While a number of devices have recently been developed to facilitate hand rehabilitation after stroke, most place some restrictions on movement of the digits or arm. Thus, a novel glove was developed which can provide independent extension assistance to each digit while still allowing full arm movement. This pneumatic glove, the PneuGlove, can be used for training grasp-and-release movements either with real objects or with virtual objects in a virtual reality environment. Two groups of stroke survivors, with seven subjects in each group, completed a six-week rehabilitation training protocol, consisting of three 1-h sessions held each week. One group wore the PneuGlove during training, performed both within a novel virtual reality environment and outside of it with physical objects, while the other group completed the same training without the device. Across subjects, significant improvements were observed in the Fugl-Meyer Assessment for the upper extremity (p < 0.001), the hand/wrist portion of the Fugl-Meyer Assessment (p < 0.001), the Box and Blocks test (p < 0.005), and palmar pinch strength (p < 0.005). While changes in the two groups were not statistically different, the group using the PneuGlove did show greater mean improvement on each of these measures, such as gains of 3.7 versus 2.4 points on the hand/wrist portion of the Fugl-Meyer Assessment and 14 N versus 5 N in palmar pinch.
Quality improvement activities based on patient-reported outcomes require a high degree of organizational commitment and support. External facilitation can support clinics' quality improvement activities. Clinical relevance This project illustrates the challenges of sustaining quality improvement activities using patient-reported outcome data in prosthetic clinics.
Hand impairment is common following stroke and is often resistant to traditional therapy methods. Successful interventions have stressed the importance of repeated practice to facilitate rehabilitation. Thus, we have developed a servo-controlled glove to assist extension of individual digits to promote practice of grasp-and-release movements with the hand. This glove, the PneuGlove, permits free movement of the arm throughout its workspace. A novel immersive virtual reality environment was created for training movement in conjunction with the device. Seven stroke survivors with chronic hand impairment participated in 18 training sessions with the PneuGlove over 6 weeks. Overall, subjects displayed a significant 6-point improvement in the upper extremity score on the Fugl-Meyer assessment and this increase was maintained at the evaluation held one month after conclusion of all training (p < 0.01). The majority of this gain came from an increase in the hand/wrist score (3.8-point increase, p < 0.01). Thus, the system shows promise for rehabilitative training of hand movements after stroke.
Social determinants profoundly impact health. Many primary care practices now seek to screen their patients for health-related social needs (HRSN) and refer them to resources in the community. However, there is little empirical evidence to guide communication with patients in order to ensure their comfort with the process and increase the likelihood that it results in positive outcomes. This paper describes the first phase of the Improving Messaging Around Gaps in Needs and rEfferals (IMAGINE) study-a multi-phase study aiming to develop and test patient-centred messages about screening and referral for HRSN. In this initial qualitative phase, our objective was to identify communication strategies that might make western Colorado primary care patients more comfortable with the HRSN screening and referral process. From May to July 2020 we interviewed 10 staff members responsible for HRSN screening from primary care practices participating in the western Colorado Accountable Health Communities (AHC) initiative and 20 patients from 2 of these practices. We used a rapid qualitative analysis process that involved summarising interview transcripts across key domains of interest and then identifying emergent themes within each domain using a data matrix. Through this process, we examined current communication about HRSN screening, as well as suggestions for messages and other strategies that could improve communication. In most practices, the AHC Screening Tool was handed to patients by front desk staff at check-in with little explanation as to its purpose. Patients and staff alike recommended that patients be provided with information that: normalises the screening and referral process; assures privacy; clarifies that the purpose is to help and support rather than judge or report; emphasises community benefits; and respects patient autonomy. Interviewees also suggested broader strategies to support more effective communication, such as practice staff and clinicians building trusting relationships with patients and understanding and acknowledging the complex structural barriers that often prevent patients from accessing meaningful assistance. These findings provide actionable suggestions for improving communication about HRSN screening and referral in primary care settings. The next steps include developing specific messages based on these findings and testing their impact on screening tool completion rate, referral uptake, and patient-reported comfort with the process.
BACKGROUND: Obesity is of epidemic proportion in the USA but most people with obesity do not receive treatment. OBJECTIVE: To explore the experience of providing obesity management among primary care clinicians and their team members involved with weight loss in primary care practices. The study's focus was on examining the use of the Medicare payment code for intensive behavioral therapy for obesity (IBT), but other obesity management services and payment mechanisms were also studied. DESIGN/PARTICIPANTS: We conducted 85 interviews of clinicians (physician, advanced practice clinicians, registered dietitian, or other) practicing in primary care practices. Interviews gathered information about treatment approach to obesity, barriers, and facilitators to providing obesity care including the handling of billing and reimbursement (especially use of the IBT code), personal beliefs about the appropriateness of primary care providing weight loss services, and recommendations for improving weight management in primary care practice. The analysis was conducted using a grounded theory hermeneutic editing approach and the constant comparative method. KEY RESULTS: Seventy-five interviews were included in this analysis. We identified three primary themes: (1) clinicians and staff involved in obesity management in primary care believe that addressing obesity is an essential part of primary care services, (2) because providing obesity care can be challenging, many practices opt out of treatment, and (3) despite the challenges, many clinicians and others find treating obesity feasible, satisfying, and worthwhile. CONCLUSIONS: Treating obesity in primary care settings poses several challenges but can also be very satisfying and rewarding. To improve the ability of clinicians and practice members to treat obesity, important changes in payment, education, and work processes are necessary.
Background: Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation.Methods: Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n ؍ 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation. Results: In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all P < .05) at baseline. In the final multilevel model, specialty (FM vs mixed, P ؍ .0081), rural location (P ؍ .0109), and higher percent Medicaid (P < .0001) were associated with greater SMS. Practices described key facilitators (alignment, motivation, a visible champion, supporting infrastructure, and functional quality improvement and care teams) and barriers (no shared vision, no visible champion, siloed infrastructure, competing programs, turnover, and time constraints) to improving SMS delivery. Conclusions: Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices. (J Am Board Fam Med 2019;32:329 -340.) Most patients with type 2 diabetes mellitus (T2DM) in the United States receive diabetes care in primary care settings, which are undergoing rapid transformations due to the need to improve quality and decrease costs. The Patient-Centered Medical Home (PCMH) and the Chronic Care Model are complementary clinical intervention frameworks that are commonly used to support This article was externally peer reviewed. DesignCTH is a 3-arm, cluster-randomized trial to evaluate the reach, effectiveness, adoption, implementation, and maintenance of CTH for patients with 330 The details of change process capability varied widely across the 36 practices; however, there were consistent concepts that emerged about characteristics that propel implementation-supporting infrastructure, functional teams, and practice stability-and those that repel implementation-siloed infrastructure, communication issues, turnover, competing programs, and time/resource constraints. Propelling and repelling factors for change process capabilities are described in Table 5.Poten...
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