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Storylines of Family Medicine is a 12-part series of thematically linked essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.

NAPCRG celebrated 50 years of leadership and service at its 2022 meeting. A varied team of primary care investigators, clinicians, learners, patients, and community members reflected on the organization's past, present, and future. Started in 1972 by a small group of general practice researchers in the United States, Canada, and the United Kingdom, NAPCRG has evolved into an international, interprofessional, interdisciplinary, and intergenerational group devoted to improving health and health care through primary care research. NAPCRG provides a nurturing home to researchers and teams working in partnership with individuals, families, and communities. The organization builds upon enduring values to create partnerships, advance research methods, and nurture a community of contributors. NAPCRG has made foundational contributions, including identifying the need for primary care research to inform primary care practice, practice-based research networks, qualitative and mixed-methods research, community-based participatory research, patient safety, practice transformation, and partnerships with patients and communities. Landmark documents have helped define classification systems for primary care, responsible research with communities, the central role of primary care in health care systems, opportunities to revitalize generalist practice, and shared strategies to build the future of family medicine. The future of health and health care depends upon strengthening primary care and primary care research with stronger support, infrastructure, training, and workforce. New technologies offer opportunities to advance research, enhance care, and improve outcomes. Stronger partnerships can empower primary care research with patients and communities and increase commitments to diversity and quality care for all. NAPCRG offers a home for all partners in this work. Key words: primary care; family practice; general practice; research; organizations; NAPCRG; interdisciplinary research; community-based participatory research, INTRODUCTION NAPCRG celebrated its first 50 years at its 2022 annual meeting. A varied group of members reflected on the organization and its place in family medicine and primary care [...]

Several recent national initiatives have called for increased efforts to integrate social determinants of health (SDH) into health care settings using health information technology (HIT). However, there is limited evidence to guide the implementation of these recommendations in practice. Research is needed to understand what SDH information is most important to collect, how SDH information can be used to inform clinical care and referrals, and ultimately, whether and how integrating SDH screening and action into primary care affects individual and population health. We recently proposed a conceptual framework to illustrate how HIT can be used to bring SDH information into primary care. In this paper, we describe how we are putting this conceptual model into practice within the OCHIN network of community health centers by highlighting examples of ongoing research, identifying knowledge gaps, and outlining a roadmap of future research to move the field forward.

People working on behalf of population health, community health, or public health often experience confusion or ambiguity in the meaning of these and other common terms--the similarities and differences and how they bear on the tasks and division of labor for care delivery and public health. Shared language must be clear enough to help, not hinder people working together as they ultimately come to mutual understanding of roles, responsibilities, and actions in their joint work. Based on an iterative lexicon development process, the authors developed and propose a definitional framework as an aid to navigating among related population and community health terms. These terms are defined, similarities and differences clarified, and then organized into 3 categories that reflect goals, realities, and ways to get the job done. Goals include (a) health as well-being for persons, (b) population health as that goal expressed in measurable terms for groups, and (c) community health as population health for particular communities of interest, geography, or other defining characteristic--groups with shared identity and particular systemic influences on health. Realities are social determinants as influences, health disparities as effects, and health equity as both a goal and a design principle. Ways to get the job done include health care delivery systems for enrollees and public health in population-based civic activities--with a broad zone of collaboration where streams of effort converge in partnership with served communities. This map of terms can enable people to move forward together in a broad zone of collaboration for health with less confusion, ambiguity, and conflict. Key words: population health; lexicon; definitions; primary care public health integration, THE IMPERATIVE AND THE PROBLEM The terms population health, community health, and public health are often used interchangeably, yet imprecisely, leading to conceptual and practical misunderstandings. Each term relates in [...]

Abstract Background Following the ACA, millions of people gained Medicaid insurance. Most electronic health record (EHR) tools to date provide clinical-decision support and tracking of clinical biomarkers, we developed an EHR tool to support community health center (CHC) staff in assisting patients with health insurance enrollment documents and tracking insurance application steps. The objective of this study was to test the effectiveness of the health insurance support tool in (1) assisting uninsured patients gaining insurance coverage, (2) ensuring insurance continuity for patients with Medicaid insurance (preventing coverage gaps between visits); and (3) improving receipt of cancer preventive care. Methods In this quasi-experimental study, twenty-three clinics received the intervention (EHR-based insurance support tool) and were matched to 23 comparison clinics. CHCs were recruited from the OCHIN network. EHR data were linked to Medicaid enrollment data. The primary outcomes were rates of uninsured and Medicaid visits. The secondary outcomes were receipt of recommended breast, cervical, and colorectal cancer screenings. A comparative interrupted time-series using Poisson generalized estimated equation (GEE) modeling was performed to evaluate the effectiveness of the EHR-based tool on the primary and secondary outcomes. Results Immediately following implementation of the enrollment tool, the uninsured visit rate decreased by 21.0% (Adjusted Rate Ratio [RR] = 0.790, 95% CI = 0.621–1.005, p = .055) while Medicaid-insured visits increased by 4.5% (ARR = 1.045, 95% CI = 1.013–1.079) in the intervention group relative to comparison group. Cervical cancer preventive ratio increased 5.0% (ARR = 1.050, 95% CI = 1.009–1.093) immediately following implementation of the enrollment tool in the intervention group relative to comparison group. Among patients with a tool use, 81% were enrolled in Medicaid 12 months after tool use. For the 19% who were never enrolled in Medicaid following tool use, most were uninsured (44%) at the time of tool use. Conclusions A health insurance support tool embedded within the EHR can effectively support clinic staff in assisting patients in maintaining their Medicaid coverage. Such tools may also have an indirect impact on evidence-based practice interventions, such as cancer screening. Trial registration This study was retrospectively registered on February 4th, 2015 with Clinicaltrials.gov (#NCT02355262). The registry record can be found at https://www.clinicaltrials.gov/ct2/show/NCT02355262 .

Electronic health record (EHR) tools such as documentation shortcuts and ordering templates are designed to enhance both the efficiency and quality of care delivery. Use of such tools vary widely in primary care. Understanding patterns of use as a means to identify priority areas for improvement are lacking. Objective: This study is designed to identify and understand patterns of EHR efficiency use among primary care clinicians as a means to inform training support needs. Study Design: Retrospective observational study. Setting or Dataset: 340 Community Health Centers (CHCs) across 48 US states from the OCHIN Network. Population Studied: The OCHIN's network and 2033 primary care clinicians engaged in patient care at least 2 days a week during DEC 2019-FEB 2020. Methods: Six EHR efficiency indicators were drawn from the Epic EHR Signal efficiency indicators which are automatically generated monthly for clinicians. Indicators include: use of quick actions, preference lists, level of service and diagnosis speed buttons and chart search functions and notes written with smart tools. A weighted score of these indicators represented overall EHR proficiency with a possible range of 0- 10 with higher scores suggesting higher efficiency. Latent profile analysis (LPA) was used to identify clusters of clinicians defined by distinct patterns of efficiency indicators. Results: The median EHR proficiency score was 4 and ranged from 0 to 9.5. The 9 cluster LPA solution the best overall fit. Clusters represented different patterns with notable strengths and deficiencies in EHR use efficiency. Cluster 2 was large (n=518) and characterized by being low on all indicators except for chart search. In contrast, cluster 9 was very small (n=12) and characterized by high scores for 4/6 indicators and low on quick actions. Conclusions: Substantial variation in EHR use efficiency among primary care clinicians was observed and can be represented by nine different patterns of indicators. These patterns show strengths and deficiencies in EHR use efficiency and could guide a tailored training approach to improve EHR efficiency., Presenters Jeremy Erroba, Miguel Marino, PhD, Rachel Gold, PhD, MPH, Rachel Springer, MS, Jennifer DeVoe, MD, DrPH, FAAFP, DPhil, Susan Flocke, PhD, David Boston, MD, [...]

Context: Acute complications are responsible for the majority of morbidity and mortality of patients with diabetes. Health insurance increases access to needed healthcare and receipt of diabetes-related preventive care. The Affordable Care Act (ACA) Medicaid eligibility provision was enacted in 2014 with the goal of expanding coverage to all US citizens and legal residents. The ACA led to improvement in healthcare access and health outcomes among patients with diabetes. Objective: To understand whether patients with diabetes in states that expanded Medicaid had greater reductions in the rate of acute complications post-ACA than those in states that did not expand Medicaid. Study Design: Retrospective observational cohort study. Setting or Dataset: Electronic health record data: 274 community health centers from the Accelerating Data Value Across a National Community Health Center Network clinical research network. Population Studied: Non-pregnant adults (n=5,176) aged 19-64 without Medicare coverage history, newly diagnosed with diabetes in 2013 with [greater than or equal to] 1 visit in each of the following periods: 2013, 2014-2016, 2017-2019. Outcome Measures: Rates of acute complications identified using ICD-9/10-CM codes and counted distinctly if the interval between each diagnosis was at least 10 days. Patients' annual acute complication rates were compared using a covariate-adjusted GEE Poisson model clustering on patients assuming an exchangeable working correlation. Outcome trends over time between expansion and non-expansion states were tested using interaction terms for time and expansion status. Results: From 2013 through 2019, annual acute complication rates declined overall for patients in both expansion (2013: 0.35; 2019: 0.18) and non- expansion (2013: 0.13; 2019: 0.10) states, with higher observed rates of acute complications in expansion (compared to non-expansion) states throughout the study period. Trends in acute complication rates were not parallel over time between expansion and non-expansion states (p, Presenters Nathalie Huguet, PhD, Dang Dinh, MSc, Hojun Hwang, MS, Miguel Marino, PhD, Heather Angier, PhD, MPH, Annie Larson, PhD, MPH, Irina Chamine, PhD, Jennifer DeVoe, MD, DrPH, FAAFP, DPhil, [...]

Earlier this year, the National Academies of Sciences, Engineering, and Medicine (NASEM) published the first formal consensus study of primary care in 25 years. The consensus committee's report, 'Implementing High-Quality [...]

During a pandemic, primary care is the first line of defense. It is able to reinforce public health messages, help patients manage at home, and identify those in need of hospital care. In response to the COVID-19 pandemic, primary care scrambled to rapidly transform itself and protect clinicians, staff, and patients while remaining connected to patients. Using the established public health framework for addressing a pandemic, we describe the actions primary care needs to take in a pandemic. Recommended actions are based on observed experiences of the authors' primary care practices and networks. Early in the COVID-19 pandemic, tasks focused on promoting physical distancing and encouraging patients with suspected illness or exposure to self-quarantine. Testing was not available and contract tracing was not possible. As the pandemic spread, in-person care was converted to virtual care using telehealth. Practices remained connected to patients using registries to reach out to those at risk for infection, with uncontrolled chronic conditions, or were socially vulnerable. Practices managed most patients with suspected COVID-19 at home. As the pandemic decelerates, practices are now preparing to address the direct and indirect consequences--complications from COVID-19 infections, missed treatment for acute problems, inadequate prevention, uncontrolled chronic disease, mental illness, and greater social needs. Throughout, practices bore tremendous financial burden, laying off staff or even closing at a time when most needed. Primary care must learn from this experience and be ready for the next pandemic. Policymakers and payers cannot fail primary care during their next time of need. Key words: COVID-19; primary care; pandemic; practice transformation; public health https://doi.org/10.1370/afm.2557., INTRODUCTION In normal times, 75% of adults report 1 or more illness or injury per month. Most manage symptoms on their own, but 25% consult a clinician. (1) Our health [...]

PURPOSE The Patient Protection and Affordable Care Act (ACA) has improved access to health insurance, yet millions remain uninsured. Many patients who remain uninsured access care at community health centers (CHCs); however, little is known about their health conditions and health care use. We assessed ambulatory care use and diagnosed health conditions among a cohort of CHC patients uninsured before enactment of the ACA (pre-ACA: January 1, 2012 to December 31, 2013) and followed them after enactment (post-ACA: January 1, 2014 to December 31, 2015). METHODS This retrospective cohort analysis used electronic health record data from CHCs in 11 US states that expanded Medicaid eligibility. We assessed ambulatory care visits and documented health conditions among a cohort of 138,246 patients (aged 19 to 64 years) who were uninsured pre-ACA and either remained uninsured, gained Medicaid, gained other health insurance, or did not have a visit post-ACA. We estimated adjusted predicted probabilities of ambulatory care use using an ordinal logistic mixed-effects regression model. RESULTS Post-ACA, 20.9% of patients remained uninsured, 15.0% gained Medicaid, 12.4% gained other insurance, and 51.7% did not have a visit. The majority of patients had [greater than or equal to]1 diagnosed health condition. The adjusted proportion of patients with high use ([greater than or equal to]6 visits over 2 years) increased from pre-ACA to post-ACA among those who gained Medicaid (pre-ACA: 23%, post-ACA: 34%, P CONCLUSIONS A significant percentage of CHC patients remained uninsured; many who remained uninsured had diagnosed health conditions, and one-half continued to have [greater than or equal to]3 visits to CHCs. CHCs continue to be essential providers for uninsured patients., INTRODUCTION In 2010, the Patient Protection and Affordable Care Act (ACA) was enacted with the goal of expanding health insurance coverage to all US citizens and legal residents. (1) The [...]

Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, "Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?" We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities. [ABSTRACT FROM AUTHOR]

Background: Following the ACA, millions of people gained Medicaid insurance. Most electronic health record (EHR) tools to date provide clinical-decision support and tracking of clinical biomarkers, we developed an EHR tool to support community health center (CHC) staff in assisting patients with health insurance enrollment documents and tracking insurance application steps. The objective of this study was to test the effectiveness of the health insurance support tool in (1) assisting uninsured patients gaining insurance coverage, (2) ensuring insurance continuity for patients with Medicaid insurance (preventing coverage gaps between visits); and (3) improving receipt of cancer preventive care.Methods: In this quasi-experimental study, twenty-three clinics received the intervention (EHR-based insurance support tool) and were matched to 23 comparison clinics. CHCs were recruited from the OCHIN network. EHR data were linked to Medicaid enrollment data. The primary outcomes were rates of uninsured and Medicaid visits. The secondary outcomes were receipt of recommended breast, cervical, and colorectal cancer screenings. A comparative interrupted time-series using Poisson generalized estimated equation (GEE) modeling was performed to evaluate the effectiveness of the EHR-based tool on the primary and secondary outcomes.Results: Immediately following implementation of the enrollment tool, the uninsured visit rate decreased by 21.0% (Adjusted Rate Ratio [RR] = 0.790, 95% CI = 0.621-1.005, p = .055) while Medicaid-insured visits increased by 4.5% (ARR = 1.045, 95% CI = 1.013-1.079) in the intervention group relative to comparison group. Cervical cancer preventive ratio increased 5.0% (ARR = 1.050, 95% CI = 1.009-1.093) immediately following implementation of the enrollment tool in the intervention group relative to comparison group. Among patients with a tool use, 81% were enrolled in Medicaid 12 months after tool use. For the 19% who were never enrolled in Medicaid following tool use, most were uninsured (44%) at the time of tool use.Conclusions: A health insurance support tool embedded within the EHR can effectively support clinic staff in assisting patients in maintaining their Medicaid coverage. Such tools may also have an indirect impact on evidence-based practice interventions, such as cancer screening.Trial Registration: This study was retrospectively registered on February 4th, 2015 with Clinicaltrials.gov (#NCT02355262). The registry record can be found at https://www.clinicaltrials.gov/ct2/show/NCT02355262 . [ABSTRACT FROM AUTHOR]