Journal of general internal medicine
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Observational Study
Terminations in Primary Care: a Retrospective Observational Study of 16 Primary Care Clinics.
The relationship between clinician and patient is the cornerstone of primary care. Breakdown and termination of this relationship are understudied yet important, undesirable outcomes. ⋯ Detailed chart review found that, unlike previous survey-based studies, dismissal was often for missed appointments based on enforcement of no-show policies. Many sociodemographic factors were associated with termination. Variability among clinics highlights the need for further research to better understand circumstances surrounding terminations, with the principal goals of improving patient-provider relationships and providing equitable care.
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VA clerks, or medical support assistants (MSAs), are a critical part of patients' primary care (PC) experiences and are often the first points of contact between Veterans and the healthcare system. Despite the important role they might play in assisting Veterans with accessing care, research is lacking on the specific tasks they perform and what training and preparation they receive to perform their roles. ⋯ As healthcare systems continue expanding virtual access, the roles of administrative call center and PC MSAs as first points of contact will be increasingly important for shaping patient experiences. Our research suggests that MSAs may need better training and preparation for the roles they perform assisting Veterans with accessing care, coupled with an intentional approach by healthcare systems to address MSAs' concerns about recognition/compensation. Future research should explore the potential for enhanced MSA customer service training to improve the Veteran patient experience.
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Residents and fellows receive little feedback on their clinical reasoning documentation. Barriers include lack of a shared mental model and variability in the reliability and validity of existing assessment tools. Of the existing tools, the IDEA assessment tool includes a robust assessment of clinical reasoning documentation focusing on four elements (interpretive summary, differential diagnosis, explanation of reasoning for lead and alternative diagnoses) but lacks descriptive anchors threatening its reliability. ⋯ The Revised-IDEA assessment tool is reliable and easy to use for feedback on clinical reasoning documentation in resident and fellow admission notes with descriptive anchors that facilitate a shared mental model for feedback.
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Transitions of care experiences leave patients vulnerable to adverse outcomes, including readmissions, worsening symptoms, and reductions in functional status. ⋯ A primary care transitions clinic can provide accessible, attentive care post-discharge with positive effects on healthcare utilization. Availability of a multidisciplinary team that can see patients for repeated visits until establishment of PCP care was a key success factor for the transitions clinic.
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Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act.
Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored. ⋯ ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.