Behavioral preventive service delivery, productivity, and staff turnover in primary care practices: The role of participation in decision making, provider characteristics, and the chronic care model

This dissertation explores the relationships between various structures and processes of primary care practice. The Institute of Medicine defines primary care as the "provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." These areas as defined include the provision of services for personal health behaviors, practice productivity and effectiveness in meeting the needs of patient populations, and the development of longitudinal patient relationships by reducing staff turnover and maintaining practice stability. However, rising expectations for performance and cost containment create a threatening climate in which there is a substantial need for quality improvement and redesign of primary care practices. Opportunities for innovation include leadership and participation by frontline staff, new models of care management, greater use of information technology, and reorganization of the clinical work environment.; This dissertation takes the form of three separate studies conducted among primary care practices. All three studies use data collected from a national initiative targeting lifestyle behaviors such as physical activity, eating habits, tobacco and alcohol use. Interventions were conducted in and data were obtained from primary care practices located in approximately 10 states throughout the northeast, southern, midwest, and western regions of the U.S. Hierarchical linear modeling was used to analyze the simultaneous effects of organizational and individual level data on provider outcome measures. In addition, ordinary least squares estimation was used to analyze the associations between various practice features and organizational outcomes.; The first study seeks to identify both primary care practice and provider characteristics associated with the delivery of preventive services for health behaviors. Staff participation in decisions regarding clinical operations and quality improvement is highlighted as an organizational feature that significantly moderates the effect of several practice attributes on provider performance of behavioral preventive services. Staff participation in decisions positively influences the effect of work relationships and work stress on preventive service delivery. However, the effect of practice size on service delivery is negatively influenced by high levels of participation in decision processes. (Abstract shortened by UMI.)...