Enhancing Patient-Centered Care

Abstract

Health care reform focuses on primary care and development of Health Care Homes to improve patient-centered chronic illness care. This pilot study evaluated a community care team intervention that linked chronically ill older patients, support persons, and nurse care coordinators from a Health Care Home with community resources using an adaptation of the Wraparound process. A pragmatic clinical trial design was used. Patient-centered chronic illness care; physical, mental, and social health; service use; and study feasibility were evaluated. Differences between groups were compared using two-sample t, Wilcoxon rank sum, chi-square, or Fisher's exact tests. At 3 months, the intervention group reported higher patient-centered chronic illness care (mean total Patient Assessment of Chronic Illness Care change scores were 0.39 for the intervention group and -0.11 for the control group, p = .03). Results indicate that the integrated community care team intervention is a promising strategy to support patient-centered chronic illness care.

Identifying and addressing gaps in the implementation of a community care team for care of Patients with multiple chronic conditions

“…First, the included work was conducted at the completion of pilot funding for the program to support its transition to a clinical resource. Because of this, additional patient outcomes are not available beyond what was reported in the earlier pilot publication [13]. Second, the most critical limitation is that this work conducted to scale up the CCT occurred in one of the two healthcare institutions in the upper Midwest the CCT served.…”

“…Modeled after Vermont’s Blueprint for Health, the Community Care Team (CCT) was developed and implemented in a county in an upper Midwestern state [13, 14]. The county is served by two healthcare delivery systems, both that have substantial primary care practices.…”

“…The Crisis Prevention Plan indicates patient-identified changes signaling a difficult day and the way they will obtain assistance before the situation spirals out of control. The Circle of Support includes community and informal resources available to assist the patient with self-management activities [13]. A copy of each group meeting proceedings and the Action Plan is made available to all team members, patients, and caregivers at the end of each group session.…”

“…In its pilot evaluation, the CCT showed significant improvement in scores on the Patient Assessment of Chronic Illness Care (PACIC), a standard validated measure of the quality of chronic illness care from the patient’s perspective [13]. Differences in patient-reported health outcomes, such as pain and anxiety/depression were not statistically significant, in part due to the small sample size in the pilot program [13]. However, scores trended toward improvement after the program despite patients reporting higher levels of pain and anxiety/depression at baseline than the control group [13].…”

“…Differences in patient-reported health outcomes, such as pain and anxiety/depression were not statistically significant, in part due to the small sample size in the pilot program [13]. However, scores trended toward improvement after the program despite patients reporting higher levels of pain and anxiety/depression at baseline than the control group [13]. Given the strong correlation between the elements of limited physical and emotional capacity and disruption to patients’ lives by their illness and treatment [17], these trends are promising.…”