Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness.

To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.

Background Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients' priorities and concerns. Objectives This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients and (b) the methods utilized in its development. Methods Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA Health Care for the Homeless Program. Using Item Response Theory, we examined Test Information Function curves to eliminate less informative items and devise plausibly distinct subscales. Results The resulting 33-item instrument (Primary Care Quality-Homeless, PCQ-H) has four subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items) and Homeless-Specific Needs (4 items). Evidence for divergent and convergent validity is provided. Test Information Function (TIF) graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (alpha=0.75) and patients frequently reported problems in this aspect of care. Conclusions Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development.

The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons’ needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers.

PurposeHomeless individuals face unique challenges in health care. Several US initiatives seeking to advance patient-centered primary care for homeless persons are more likely to succeed if they incorporate the priorities of the patients they are to serve. However, there has been no prior research to elicit their priorities in primary care. This study sought to identify aspects of primary care important to persons familiar with homelessness based on personal experience or professional commitment, and to highlight where the priorities of patients and professionals dedicated to their care converge or diverge.MethodsThis qualitative exercise asked 26 homeless patients and ten provider/experts to rank 16 aspects of primary care using a card sort. Patient-level respondents (n=26) were recruited from homeless service organizations across all regions of the USA and from an established board of homeless service users. Provider/expert-level respondents (n=10) were recruited from veteran and non-veteran-focused homeless health care programs with similar geographic diversity.ResultsBoth groups gave high priority to accessibility, evidence-based care, coordination, and cooperation. Provider/experts endorsed patient control more strongly than patients. Patients ranked information about their care more highly than provider/experts.ConclusionAccessibility and the perception of care based on medical evidence represent priority concerns for homeless patients and provider/experts. Patient control, a concept endorsed by experts, is not strongly endorsed by homeless patients. Understanding how to assure fluid communication, coordination, and team member cooperation could represent more worthy targets for research and quality improvement in this domain.

PurposeIn 1921, Alfred P. Sloan developed an extensive repositioning strategy that was instrumental to General Motors' success over the decades that followed. This paper aims to provide a review of the development and evolution of this strategy and how the later deviation from this strategy was responsible for the company's marketplace decline and eventual bankruptcy.Design/methodology/approachThe paper reviews the historical 1921 repositioning strategy developed by Sloan and the specific models and price levels that were a part of this strategy. These price levels are then examined over the following decades to determine when and how this strategy was modified over time.FindingsThe findings indicate that although Sloan developed a brilliant strategy at the time of its inception, General Motors has over time deviated from its own historic and successful repositioning strategy. It is demonstrated that the deviation from the 1921 strategy has contributed to the decline in General Motors' market share and their bankruptcy in 2009. In addition, the 1921 strategy is compared to those of successful 21st century competition.Originality/valueThe research provides the reader with a historical review and analysis of the Sloan strategy and provides evidence that a historically successful marketing strategy can be applicable in other time periods for the company that developed it and for other competitors that make use of a similar strategy.

Adequate diversity in the leadership of health care organizations is a problem that potentially affects overall performance. In this paper, we propose the application of data envelopment analysis (DEA) and strategic human information systems to determine how diversity affects the efficiency, stability, and long-term viability of health care organizations at the organization level. Data envelopment analysis could also be applied within a given health care organization to examine how the organization's diversity make-up in its various departments affects relative efficiencies across the departments. After presenting a brief introduction of DEA, we provide examples of inputs and outputs used in a proposed DEA analysis.We also propose the use of strategic information systems in health care organizations in developing countries at both organization and departmental levels. We suggest that both developed and developing countries would benefit from using these tools as they seek to control costs and improve health care systems.

Purpose: To determine daily positional variations of the target relative to skeleton during pancreatic IMRT. To assess the dosimetric impact of these variation to target and critical organ. Methods: Eight patients with pancreatic cancer underwent placement of at least 3 gold fiducials by endoscopic ultrasound guidance. Patients were immobilized using alpha‐cradle for gated CT simulation and gated IMRT. Gated CT images were acquired with either prospective gating or retrospective gating (4D‐CT). IMRT was planned and treated at end of expiration. A gated on‐board kilovoltage (kv) image was acquired daily in the treatment position prior to IMRT. The gated kV image was registered with a DRR from the gated CT based on skeletal anatomy. The deviation in fiducial position in anterior‐posterior, superior‐inferior and left‐right directions were recorded. IMRT plans were calculated to estimate change of DVH when patient was shifted with mean daily deviation for each patient. Results: The mean (and range) daily (n=25 fractions) deviation for 8 patients between images based on skeletal fusion and fiducial location were 0.2 cm (0.1–1.0 cm), 0.5 cm (0.2–1.5 cm) and 0.4 cm (0.2–2.0 cm) in the anterior‐posterior, superior‐inferior and left‐right directions. The dose coverage at 95% target volume would decrease by 3.7% (median, ranged 1.5–6.2%; n=8) when patient daily position was not adjusted. The cord max dose would increase by 5.8% (median, range 0.1–26.6%, n=8) when patient daily position was adjusted. The cord dose would not change (median 0% range −1.2–5.1%, n=8) when patient daily position was adjusted only in the S‐I direction. Conclusions: The daily soft‐tissue set‐up variations of target in the treatment of pancreatic cancer were measured. An additional margin is needed around the target when IMRT is delivered using skeletal registration without fiducials. Without real‐time re‐optimization, position adjustment using daily image‐guidance might need compromise between tumor and critical organs.