Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: Experiences from the Ann Arbor Patient-Aligned Care Team Laboratory

Translational Behavioral Medicine

Volumn 1, Issue 4, 2011, Pages 615-623

  Piette, John D ^a,b   Holtz, Bree ^a   Beard, Ashley J ^a,b   Blaum, Caroline ^a,b,c   Greenstone, C Leo ^a,b   Krein, Sarah L ^a,b   Tremblay, Adam ^a,b   Forman, Jane ^a   Kerr, Eve A ^a,b  

^a VA ANN ARBOR HEALTHCARE SYSTEM   (United States)

^b UNIVERSITY OF MICHIGAN MEDICAL SCHOOL   (United States)

^c Ann Arbor VA Geriatric Research Education and Clinical Center   (United States)

Author keywords

Access to care; Chronic disease; Health system change; Information technology; Self management; Telehealth; Veterans

Indexed keywords

CHRONIC DISEASE; CONCEPTUAL FRAMEWORK; HEALTH PROGRAM; HOSPITAL; HUMAN; PATIENT CARE; PATIENT CENTERED MEDICAL HOME PROGRAM; PRIORITY JOURNAL; REVIEW; SELF CARE; VETERAN;

EID: 84862885082     PISSN: 18696716     EISSN: 16139860     Source Type: Journal    
DOI: 10.1007/s13142-011-0065-8     Document Type: Review

References (90)

1. Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Aff (Millwood), 28, 175-185.
2. Chen, E., Thorn, D., Hessler, D., et al. (2010). Using the teamlet model to improve chronic care in an academic primary care practice. Journal of General Internal Medicine, 25(Suppl. 4), 610-614.
3. Ostbye, T., Yarnall, K., Krause, K., Pollack, K., Gradison, M., & Michener, J. (2005). Is there time for management of patients with chronic disease in primary care? Annals of Family Medicine, 3, 209-214.
4. Yarnall, K., Pollack, K., Ostby, T., Krause, K., & Michener, J. (2003). Prmary care: Is there enough time for prevention? American Journal of Public Health, 93(4), 635-641.
5. Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patient with chronic illness: The chronic care model, part 2. Journal of the American Medical Association, 288(15), 1909-1914.
6. McGlynn, E., Asch, S., Adams, J., & Kessesy, J. (2003). The quaity of health care delivered to adults in the United States. The New England Journal of Medicine, 348(26), 2635-2646.
7. Chobanian, A. V., Bakris, G. L., Black, H. R., et al. (2003). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. Journal of the American Medical Association, 289(19), 2560-2571.
8. Boyd, C. M., Darer, J., Boult, C., Fried, L., Boult, L., & Wu, A. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid disease. Journal of the American Medical Association, 294(6), 716-724.
9. Glasgow, R. E., Funnell, M. M., Bonomi, A., Davis, C., Beckham, V., & Wagner, E. H. (2002). Self-management aspects of the improving chronic illness care breakthrough. Annals of Behavioral Medicine, 24(2), 80-87.
10. Barlow, J., Wright, C., Sheasby, J., Turner, A., & Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: A review. Patient Education and Counseling, 48(2), 177-187.
11. Holman, H., & Lorig, K. (2004). Patient self-management: A key to effectiveness and efficiency in care of chronic disease. Public Health Reports, 119(3), 239-243.
12. American College of Physicians (2007) Joint principles of a patient-centered medical home released by organizations representing more than 300, 000 physicians. http://www. acponline. org/pressroom/pcmh. htm. Accessed September 2, 2008.
13. Barr M, Ginsburg J (2008) The advanced medical home: A patient-centered, physician-guided model of health care. www. acponline. org/running_practice/pcmh. Accessed 5 December 2008.
14. Stange, K. C., Nutting, P. A., Miller, W. L., et al. (2010). Defining and measuring the patient-centered medical home. Journal of General Internal Medicine, 25(6), 601-612.
15. Paulus, R., Davis, K., & Steele, G. (2008). Continuous innovation in health care: Implications of the Geisinger Experience. Health Affairs, 27(5), 1235-1245.
16. Reid, R., Fishman, P., Yu, O., et al. (2009). Patient-centered medical home demonstration: A prospective, quasi-experimental before and after evaluation. The American Journal of Managed Care, 15(9), e71-e87.
17. Bitton, A., Martin, C., & Landon, B. E. (2010). A nationwide survey of patient centered medical home demonstration projects. Journal of General Internal Medicine, 25, 584-592.
18. Crabtree, B. F., Chase, S. M., Wise, C. G., et al. (2011). Evaluation of patient centered medical home practice transformation initiatives. Medical Care, 49(1), 10-16.
19. Crabtree, B. F., Nutting, P. A., Miller, W. L., Stange, K. C., Stewart, E. E., & Jaen, C. R. (2010). Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Annals of Family Medicine, 8(Suppl 1), S80-S90. S92.
20. Friedberg, M. W., Safran, D. G., Coltin, K. L., Dresser, M., & Schneider, E. C. (2009). Readiness for the patient-centered medical home: Structural capabilities of Massachusetts primary care practices. Journal of General Internal Medicine, 24(2), 162-169.
21. Miller, W. L., Crabtree, B. F., Nutting, P. A., Stange, K. C., & Jaen, C. R. (2010). Primary care practice development: A relationship-centered approach. Annals of Family Medicine, 8(Suppl 1), S68-S79. S92.
22. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association (2007) Joint Principles of the Patient-Centered Medical Home. http://www. medicalhomeinfo. org/downloads/pdfs/jointstatement. pdf. Accessibility verified 2011.
23. American College of Physicians (2006) The advanced medical home: A patient-centered, physician-guided model of health care. http://www. hhs. gov/healthit/ahic/materials/meeting03/cc/ACP_Initiative. pdf.
24. Affairs USDoV. Patient-Centered Medical Home Concept Paper. Patient Aligned Care Team (PACT) [2010; http://www. va. gov/PrimaryCare/docs/pcmh_ConceptPaper. doc. Accessed March 22, 2011.
25. Homer, C. J., & Baron, R. J. (2010). How to scale up primary care transformation: What we know and what we need to know? Journal of General Internal Medicine, 25(6), 625-629.
26. Takach, M. (2011). Reinventing Medicaid: State innovations to qualify and pay for patient-centered medical homes show promising results. Health Affairs (Millwood), 30(7), 1325-1334.
27. Jaen, C. R., Crabtree, B. F., Palmer, R. F., et al. (2010). Methods for evaluating practice change toward a patient-centered medical home. Annals of Family Medicine, 8(Suppl 1), S9-S20. S92.
28. Jaen, C. R., Ferrer, R. L., Miller, W. L., et al. (2010). Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Annals of Family Medicine, 8(Suppl 1), S57-S67, S92.
29. Nutting, P. A., Crabtree, B. F., Miller, W. L., Stewart, E. E., Stange, K. C., & Jaen, C. R. (2010). Journey to the patient-centered medical home: A qualitative analysis of the experiences of practices in the National Demonstration Project. Annals of Family Medicine, 8(Suppl 1), S45-S56.
30. Stange, K. C., Miller, W. L., Nutting, P. A., Crabtree, B. F., Stewart, E. E., & Jaen, C. R. (2010). Context for understanding the National Demonstration Project and the patient-centered medical home. Annals of Family Medicine, 8(Suppl 1), S2-8.
31. Stewart, E. E., Nutting, P. A., Crabtree, B. F., Stange, K. C., Miller, W. L., & Jaen, C. R. (2010). Implementing the patient-centered medical home: observation and description of the National Demonstration Project. Annals of Family Medicine, 8(Suppl 1), S21-S32.
32. Bojadzievski, T., & Gabbay, R. A. (2011). The patient-centered medical home and diabetes care. Diabetes Care, 34(4), 1047-1053.
33. Nazi, K. M., Hogan, T. P., Wagner, T. H., McInnes, D. K., et al. (2010). Embracing a health services research perspective on personal health records: Lessons learned from the VA My HealtheVet system. Journal of General Internal Medicine, 25(Suppl 25), 62-67.
34. Kilbourne, A., Schulberg, H., Post, E., Rollman, B., Herbeck Belnap, B., & Pincus, H. (2004). Translating evidence-based depression management services to community-based primary care practices. The Milbank Quarterly, 82(4), 631-659.
35. Nobel, J. J., & Norman, G. K. (2003). Emerging information management technologies and the future of disease management. Disease Management, 6(4), 219-231.
36. Wagner, E., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: Translating evidence into action. Health Affairs, 20(6), 64-78.
37. Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. The Milbank Quarterly, 74(4), 511-544.
38. Rice, K., Dewan, N., Bloomfield, H., et al. (2010). Disease management program for chronic obstructive plumonary disease: A randomized controlled trail. American Journal of Respiratory and Critical Care Medicine, 182(7), 890-896.
39. Grumbach K, Grundy P (2010). Outcomes of implemented patient centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. Patient-Centered Primary Care Collaborative. http://www. pcpcc. net/content/pchm-outcome-evidence-quality. Accessed 5 April 2011.
40. Fihn, S. D., McDonell, M., Martin, D., et al. (1993). Risk factors for complications of chronic anticoagulation: A multicenter study. Annals of Internal Medicine, 118(7), 511-520.
41. Brooks, F., Kendall, S., Bunn, F., Bindler, R., & Bruya, M. (2007). The school nurse as navigator of the school health journey: Developing the theory and evidence for policy. Primary Health Care Research and Development, 8, 226-234.
42. Carroll, J. K., Humiston, S. G., Meldrum, S. C., et al. (2010). Patients' experiences with navigation for cancer care. Patient Education and Counseling, 80, 241-247.
43. Druss, B. G., Marcus, S. C., Olfson, M., Tanielian, T., & Pincus, H. A. (2003). Trends in care by nonphysician clinicians in the United States. The New England Journal of Medicine, 348(2), 130-137.
44. Freeman, H., Muth, B., & Kerner, J. (1995). Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Practice, 3(1), 19-30.
45. Robinson-White, S., Conroy, B., Slavish, K., & Rosenzweig, M. (2010). Patient navigator in breast cancer: A systematic review. Cancer Nursing, 33(2), 127-140.
46. Unutzer, J., Rubenstein, L., Katon, W. J., et al. (2001). Two-year effects of quality improvement programs on medication management for depression. Archives of General Psychiatry, 58(10), 935-942.
47. Dohan, D., & Schrag, D. (2005). Using navigators to improve care of underserved patients: current practices and approaches. Cancer, 104, 848-855.
48. Seek, A., & Hogle, W. (2007). Modeling a better way: Navigating the healthcare system for patients with lung cancer. Clinical Journal of Oncology Nursing, 11(1), 81-85.
49. Shockney, L. (2011). Becoming a breast cancer nurse navigator. Sudbury: Jones and Barlett.
50. Ruland, C. M., Holte, H. H., Røislien, J., et al. (2010). Effects of a computer-supported interactive tailored patient assessment tool on patient care, symptom distress, and patients' need for symptom management support: A randomized clinical trial. Journal of the American Medical Informatics Association, 17(4), 403-410.
51. Bosworth, H., Powers, B., & Oddone, E. (2010). Patient self-management support: Novel strategies in hypertension and heart disease. Cardiology Clinic, 28, 655-663.
52. Darkins, A. (2009). Remote patient monitoring in home healthcare: Lessons learned from advanced users. Journal of Management and Marketing in Healthcare, 2, 238-252.
53. Darkins, A. (2009). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine Journal and e-Health, 14, 1118-1126.
54. Inglis, S., Clark, R., McAlister, G., et al. (2010). Structured telephone support or telemonitoring programs for patients with chornic heart failure. Cochrane Database Syst Rev. doi: 10. 1002/14651858. CD007228. pub2.
55. Piette, J. D., Weinberger, M., Kraemer, F. B., & McPhee, S. J. (2001). Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: A randomized controlled trial. Diabetes Care, 24(2), 202-208.
56. Wasson, J., Gaudette, C., Whaley, F., Sauvigne, A., Baribeau, P., & Welch, H. (1992). Telephone care as a substitute for routine clinic follow-up. Journal of the American Medical Association, 267(13), 1788-1793.
57. Darkins, A., Ryan, P., Kobb, R., et al. (2009). Care coordination/Home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine Journal and e-Health, 14(10), 1118-1126.
58. Piette, J. D., Weinberger, M., & McPhee, S. J. (2000). The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Medical Care, 38(2), 218-230.
59. Piette, J. D., Weinberger, M., McPhee, S. J., Mah, C. A., Kraemer, F. B., & Crapo, L. M. (2000). Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? The American Journal of Medicine, 108(1), 20-27.
60. Piette J, Beard A. Automated telephone monitoring and behavior change calls (IVR). Interactive Health Communication Technologies: Promising strategies for health behavior change. (in press).
61. Piette, J., Gregor, M. A., Share, D., Heisler, M., Bernstein, S., Koelling, T., et al. (2008). Improving heart failure self-management support by actively engaging out-of-home caregivers: results of a feasibility study. Congestive Heart Failure, 14(1), 12-18.
62. Heisler M (2006). Building peer support programs to manage chronic disease: seven models for success. pp. 1-41. http://www. chcf. org/topics/chronicdisease/index. cfm?itemID=127997. Accessed 4 May 2011.
63. Boothroyd, R. I., & Fisher, E. B. (2010). Peers for progress: Promoting peer support for health around the world. Family Practice, 27(Suppl 1), i62-i68.
64. Fisher, E. B., Brownson, C. A., O'Toole, M. L., & Anwuri, V. V. (2007). Ongoing follow-up and support for chronic disease management in the Robert Wood Johnson Foundation Diabetes Initiative. The Diabetes Educator, 33(Suppl 6), 201S-207S.
65. Greden, J. F., Valenstein, M., Spinner, J., et al. (2010). Buddy-to-Buddy, a citizen soldier peer support program to counteract stigma, PTSD, depression, and suicide. Annals of the New York Academy of Sciences, 1208, 90-97.
66. Heisler, M., Vijan, S., Makki, F., & Piette, J. D. (2010). Diabetes control with reciprocal peer support versus nurse care management: A randomized trial. Annals of Internal Medicine, 153(8), 507-515.
67. Baksi, A. K. (2010). Experiences in peer-to-peer training in diabetes mellitus: challenges and implications. Family Practice, 27(Suppl 1), i40-45.
68. Travis, J., Roeder, K., Walters, H., et al. (2010). Telephone-based mutual peer support for depression: A pilot study. Chronic Illness, 6(3), 183-191.
69. Davis, K. L., O'Toole, M. L., Brownson, C. A., Llanos, P., & Fisher, E. B. (2007). Teaching how, not what: The contributions of community health workers to diabetes self-management. The Diabetes Educator, 33(Suppl 6), 208S-215S.
70. Schopp, L. H., Hales, J. W., Quetsch, J. L., Hauan, M. J., & Brown, G. D. (2004). Design of a peer-to-peer telerehabilitation model. Telemedicine Journal and e-Health, 10(2), 243-251.
71. Heisler, M., Halasyamani, L., Resnicow, K., et al. (2007). "I am not alone": The feasibility and acceptability of interactive voice response-facilitated telephone peer support among older adults with heart failure. Congestive Heart Failure, 13(3), 149-157.
72. Levine, M. D., Ross, T. R., Balderson, B. H., & Phelan, E. A. (2010). Implementing group medical visits for older adults at group health cooperative. Journal of the American Geriatrics Society, 58(1), 168-172.
73. Heisler, M., & Piette, J. D. (2005). "I help you, and you help me": Facilitated telephone peer support among patients with diabetes. Diabetes Educator, 31(6), 869-879.
74. Kilbourne, A., Flanders McGinnis, G., Herbeck Belnap, B., Klinkman, M., & Thomas, M. (2006). The role of clinical information technology in depression care management. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 54-64.
75. Forster, A. J., Clark, H. D., & Menard, A. (2004). Adverse events affecting medical patients following discharge from hospital. Canadian Medical Association Journal, 170, 3345-3349.
76. Forster, A. J., Murff, H. J., Peterson, J. F., Ghandi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138, 3161-3167.
77. Gonseth, J., Guallar-Castillon, P., Banegas, J. R., & Rodriguez-Artalejo, F. (2004). The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: A systematic review and meta-analysis of published reports. European Heart Journal, 25(18), 1570-1595.
78. Kasper, E., Gerstenblith, G., Hefter, G., et al. (2002). A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission. Journal of the American College of Cardiology, 2002(39), 471-480.
79. Forster, A. J., Boyle, L., Shojania, K. G., Feasby, T. E., & van Walraven, C. (2009). Identifying patients with post-discharge care problems using an interactive voice response system. Journal of General Internal Medicine, 24(4), 520-525.
80. Boyd, C. M., Boult, C., Shadmi, E., et al. (2007). Guided care for multimorbid older adults. Gerontologist, 47, 697-704.
81. Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828.
82. Corrigan, J. M., & Martin, J. B. (1992). Identification of factors associated with hospital readmission and development of a predictive model. Health Services Research, 27(1), 81-101.
83. Weissman, J. S., Ayanian, J. Z., Chasan-Taber, S., Sherwood, M. J., Roth, C., & Epstein, A. M. (1999). Hospital readmissions and quality of care. Medical Care, 37(5), 490-501.
84. Blaum, C. S., Cigolle, C. T., Boyd, C. M., Wolffe, J. L., Tian, Z., Langa, K. M., et al. (2010). Clinical complexity in middle aged and older adults with diabetes: The Health and Retirement Study. Medical Care, 48(4), 327-334.
85. Creswell, J. W., & Clark, V. L. P. (2007). Designing and conducting mixed methods research. Thousand Oaks: Sage Publications, Inc.
86. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, 50.
87. Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7(3), 149-158.
88. Rogers, E. (2003). Diffusion of innovations (5th ed.). New York: Free Press.
89. Pettigrew, A., & Whipp, R. (1992). Managing change and corporate performance. In K. Cool, D. Neven, & I. Walter (Eds.), European industrial restructuring in the 1990s. New York: New York University Press.
90. Barnett, P. (2003). Determination of VA health care costs. Medical Care Research and Review, 60(Suppl. 3), 124S-141S.