield of the program could be higher given the considerable number of additional risk factors—such as elevated glucose, blood pressure and cholesterol levels—found, requiring active follow-up and presumably treatment in the future.

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