Date of Award

January 2025

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Mary Tinetti

Abstract

BARRIERS AND FACILITATORS IN IMPLEMENTATION OF PRIORITIES-ALIGNED CARE IN GERIATRIC HOME-BASED PRIMARY CARE Julia Schaffer, Eliza Kiwak, Mary Tinetti. Section of Geriatrics, Department of Internal Medicine, Yale University, School of Medicine, New Haven, CT

Abstract:Older adults, particularly those with multiple chronic conditions (MCCs) and functional limitations, vary in what matters most. Patient Priorities Care (PPC) was developed to address this variability. PPC, which involves identifying and aligning care with individuals’ goals and care preferences, has been found feasible and effective in ambulatory care settings but has not yet been studied in the home-based primary care (HBPC) setting. This study aimed to identify the key barriers and facilitators to implementing PPC in two HBPC practices in the New Haven, CT area. Implementation of PPC involved six core strategies: early inclusion of and input from stakeholders, introduction and initial training, group huddles, site-appointed champions, simplified point of care tools, and ongoing implementation support. We employed a mixed methods approach to identify factors that supported and challenged implementation including observation of the implementation process, a quantitative survey, and semi-structured interviews to evaluate healthcare professionals’ (HCPs) perception of PPC feasibility and acceptability. Hybrid inductive-deductive thematic analysis and the Consolidated Framework for Implementation Research was used to identify patterns across interview data. Observation of the implementation process across three Plan-Do-Study-Act cycles revealed three crucial drivers of success: leadership investment, early adopter role modeling, and strong champion engagement. HCPs identified value-alignment, electronic health record integration, and interdisciplinary teamwork as key facilitators of implementation. The most prominent barriers were competing workload demands, skepticism about PPC’s added value, and difficulty getting to specific, reasonable goals. Overall, while the implementation process involved many challenges, implementation of Patient Priorities Care in geriatric home-based primary care appeared feasible and acceptable provided there is leadership support, an early adopter, and opportunity to discuss real cases.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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