There are growing numbers of individuals with at least one chronic disease in the United States, creating a greater need for primary care services despite limited health care resources within safety net clinics. Patient self-management has been studied as a possible solution to improve the efficiency and effectiveness of primary care. In order to work, patients must feel confident in their ability to manage their own health and engage in the decision making process of their care. Providers also need adequate time to spend with patients to provide sufficient information as well as listen to patient concerns.
Three safety net clinics in Northern California underwent practice redesigns to enhance care for obese patients and improve their self-management skills. A mixed methods approach was used to assess the effects of the practice redesign on staff, clinicians, and patients. Patients were mailed questionnaires during early and late implementation of the practice redesign. Questionnaire measures included patient-provider communication (based on the CG-CAHPS), patient activation (PAM-13), general health (SF-12v2), physical activity, dietary habits, chronic conditions, and demographic information. Clinical outcome measures from clinic administrative data were merged with patient questionnaire data to evaluate patient outcomes relative to self-reported measures. Key informant interviews were conducted with randomly selected clinic staff and clinicians, also during the same baseline and six-month follow-up periods. Topics included practice change implementation experiences, team activities, interactions with overweight or obese patients, team development activities, and practice characteristics.
Higher patient activation was associated with increased odds of regular fruit and vegetable consumption. For physical activity, the presence of comorbidities affected the relationship between patient activation and physical activity. Although the patient-provider relationship had a strong bivariate relationship with patient activation, it did not impact the relationship between patient activation and health behaviors. As seen in previous studies, patient activation was related to systolic blood pressure, diastolic blood pressure and weight. However, the clinical practice redesign only had an effect on diastolic blood pressure. The implementation of a teamlet model within safety net clinics to improve patient health may be feasible, but the composition of the teamlet may need to be modified for financial sustainability. Future change efforts should have support from different levels of management and staff, preferably championed by multiple people to aid the sustainability of the change in the face of staffing changes.
