Steven Crane

Bio: Steven Crane is an academic researcher from University of North Carolina at Chapel Hill. The author has contributed to research in topics: Rural health & Population. The author has an hindex of 5, co-authored 13 publications receiving 139 citations.

Reducing utilization by uninsured frequent users of the emergency department: combining case management and drop-in group medical appointments

Abstract: Background: Patients with complex behavioral health and medical problems can have a disproportionate impact on emergency departments. Methods: We identified a cohort of 255 low-income, uninsured patients who had used inpatient or emergency department services more than 6 times in the previous 12 months. Between July 2010 and June 2011 we enrolled 36 of these high-risk patients to participate in a twice-weekly drop-in group medical appointment staffed by an interdisciplinary team of a family physician, behavioral health professional, and nurse case manager. The team provided 705 patient visits in a group setting (a total of 108 group sessions) and 652 case manager phone calls. The average number of clients per drop-in group medical appointment was 6.5. Results: Emergency department use dropped from a rate of 0.58 per patient per month to 0.23 (P Conclusions: Team-based drop-in group medical appointments coupled with case management seem to be a cost-effective model to reduce emergency department visits by some patients with complex behavioral health and medical needs.

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

Abstract: Purpose: Near-miss events represent an opportunity to identify and correct errors that jeopardize patient safety. This study was undertaken to assess the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them. Methods: We implemented a web-based, anonymous near-miss reporting system into 7 diverse practices, collecting and categorizing all reports. At the end of the study period, we interviewed practice leaders to determine how the near-miss reports were used for quality improvement (QI) in each practice. Results: All 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 QI projects based on the reports. The most frequent events reported were breakdowns in office processes (47.3%); of these, filing errors were most common, with 38% of these errors judged by external coders to be high risk for an adverse event. Electronic medical records were the primary or secondary cause of the error in 7.8% and 14.4% of reported cases, respectively. The pattern of near-miss events across these diverse practices was similar. Conclusions: Anonymous near-miss reporting can be successfully implemented in primary care practices. Near-miss events occur frequently in office practice, primarily involve administrative and communication problems, and can pose a serious threat to patient safety; they can, however, be used by practice leaders to implement QI changes.

Aspects of the Patient-centered Medical Home currently in place: initial findings from preparing the personal physician for practice.

Abstract: BACKGROUND AND OBJECTIVES The Patient-centered Medical Home (PCMH) is a central concept in the evolving debate about American health care reform. We studied family medicine residency training programs' continuity clinics to assess baseline status of implementing PCMH components and to compare implementation status between community-based and university training programs. METHODS We conducted a survey 24 continuity clinics in 14 residency programs that are part of the Preparing the Personal Physicians for Practice (P(4)) program. We asked questions about aspects of P(4) that had been already implemented at the beginning of the P(4) program. We defined high implementation as aspects that were present in >50% of clinics and low implementation as those present in <50% of clinics. We compared features at university-based and community-based clinics. RESULTS High areas of implementation were having an electronic health record (EHR), fully secured remote access, electronic patient notes/scheduling/billing, chronic disease management registries, and open-access scheduling. Low areas of implementation included hospital EHR with computerized physician order entry, asynchronous communication with patients, ongoing population-based QA using EHR, use of preventive registries, and practice-based research using EHR. Few differences were noted between university- and community-based residency programs. CONCLUSIONS Many features of the PCMH were already established at baseline in programs participating in P(4).

Financing Residency Training Redesign.

Abstract: Background Redesign in the health care delivery system creates a need to reorganize resident education How residency programs fund these redesign efforts is not known Methods Family medicine residency program directors participating in the Preparing Personal Physicians for Practice (P4) project were surveyed between 2006 and 2011 on revenues and expenses associated with training redesign Results A total of 6 university-based programs in the study collectively received $5,240,516 over the entire study period, compared with $4,718,943 received by 8 community-based programs Most of the funding for both settings came from grants, which accounted for 578% and 869% of funding for each setting, respectively Department revenue represented 34% of university-based support and 131% of community-based support The total average revenue (all years combined) per program for university-based programs was just under $875,000, and the average was nearly $590,000 for community programs The vast majority

Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home

Abstract: This article summarizes findings from the National Demonstration Project (NDP) and makes recommendations for policy makers and those implementing patient-centered medical homes (PCMHs) based on these findings and an understanding of diverse efforts to transform primary care. The NDP was launched in June 2006 as the first national test of a particular PCMH model in a diverse sample of 36 family practices, randomized to facilitated or self-directed groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical record audits, and patient and clinical staff surveys. Peer-reviewed manuscripts from the NDP provide answers to 4 key questions: (1) Can the NDP model be built? (2) What does it take to build the NDP model? (3) Does the NDP model make a difference in quality of care? and (4) Can the NDP model be widely disseminated? We find that although it is feasible to transform independent practices into the NDP conceptualization of a PCMH, this transformation requires tremendous effort and motivation, and benefits from external support. Most practices will need additional resources for this magnitude of transformation. Recommendations focus on the need for the PCMH model to continue to evolve, for delivery system reform, and for sufficient resources for implementing personal and practice development plans. In the meantime, we find that much can be done before larger health system reform.

Reducing frequent visits to the emergency department: a systematic review of interventions.

Abstract: Objective The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population. Methods Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized. Results Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient. Conclusions The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.

Effectiveness of Interventions to Decrease Emergency Department Visits by Adult Frequent Users: A Systematic Review.

Abstract: Objectives Frequent emergency department (ED) users are high-risk and high-resource-utilizing patients. This systematic review evaluates effectiveness of interventions targeting adult frequent ED users in reducing visit frequency and improving patient outcomes. Methods An a priori protocol was published in PROSPERO. Two independent reviewers screened, selected, rated quality, and extracted data. Third-party adjudication resolved disagreements. Rate ratios of post- versus pre-intervention ED visits were calculated. Data sources were from a comprehensive search that included seven databases and the gray literature. Eligibility criteria for selecting studies included experimental studies assessing the effect of interventions on frequent users’ ED visits and patient-oriented outcomes. Results A total of 6,865 citations were identified and 31 studies included. Designs were noncontrolled (n = 21) and controlled (n = 4) before–after studies and randomized controlled trials (n = 6). Frequent user definitions varied considerably and risk of bias was moderate to high. Studies examined general frequent users or those with psychiatric comorbidities, chronic disease, or low socioeconomic status or the elderly. Interventions included case management (n = 18), care plans (n = 8), diversion strategies (n = 3), printout case notes (n = 1), and social work visits (n = 1). Post- versus pre-intervention rate ratios were calculated for 25 studies and indicated a significant visit decrease in 21 (84%) of these studies. The median rate ratio was 0.63 (interquartile range = 0.41 to 0.71), indicating that the general effect of the interventions described was to decrease ED visits post-intervention. Significant visit decreases were found for a majority of studies in subgroup analyses based on 6- or 12-month follow-up, definition thresholds, clinical frequent user subgroups, and intervention types. Studies reporting homelessness found consistent improvements in stable housing. Overall, interstudy heterogeneity was high. Conclusions Interventions targeting frequent ED users appear to decrease ED visits and may improve stable housing. Future research should examine cost-effectiveness and adopt standardized definitions.

Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review.

Abstract: PurposeThe authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States.MethodIn November 2015, the authors searched databases (MEDLINE, ERIC,