Ambulatory Care Research Paper
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Ambulatory Care: A New World of Patient Care Opportunities
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Effective primary care teams include individuals working at the top of their skill set, who are encouraged to operate independently, and collaborate to plan and deliver care that meets patient needs. High-functioning teams are interdependent, have shared goals, and have defined roles and work flows. Patients as part of the Primary Care Team. The conceptual blueprint for the provision of patient-centered team-based care see Figure 4 below, excerpted from the AHRQ White Paper: Creating Patient-Centered Team-Based Primary Care highlights some important elements about the role of patients in team-based care. First, a coherent and identifiable provider team must be designed in response to the needs of the patient panel.
Comprehensiveness means that the provider team responds to the most common patient needs in a given community. So it follows that different types of staff and providers make up the care team in different communities. An intentional understanding of the medical and social needs of the patient panel should shape the array of staff and providers that together make up the team. In the same way, individual patient preferences, skills, information, and agency are central to good care.
Patients and their provider teams co-create health in the context of long-term relationships. The full partnership and mutual respect for the perspectives and information of both patients and care teams is crucial. Third, the unique needs of each patient may mean that a different array of individuals from the expanded care team is called upon to best partner with different patients. As patients age and as their social and medical needs change, the configuration of care providers called on to partner with them must also change. It should be noted that patients may also rely heavily on individuals outside of the organized provider care team to support their health and well-being.
In the context of patient-centered care, this rich array of support is taken into account and welcomed. Figure 4. Over the last decade payers, employers, grant makers, community groups, and local and national government agencies have made a concerted effort to understand, measure, and evaluate high-quality, comprehensive primary care. As quality improvement efforts aimed at improving patient health outcomes by redesigning primary care practice have flourished, e. Led by the Institute for Healthcare Improvement and bolstered by independent efforts from the Patient-Centered Medical Home Evaluators Collaborative and others, a consensus is emerging on the value of assessing practices based on the Triple Aim of better health and better experience at a lower cost.
Assessing a practice's ability to achieve the triple or quadruple or quintuple aim means looking at specific measures for each aim. Much work has been done through a variety of partners to develop consensus measure sets. An illustrative sample is presented below in Table 2. Table 2. Domains of the triple, quadruple, or quintuple aim and illustrative measure examples. As discussed above, we need more than outcomes metrics to know if a primary care is high-quality and comprehensive. These infrastructure measurements should focus on the capacities and competencies shown in Figure 1 ; those elements that we know lead to improvements in outcomes overtime.
Examples of tools that assess practice infrastructure include:. In addition to these broad tools, assessing the general capacity and functions performed in a primary care practice, AHRQ has supported efforts to consolidate and make sense of the many measures of individual capacity and function available through their Atlas' project. Examples of in-depth reports that present frameworks, definitions, and measures include:. It should be noted that the purpose—and subsequently the method—of measuring practice infrastructure and outcomes varies depending on the interested stakeholders. For each of the measures discussed above, the frequency, modality, and approach can greatly influence the findings observed. Indeed some measures like total cost of care may be irrelevant or impossible to capture, depending on the purpose and stakeholders.
In an increasingly specialized and expensive health system, primary care has the opportunity and the mandate to reimagine high-quality, comprehensive care for the 21st century. Practices must build the capacity and develop the competencies to improve care, utilizing care teams in new ways to meet patients' needs. Many primary care practices are already experimenting with new ways of using core and extended care team members to offer more comprehensive and higher-quality care for patients. Interestingly, practices embracing team-based care are operating in urban and rural settings, integrated group practice, and independent provider offices. In practice settings where most revenue is generated through fee-for-service contracts, care teams are used to create more capacity for provider visits.
In settings largely reimbursed under capitated or value-based contracts, teams support the wide range of patients' complex needs in the primary care setting, avoiding expensive and unnecessary secondary and tertiary care. Despite widely varying contexts, what is clear is that primary care teams are necessary to deliver the full range of recommended preventive, chronic, and acute care to the U. What remains now is to understand how to optimally configure and pay for these teams.
This paper provides a start with definitions and frameworks, laying the groundwork for more granular, operational models of the primary care work force that are designed to provide high-quality comprehensive care in urban and rural settings, integrated and independent practices, and for a diversity of patient needs. Deploying these model primary care teams may be a key to unlocking improved population health and well-being.
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The patient-centered medical home: a systematic review. PMID: ; 3 , Early evaluations of the medical home: building on a promising start. Am J Manag Care. The World Bank Group. Accessed April 9, Projecting US primary care physician workforce needs: Ann Fam Med. November IHS Inc. Prepared for the Association of American Medical Colleges. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.
The safety net medical home initiative: transforming care for vulnerable populations. Med Care. The 10 building blocks of high-performing primary care. National Committee for Quality Assurance. Patient-Centered Medical Home Recognition Accessed April 22, Improving chronic illness care: translating evidence into action. Health Aff. Institute of Medicine. Through the patient's eyes: understanding and promoting patient-centered care. San Francisco: Jossey-Bass; Engaging Patients and Families in the Medical Home. June Hsu C.
Is there time for management of patients with chronic diseases in primary care? Primary care: is there enough time for prevention? Am J Public Health. Certification Review Course. Contact Hours. No materials, including graphics, may be reused, modified, or reproduced without written permission. Skip to main content. Log In search menu. If you practice in a setting other than a traditional inpatient arena, you are an ambulatory care nurse and we are here for you. Oct 8, Oct 7, Leader and Member Dr.
Toyin Lawal Receives Humanitarian Award. Oct 1, Read More Headlines. View All Jobs Post a Job. Oct 14, Oct 20, Oct 27, Accessed January 12, Zinc in infection and inflammation. Vitamin C and infections. Vitamin C for preventing and treating the common cold. Zinc for the common cold. Reduction in duration of common colds by zinc gluconate lozenges in a double-blind study.
Zinc lozenges and the common cold: a meta-analysis comparing zinc acetate and zinc gluconate, and the role of zinc dosage. Vitamin C administration in the critically ill: a summary of recent meta-analyses. Angiotensin-converting enzyme 2 is a functional receptor for the SARS coronavirus. Antiviral activity of the zinc ionophores pyrithione and hinokitiol against picornavirus infections. Vitamin C, respiratory infections and the immune system. Ascorbic acid and infectious bronchitis infections in broilers.
In this study, Suma et al fail to supplement the zinc with an ionophore, either hydroxychlorquine or quercetin. All successful treatments using zinc, whether as a prophylaxis or as early or late stage infection applications, have and must use the ionophore that allows easy insertion of zinc into the cell. As someone who has actually taught nutraceutical science at the university level, I would say that this study is unfortunately flawed.
First, trying to "load up" on zinc doesn't really work. It's a little like telling somebody to quit smoking and then expecting them to have an immediate reduction in cancer risk. That risk will last for more than a decade. Intracellular sink is what matters. It takes several months for intracellular levels to rise to a meaningful level, much more than a few days of loading up. The vitamin C that was administered is largely not absorbed, hence the side effects. Also, micronutrients don't function in a vacuum. It's nice to see someone giving some attention to this, but one could have predicted that this particular effort would not be a very credible effort.
Broader understanding of how to use dietary supplements needed. William Sardi, B. Knowledge of Health, Inc. The use of dietary supplements by the public to prevent or allay symptoms of COVID is large because no few medicines have been specifically licensed or approved for use against Coronavirus. The study did attempt to employ frequent divided doses of vitamin C to presumably achieve high blood levels given that ascorbic acid as a water-soluble nutrient is rapidly excreted; and an ample dose 50 mg as gluconate of zinc was employed many time above typical dietary intake 10 mg.
Zinc elevates metallothionein, its carrier protein. Excessive zinc may bind up all of the supplemental zinc rendering it non-bioavailable. Vitamin D is better known to activate an adaptive immune response specific to the pathogen involved by activation of memory T-cells. Hannah Bisht. The study reports to use 50mg of zinc gluconate, which contains 7mg of the elemental zinc. That is not a high dose. It is generally a good idea to put on one's bullet proof vest before going into combat. Further studies should enroll patients to see if they were able to avoid developing coronavirus infection after being on vitamin D3 5, IU, zinc 50 mg, selenium ug, and vitamin C at least ie, 3, mg days a week after 1 month of such continuing treatment vs placebo.
Do we know the participants baseline and test Zn levels? Ascorbic acid can enhance Zn uptake in many instances but this is blunted by diabetes and it appears many patients in the experimental arm had diabetes. Viruses may induce a Zn deficiency upon infection and immune response. M Sickels, MD Private practice. I checked with the author and verified that they did use 50mg of elemental zinc. If you look at figure 3, you will see that all of the treatment showed some improvement over standard of care during days , and then standard of care started catching up until it was similar to the rest though AA alone remained somewhat better. Vitamin C levels in the blood are tightly controlled by the gut and in ideal healthy, non-stressed circumstances a modest dose of mg should max out absorption but with stress and infection, vitamin C requirements go up such that ICU patients required mg IV daily to maintain normal plasma levels, see DOI: So, the substantial dose of vitamin C used in this article should have been adequate to top off the blood levels.
The hyperbolic claims of greater absorption of liposomal vitamin C are not supported by the literature, which only show relatively modest increases in plasma levels for liposomal compared to plain ascorbate at best see doi: Trial stopped early despite promising interim results. Another issue with the study design is that the duration of infection prior to presentation to outpatients and initiation of intervention was not reported and was likely variable. Study population selection likely excluded high-risk patients most likely to benefit. In this study, the authors selected ambulatory patients recruited from outpatient facilities and thus may have underrepresented high-risk patients such as the elderly and minorities.
Older patients, males and racial or ethnic minorities are demographic groups at high risk of infection, progression of diseases and death from COVID These groups have also been shown to be likely to have zinc Ref. Thus, the study may have inadvertently underrepresented exactly those patients e. References: 1. Eur J Intern Med. It is nice to see that individuals have the courage to take on myths and attempt to prove them either correct and therefore not a myth or to demonstrate with no bias that the myth is just that and not a real effect. Well done! It is unclear what dose of elemental zinc was used in this study from the text provided.
PubChem lists the molecular weight of zinc gluconate at If 50 mg.