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O'Donnell A.N.,Ann Arbor Center for Clinical Management Research | Williams M.,Health Integrated | Kilbourne A.M.,Ann Arbor Center for Clinical Management Research | Kilbourne A.M.,University of Michigan
Journal of General Internal Medicine | Year: 2013

The Chronic Care Model (CCM) has been shown to improve medical and psychiatric outcomes for persons with mental disorders in primary care settings, and has been proposed as a model to integrate mental health care in the patient-centered medical home under healthcare reform. However, the CCM has not been widely implemented in primary care settings, primarily because of a lack of a comprehensive reimbursement strategy to compensate providers for day-to-day provision of its core components, including care management and provider decision support. Drawing upon the existing literature and regulatory guidelines, we provide a critical analysis of challenges and opportunities in reimbursing CCM components under the current fee-for-service system, and describe an emerging financial model involving bundled payments to support core CCM components to integrate mental health treatment into primary care settings. Ultimately, for the CCM to be used and sustained over time to integrate physical and mental health care, effective reimbursement models will need to be negotiated across payers and providers. Such payments should provide sufficient support for primary care providers to implement practice redesigns around core CCM components, including care management, measurement-based care, and mental health specialist consultation. © 2013 Society of General Internal Medicine.


Tang T.S.,University of British Columbia | Funnell M.,University of Michigan | Sinco B.,University of Michigan | Piatt G.,University of Michigan | And 5 more authors.
Diabetes Care | Year: 2014

OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach intervention in sustaining improvements in HbA1c over 12 months after a 6-month diabetes self-management education (DSME) program. RESEARCH DESIGN AND METHODS One hundred and sixteen Latino adults with type 2 diabetes were recruited froma federally qualified health center and randomized to 1) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2) a 6-month DSME programfollowed by 12 months ofmonthly telephone outreach delivered by CHWs. The primary outcome was HbA1c. Secondary outcomes were cardiovascular disease risk factors, diabetes distress, and diabetes social support. Assessments were conducted at baseline, 6, 12, and 18 months. RESULTS After DSME, the PL group achieved a reduction in mean HbA1c (8.2-7.5% or 66-58 mmol/mol, P < 0.0001) that wasmaintained at 18months (20.6%or26.6mmol/mol from baseline [P = 0.009]). TheCHW group also showed a reduction in HbA1c (7.8 vs. 7.3% or 62 vs. 56 mmol/mol, P = 0.0004) post-6 month DSME; however, it was attenuated at 18 months (20.3% or 23.3 mmol/mol from baseline, within-group P = 0.234). Only the PL group maintained improvements achieved in blood pressure at 18 months. At the 18-month follow-up, both groups maintained improvements in waist circumference, diabetes support, and diabetes distress, with no significant differences between groups. CONCLUSIONS Both low-cost maintenance programs led by either a PL or a CHW maintained improvements in key patient-reported diabetes outcomes, but the PL intervention may have additional benefit in sustaining clinical improvements beyond 12 months. © 2014 by the American Diabetes Association.


Scherer L.D.,Ann Arbor Center for Clinical Management Research | Scherer L.D.,University of Missouri | Zikmund-Fisher B.J.,University of Michigan | Fagerlin A.,Ann Arbor Center for Clinical Management Research | And 2 more authors.
Pediatrics | Year: 2013

BACKGROUND: The factors that drive overtreatment of gastroesophageal reflux disease (GERD) are not well understood, but it has been proposed that the use of the "GERD" disease label could perpetuate use of medication in otherwise healthy infants. METHODS: To determine if use of the disease label GERD influences parents' perceived need to medicate an infant, we surveyed parents in a general pediatric clinic. Parents were given a hypothetical clinical scenario describing an infant who cries and spits up excessively but is otherwise healthy. Using a 2 X 2 factorial design, parents were randomized to receive a scenario in which the doctor either gave a diagnosis of GERD or did not provide a disease label; additionally, half of parents were told that existing medications are probably ineffective, whereas the rest were not given any effectiveness information. We measured parent interest in medication, perception of illness severity, and appreciation of medication offer. RESULTS: Parents who received a GERD diagnosis were interested in medicating their infant, even when they were told that the medications are likely ineffective. However, parents not given a disease label were interested in medication only when medication effectiveness was not discussed (and hence likely assumed). CONCLUSIONS: Labeling an otherwise healthy infant as having a "disease"increased parents' interest in medicating their infant when they were told that medications are ineffective. These findings suggest that use of disease labels may promote overtreatment by causing people to believe that ineffective medications are both useful and necessary. Copyright © 2013 by the American Academy of Pediatrics.


Goldberger Z.D.,University of Washington | Nallamothu B.K.,University of Michigan | Nallamothu B.K.,Ann Arbor Center for Clinical Management Research | Nichol G.,University of Washington | And 3 more authors.
Circulation: Cardiovascular Quality and Outcomes | Year: 2015

Background - A growing number of hospitals have begun to implement policies allowing for family presence during resuscitation (FPDR). However, the overall safety of these policies and their effect on resuscitation care is unknown. Methods and Results - We conducted an observational cohort study of 252 hospitals in the United States with 41 568 adults with cardiac arrest. Multivariable hierarchical regression models were used to evaluate patterns of care at hospitals with and without an FPDR policy. Primary outcomes included return of spontaneous circulation and survival to discharge. Secondary outcomes included resuscitation quality, interventions, and facility-reported potential resuscitation systems errors. There were no significant differences in facility characteristics between hospitals with and without an FPDR policy, nor were there significant differences in return of spontaneous circulation (adjusted risk ratio, 1.02; 95% confidence interval, 0.95-1.06) or survival to discharge (adjusted risk ratio, 1.05; 95% confidence interval, 0.95-1.15). There was a small, borderline significant decrease in the mean time to defibrillation at hospitals with an FPDR policy compared with hospitals without the policy (mean difference, 0.32 minutes; 95% confidence interval, -0.01 to 0.64). Resuscitation quality, interventions, and facility-reported potential resuscitation systems errors did not meaningfully differ between hospitals with and without an FPDR policy. Conclusions - Hospitals with an FPDR policy generally have no statistically significant differences in outcomes and processes of care as hospitals without this policy, suggesting such policies may not negatively affect resuscitation care. Further study is warranted about the direct effect of FPDR attempts on adult patients with an in-hospital cardiac arrest and their families. © 2015 American Heart Association, Inc.


Tang T.S.,University of British Columbia | Funnell M.M.,University of Michigan | Sinco B.,University of Michigan | Spencer M.S.,University of Michigan | And 2 more authors.
Annals of Family Medicine | Year: 2015

PURPOSE We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month peer support intervention with a 3-month DSME program alone in terms of initial and sustained improvements in glycated hemoglobin (HbA1c). Secondary outcomes were risk factors for cardiovascular disease (CVD), diabetes distress, and social support. METHODS We randomized 106 community-dwelling African American adults with type 2 diabetes to a 3-month DSME program followed by 12 months of weekly group sessions and supplementary telephone support delivered by peer leaders or to a 3-month DSME program with no follow-up peer support. Assessments were conducted at baseline, 3, 9, and 15 months. RESULTS No changes in HbA1c were observed at 3 months or at 15 months for either group. The peer support group either sustained improvement in key CVD risk factors or stayed the same while the control group worsened at 15 months. At 15 months, the peer-support group had significantly lower low-density lipoprotein cholesterol levels (-15 mg/dL, P =.03), systolic blood pressure (-10 mm Hg, P =.01), diastolic blood pressure (-8.3 mm Hg, P =.001), and body mass index (-0.8 kg/m2, P =.032) than the DSME-alone group. CONCLUSIONS In this population of African American adults, an initial DSME program, whether or not followed by 12 months of peer support, had no effect on glycemic control. Participants in the peer-support arm of the trial did, however, experience significant improvements in some CVD risk factors or stay approximately the same while the control group declined. © 2015, Annals of Family Medicine, Inc. All rights reserved.


Duffy S.A.,University of Michigan | Scholten R.L.,University of Michigan | Karvonen-Gutierrez C.A.,Ann Arbor Center for Clinical Management Research
Preventive Medicine | Year: 2010

Objective: The objective of this study was to determine if tobacco use while in the hospital was associated with post-discharge cessation rates. Methods: During 2006-2008, smokers from three Veterans Affairs hospitals (n= 354) were surveyed during their hospitalization and again 6 months later. Data analysis was conducted in 2009. Results: While veterans smoked an average of 19 cigarettes per day, prior to admission, the average was 6-7 cigarettes per day during hospitalization. About 40% (n= 140) were able to quit smoking for more than 24 h and the median days quit was 29. The 6-month self-reported quit rate was 15% (n= 53). Multivariate analyses showed that veterans who quit tobacco use during their hospitalization had nearly 4 times increased odds of quitting smoking for more than 24 h and 2.7 times increased odds of quitting at 6 months post-hospitalization as compared to veterans that did not quit using tobacco during hospitalization. Conclusion: Many veterans quit tobacco use during hospital admissions and those who do not quit, tended to decrease their use. Veterans who quit tobacco use were more likely to be abstinent at 6-month follow-up. State-of-the-art cessation interventions need to be provided to smokers hospitalized in Veterans Affairs hospitals. © 2010.


Rosland A.-M.,Ann Arbor Center for Clinical Management Research | Heisler M.,Ann Arbor Center for Clinical Management Research | Heisler M.,University of Michigan | Piette J.D.,Ann Arbor Center for Clinical Management Research
Journal of Behavioral Medicine | Year: 2012

In general, social support from family members affects chronic illness outcomes, but evidence on which specific family behaviors are most important to adult patient outcomes has not been summarized. We systematically reviewed studies examining the effect of specific family member behaviors and communication patterns on adult chronic illness self-management and clinical outcomes. Thirty studies meeting inclusion criteria were identified, representing 22 participant cohorts, and including adults with arthritis, chronic cardiovascular disease, diabetes, and/or end stage renal disease. Family emphasis on self-reliance and personal achievement, family cohesion, and attentive responses to symptoms were associated with better patient outcomes. Critical, overprotective, controlling, and distracting family responses to illness management were associated with negative patient outcomes. Study limitations included cross-sectional designs (11 cohorts); however results from longitudinal studies were similar. Findings suggest that future interventions aiming to improve chronic illness outcomes should emphasize increased family use of attentive coping techniques and family support for the patient's autonomous motivation. © Springer Science+Business Media, LLC 2011.


Noonan D.,University of Michigan | Jiang Y.,University of Michigan | Duffy S.A.,University of Michigan | Duffy S.A.,Ann Arbor Center for Clinical Management Research
Addictive Behaviors | Year: 2013

Research on the validity of self-report tobacco use has varied by the population studied and has yet to be examined among smokers serviced by the Department of Veterans Affairs (VA). The purpose of this study was to determine the predictors of returning a biochemical urine test and the specificity and sensitivity of self-reported tobacco use status compared to biochemical verification. This was a sub-analysis of the larger Tobacco Tactics research study, a pre-/post-non-randomized control design study to implement and evaluate a smoking cessation intervention in three large VA hospitals. Inpatient smokers completed baseline demographic, health history and tobacco use measures. Patients were sent a follow-up survey at six-months to assess tobacco use and urine cotinine levels. A total of 645 patients returned six-month surveys of which 578 also returned a urinary cotinine strip at six-months. Multivariate analysis of the predictors of return rate revealed those more likely to return biochemical verification of their smoking status were younger, more likely to be thinking about quitting smoking, have arthritis, and less likely to have heart disease. The sensitivity and specificity of self-report tobacco use were 97% (95% confidence interval = 0.95-0.98) and 93% (95% confidence interval = 0.84-0.98) respectively. The misclassification rate among self-reported quitters was 21%. The misclassification rate among self-reported tobacco users was 1%. The sensitivity and specificity of self-report tobacco use were high among veteran smokers, yet among self-report quitters that misclassification rate was high at 21% suggesting that validating self-report tobacco measures is warranted in future studies especially in populations that are prone to misclassification. © 2012.


Damschoder L.J.,Ann Arbor Center for Clinical Management Research | Goodrich D.E.,Ann Arbor Center for Clinical Management Research | Robinson C.H.,Ann Arbor Center for Clinical Management Research | Fletcher C.E.,Ann Arbor Center for Clinical Management Research | Lowery J.C.,Ann Arbor Center for Clinical Management Research
BMC Health Services Research | Year: 2011

Background: In January 2006, Veterans Affairs (VA) disseminated the MOVE! Weight Management Program to VA medical centers to address the high prevalence of overweight/obesity. In its second year, MOVE! implementation varied widely across facilities. The objective of this study was to understand contextual factors that facilitated or impeded implementation of MOVE! in VA medical centers in the second year after its dissemination. Methods. We used an embedded mixed methods cross-sectional study design. Qualitative and quantitative data were collected simultaneously with the primary purpose to explore contextual factors most likely to influence MOVE! implementation effectiveness at five purposively selected facilities. Facilities were selected to maximize variation with respect to participation in MOVE! by candidate Veterans. Semi-structured phone interviews were conducted with 24 staff across the five facilities. Quantitative responses were elicited followed by open-ended questions. The quantitative measures were adapted from a published implementation model. Qualitative analysis was conducted using rigorous content analysis methods. Results: Qualitative and quantitative data converged to strengthen findings that point to several recommendations. Management support can help increase visibility of the program, commit needed resources, and communicate the importance of implementation efforts. Establishing a receptive implementation climate can be accomplished by emphasizing the important role that weight management may have in reducing incidence and severity of obesity-related chronic conditions. Coalescing highly functioning multi-disciplinary teams was an essential step for more effective implementation of MOVE!. In some situations, local champions can overcome challenging barriers in facilities that lack sufficient management support. Conclusions: Key organizational factors at local VA medical centers were strongly associated with MOVE! implementation. Results pointed to recommendations that can help accelerate large-scale dissemination of complex weight management programs. © 2011Damschoder et al; licensee BioMed Central Ltd.


Janney C.A.,Ann Arbor Center for Clinical Management Research | Bauer M.S.,Ann Arbor Center for Clinical Management Research | Kilbourne A.M.,Ann Arbor Center for Clinical Management Research
Current psychiatry reports | Year: 2014

This review provides clinicians and individuals with bipolar disorder (BD) with an overview of evidence-based skills shown to be effective in BD and amenable to self-management including psychoeducation; monitoring moods, medications, and social function; sleep hygiene; setting goals and relapse plans; and healthy lifestyles (physical activity, healthy eating, weight loss and management, medical comorbidities). Currently available self-management resources for BD are summarized by mode of delivery (workbooks, mobile technologies, internet, and peer-led interventions). Regardless of the self-management intervention/topic, the research suggests that personally tailored interventions of longer duration and greater frequency may be necessary to achieve the maximal benefit among individuals with BD. Means to support these self-management interventions as self-sustaining identities are critically needed. Hopefully, the recent investment in patient-centered research and care will result in best practices for the self-management of BD by mode of delivery. Since self-management of BD should complement rather than replace medical care, clinicians need to partner with their patients to incorporate and support advances in self-management for individuals with BD.

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