Search

Introduction: Workforce development is a vital process for advancing the field of integrated behavioral health in primary care (IBHPC) and depends on the development of job-specific skills that meet the needs of patients and other team members. Job-specific skills guide both university- and worksite-based training programs in preparing future cohorts of health care professionals in IBHPC; however, there are no extant training criteria for nontrainee primary care providers. Method: A multiround survey using a modified Delphi technique was conducted. Participants were recruited from a large national research network, university alumni and community health center partners. Participants included allopathic and osteopathic physicians, physician assistants and nurse practitioners serving as primary care providers in a variety of IBHPC settings. In the survey, participants were instructed to categorize 22 skills as 'Essential,' 'Compatible,' or 'Irrelevant' for IBHPC practice. Categorized responses were analyzed using descriptive statistics and comments were analyzed using a modified thematic analysis method. Results: Fifty-four participants were recruited for the study, with 43 participating in round 1, 38 participating in round 2, and 36 participating in round 3. After 3 rounds, 19 skills received at least 80% consensus as 'Essential' and 22 received at least 50% consensus as 'Essential.' Comment themes revealed participants were overall agreeable with skills, but had concerns about role, training, and time constraints. Discussion: Primary care providers can prepare for and enhance IBHPC practice by developing skills identified as essential. Employers can adapt this skill list for efforts related to recruiting, hiring, and onboarding. Keywords: integrated primary care, workforce development, medical providers, Delphi survey, Workforce development is an essential part of accelerating the adoption of integrated behavioral health in primary care (IBHPC) and improving extant programs. Enhanced training for primary care providers (PCPs; i.e., [...]

Being a primary care physician isn't the most enticing job right now. The average salary is six figures below that of most specialists, according to Medical Economics[R] survey data, yet [...]

PURPOSE Evidence supports treatment for opioid use disorder (OUD) with buprenorphine in primary care practices (PCPs). Barriers that slow implementation of this treatment include inadequately trained staff. This study aimed to increase the number of rural PCPs providing OUD treatment with buprenorphine. This evaluation describes the impact of a practice team training on the implementation and delivery of OUD treatment with buprenorphine in PCPs of rural Colorado. METHODS Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) was a multilevel implementation study that included a practice-focused intervention to improve awareness, adoption, and use of buprenorphine treatment for OUD. Participating PCP teams received the IT MATTTRs Practice Team Training and support. Practices' implementation of treatment components was assessed before and after training. Practice-reported and population-level data from the Prescription Drug Monitoring Program were obtained to describe changes in delivery of treatment after training. RESULTS Forty-two practices received team training. Practices reported an average of 4.7 treatment-related components in place at baseline compared with 13.0 at 12-month follow-up (F[2,56] = 31.17, P CONCLUSIONS The IT MATTTRs training for PCP teams in OUD treatment with buprenorphine addressed elements beyond clinician waiver training to make implementation feasible and effectively increased implementation and delivery of this treatment in rural Colorado. Key words: buprenorphine; education; opioid-related disorders; primary health care; rural health, INTRODUCTION The United States has an epidemic of opioid use disorder (OUD). Over 4 million Americans report using prescription pain medicine for nonmedical reasons. (1) First-time heroin users increased from [...]

Background and Implementation: Novel coronavirus disease 2019 (COVTD-19) has presented unique challenges for patients and health care systems, including a surge in behavioral health (BH) needs. A community teaching public hospital system in Massachusetts (MA) whose 13 primary care (PC) clinics serve a diverse patient population, has developed a model for Primary Care Behavioral Health Integration (PCBHI) to provide brief, evidence-based interventions to patients in PC. In response to COVID-19, the system developed an intensive community management strategy to care for patients with COVID-19 outside of the hospital, and its PCBHI program adapted alongside this strategy to provide rapid support to patients in emotional distress. Over a 13-week period, 78 patients were specifically referred to the PCBHI COVID clinic and received rapid therapeutic support and/or care navigation. Recommendations: This article will discuss the development and implementation of the PCBHI COVID clinic, common presenting issues and clinical interventions used, and lessons that informed our adaptation of clinic operations and that can serve as recommendations to other health systems in establishing similar services. Public Significance Statement This report describes how an integrated primary care/behavioral health program adapted its safety net health system's response to COVID-19. and was able to provide rapid behavioral health support to patients in emotional distress related to the pandemic. The program's use of brief evidence-based therapies, team coordination, continuous workflow improvement, and multidisciplinary education based on emerging needs can serve as a model for other health care systems. Keywords: primary care behavioral health integration, trauma, COVID, Novel coronavirus disease 2019 (COVID-19) has presented unique challenges for patients and health care systems, including a surge in behavioral health (BH) needs. According to a survey of 1,500 people [...]

Introduction: Integrated primary care teams are increasingly relying upon virtual care, including both telehealth and team members who are teleworking, due to the COVID-19 pandemic. This shift to virtual care can present challenges for the coordination and provision of team-based care in primary care. The current report uses extant literature on teams to provide recommendations to support integrated primary care teams, including behavioral health providers, in adapting to and sustaining virtual team-based care. Method: We used the Seven C's framework by Salas and colleagues (2015) to organize our findings and recommendations, focusing on coordination, cooperation, cognition, and communication. Results: Integrated primary care teams may benefit from tending to both implicit and explicit forms of coordination and the use of debriefs to improve team coordination. Given the potential challenge of trust in a virtual team, documentation of care coordination and reexamination of how feedback is provided to primary care providers may benefit team cooperation. Sharing team goals and crosstraining on specific aspects of team processes, such as communicating essential information to behavioral health providers for a warm handoff, may improve the cognition of the team. Teams may also benefit by findings ways to incorporate informal communication into the workflow and using closed-loop communication to decrease missed communications. Discussion: This report provides initial recommendations based on extant team literature to support integrated primary care teams in adapting to virtual care. Future work should build off this report by examining virtual integrated primary care teams and providing evidence-based recommendations to optimize virtual care. Public Significance Statement This brief report uses evidence from extant literature on teams to provide recommendations for integrated primary care teams that are increasingly relying upon virtual care during the COVID-19 pandemic. These recommendations may help integrated primary teams successfully transition to virtual team-based care during the pandemic and beyond. Keywords: integrated primary care, team-based care, behavioral health provider, virtual, The shift of primary care toward team-based care (Jackson et al., 2013) and integration of behavioral health providers (BHPs) to improve mental and behavioral health access (Possemato et al., 2018) [...]

In an age where digital advancement is permeating every sector of the economy, health care is no exception. Innovations, especially in telehealth and e-visits, promise to deliver health care more [...]

There is an inherent tension between standardization and customization of care delivery processes. The challenge for health care systems is to achieve the right balance. At its best, standardized work can create efficiencies that generate the additional time needed for personalized care. Similarly, at its best, customization allows the people within a system to accommodate the needs, preferences, and circumstances of the unique individuals and local communities they serve. We provide examples and offer principles to decide when standardization offers the most successful path and when customization may be preferred. We believe that, in sum, the balance has shifted too far toward standardization and that a rebalancing toward customization will benefit patients, clinicians, and the health care system. Key words: customization; standardization; burnout; administrative burden; quality measurement; transactional; primary care issues: clinician-patient communication/relationship; teamwork; leadership, INTRODUCTION There is an inherent tension between standardization and customization of care delivery processes. Too much customization can be chaotic, time-consuming, and result in suboptimal outcomes. On the other hand, [...]

Hepatic encephalopathy (HE), a brain dysfunction caused by liver insufficiency and/or portosystemic shunting, manifests as a wide spectrum of neurological or psychiatric abnormalities, ranging from subclinical alterations to coma. (1) [...]

Context: Primary care practices are well-suited to address food insecurity (FI) in patients by conducting routine screening, hosting practice-based food programs, and connecting patients to community resources. Rural practices face unique barriers addressing FI, which may have been impacted by changes in clinic processes, resources, and food needs due to the COVID-19 pandemic. Objective: We sought to understand the impact of the COVID-19 pandemic on FI screening and interventions in rural primary care practices. Study Design and Analysis: We conducted thematic analysis of semi-structured qualitative interviews with practice staff using data from a larger mixed- methods study on FI in rural primary care during the pandemic. Setting: Rural areas of New Hampshire, Vermont, and Maine, USA. Population Studied: Clinicians and staff from rural (Rural-Urban Commuting Area Code >= 4) primary care practices in northern New England were recruited through three networks: a practice-based research network, a clinical and translational research network, and a practice-based network for federally qualified health centers. Instrument: A semi-structured interview guide created by the study team included questions regarding: 1) impact of the pandemic on FI screening and interventions; 2) changes to community resources and clinic-community partnerships; and 3) impact of the pandemic on patient food needs. Outcome Measures: Themes and exemplar quotes related to the impact of the pandemic on identifying and addressing FI in rural primary care were identified. Results: Thirteen staff and clinicians from unique rural primary care practices participated in interviews. Themes were organized around categories of Screening/Intervention Processes, Community Factors, Patient Factors, External Factors, and Practice Factors. Key themes included: 1) changes in screening and interventions due to telemedicine; 2) new and stronger connections between practices and community programs; 3) decreased patient stigma around accessing food resources; 4) new practice- based food programs facilitated by state and federal funding; and 5) greater practice prioritization of FI. Conclusions: Barriers to FI screening and interventions during the pandemic included geographic distance and loss of existing food programs. Facilitators included new community connections, decrease in stigma, and increased funding. Identifying and addressing FI was a priority for rural primary care practices during the pandemic., Presenters Arvind Suresh, BA, Kayla Hatchell, MD, Maureen Boardman, APRN, ARNP, Chelsey Canavan, MSPH, Tiffany D'cruze, BA, Alka Dev, DrPH, MHS, Meaghan Kennedy, MD, [...]

Context: An effective clinic-based population care management program requires an accurate understanding of the complexity and care needs of the patient population. Patient empanelment is the assignment of patients to a provider and/or provider team. However, many patient empanelment methodologies are unidimensional, focusing solely on clinic use or disease state or severity, and do not address the wholistic care needs of the patient. Objective: This study develops a Patient Resource Intensity Scale (PRIS) that includes three dimensions based on resource use, severity, and social determinants of health. The goal is to accurately categorize patients according to their care needs and develop care teams who can meet these needs. Study Design and Analysis: Create and validate a patient stratification scale using a retrospective longitudinal analysis. Setting, Dataset, and Population Studied: The study setting is a large primary care safety net system with 32 sites and over 100,000 patients. The dataset consists of all patients seen by the clinic over a 3-year period (2019-2021). Data were extracted from the electronic health record and the billing system. Instrument: We developed the PRIS scale which incorporates three dimensions: 1) Chronicity/Severity; 2) Resource Intensity/Utilization; and 3) Social Determinants of Health. Outcome Measures and Results: The PRIS scale was used to assign patients to four quadrants based on chronicity and resource use. Patients in each quadrant were then classified according to social determinants of health (SDoH) risk. The findings indicate that approximately 83% of the patients were categorized into Quadrant 1 (low resource, low chronicity); approximately 16% in Quadrant 2 (high resource, low chronicity), and less than 0.7% are categorized in Quadrants 3 (high resource, low chronicity) and 4 (high resource, high chronicity) respectively. Conclusions: Many population care management strategies rely on one dimension, such as total resource use or diagnosis, which often fail to address the complexity of the patient care needs. The PRIS scale developed in this study can be used to better serves the needs of the patient population. The study findings are used to develop interdisciplinary care team models based on patient needs., Presenters Kailey Love, MBA, MS, Jaeson Fournier, MPH, D.C, Nicholas Yagoda, MD, George Runger, William Riley, [...]

Context: The high dose flu vaccination is newly available to Canadians and recommended for adults aged 65 years and older. Describing patterns of flu vaccination in Canadian primary care using electronic medical records (EMR) is challenging. However, we have established that by using a combination of the ATC code and the lot number of the product administered, we can differentiate between high and standard dose flu vaccination using routinely collected structured EMR data. Objectives: 1) Construct a baseline cohort of patients who received a flu vaccine during the 2018- 2019 and 2019-2020 flu seasons. 2) Describe age, SES and comorbidity related patterns of standard vs. high dose flu vaccination. Design: Baseline cohort pilot study Dataset: Data from the Eastern Ontario Network (EON), a repository of EMR data drawn from primary care practices in south-eastern Ontario. Population Studied: Patients aged 65 and older who received a flu vaccination in a primary care setting during the 2018-2019 and/or 2019-2020 flu seasons (June 1 2018-May 31 2020). Outcome Measures: Flu vaccinations were determined by ATC code (J07BB). All patients who were vaccinated with a high dose lot number product were classified as 'high dose', all others were classified as 'standard dose'. Logistic regression was used to describe odds of high vs standard dose flu vaccinations related to age, sex, location, socioeconomic status, and comorbidity. Results: Baseline cohorts of patients aged 65 and older who received flu vaccinations during the 2018-2019 (n=19,037) and 2019-2020 (n=18,908) flu seasons were constructed. Over one-third of patients 65 and older received a high dose flu vaccination in the 2018- 2019 (36.6%) and 2019-2020 (35.4%) flu seasons. Both cohorts (2019-2019 vs 2019-2020) were also similar in age (75.8 [+ or -] 7.6 vs. 75.9 [+ or -] 7.6 years old), sex (54.6% vs. 54.2% female), and location (65.2% vs 64.2% live in an urban setting). Age was the strongest predictor of having received a high dose flu vaccine for both cohorts. Patients aged 85 years and older were 1.44x (95% CI 1.29-162; 2018-2019) and 1.86x (95% CI 1.65-2.08; 2019-2020) more likely to have received a high dose flu vaccine compared to patients aged 65 to 69. Conclusion: Overall, Canadian primary care EMR data was effectively used to compare patterns of high and standard dose flu vaccinations in patients aged 65+. Future work will describe patterns of subsequent respiratory infections stratified by flu vaccine dose., Presenters Rebecca Theal, Rachael Morkem, MSc, David Barber, MD, BSc, John Queenan, PhD, BA, MSc, Lorne [...]

Context. Implementation of routine screening for cervical cancer and colorectal cancer (CRC) is suboptimal. Primary care is an ideal venue for disseminating self-sampling screening tools, allowing patients to collect a sample at home and send it to a lab for testing. These tools can increase population-level cancer screening and reduce cancer disparities. Objective. Assess the preliminary outcomes and acceptability of an intervention 'package' to increase cancer screening using self-sampling tools among underserved patients. This package includes a novel tool (i.e., HPV self-sampling for cervical cancer screening) and a more established tool (i.e., fecal immunochemical test [FIT] for CRC screening). Study Design and Analysis. Pilot randomized controlled trial, with telephone-administered surveys at baseline and 10-weeks follow-up. We used Fisher's exact tests to assess differences in outcome measures by study arm. Setting. Federally-qualified health centers in rural and racially- segregated counties in Pennsylvania. Population Studied. Average-risk, female patients, ages 50-65, who were eligible but out-of-date with both cervical cancer screening and CRC screening (n=48). Intervention. Participants in the intervention arm received an intervention package providing educational materials and self-sampling tools for cervical and CRC screening. Participants in the standard of care arm received a reminder to schedule cancer screening. Outcome Measures. The primary outcomes were self-reported receipt of screening for cervical cancer and for CRC at follow-up. Additional outcomes among participants in the intervention arm were return, results, and acceptability of self-sampling tools. Results. Cervical cancer screening at follow-up was higher for the intervention vs. standard of care arm (89% vs. 11%, p Conclusions. A bundled package of self-sampling tools improved screening for cervical cancer and CRC and was acceptable for among underserved patients in primary care. These tools have the potential to increase screening and reduce disparities in cancer outcomes., Presenters Jennifer Moss, PhD, Paul Reiter, PhD, Lisa Klesges, Tracy Onega, [...]

Patients with complex conditions require a multidisciplinary effort to optimize care and control costs. Care coordination is the goal, but getting there can be a challenge. What role should primary [...]

It has become common to observe that the COVID-19 pandemic has unmasked--again (1) --the inequities in health care that Black, Latino, and poor patients face in access to and delivery [...]

Introduction: The disproportionate time required to effectively manage psychosocial concerns is a key barrier to advancing delivery of behavioral care by primary care providers. Improved time efficiency is one potential benefit of the integration of behavioral health consultants (BHCs) into pediatric care, but few studies have systematically studied this outcome. We examined the impact of embedded BHCs on duration of medical encounters in a pediatric primary care clinic. Method: We conducted a retrospective matched-pairs analysis of encounters involving behavioral consultations versus encounters for similar patients that did not include a consultation (N = 114) using electronic health record timestamp data. We examined both medical duration (i.e., medical provider services) and total duration (i.e., medical services + behavioral consultation). Results: Patient encounters involving behavioral consultation had a significantly longer (+11.23 min) total duration than matched controls, but significantly shorter (-11.67 min) medical duration. Discussion: The results indicate BHCs may improve primary care provider efficiency for patients with behavioral concerns, a notable finding given the impact of clinical time-constraints on important health care outcomes. Keywords: integrated care, pediatrics, primary care, workflow, The time required to adequately manage psychosocial concerns is a significant barrier to behavioral services in pediatric primary care. Medical visits involving psychosocial concerns are significantly longer than those without [...]

Introduction: Although behavioral health treatment can improve distress and pain functioning for patients with chronic pain, few who are referred by their primary care physician will see a behavioral health specialist. Given the benefits of integrating behavioral health into primary care, this may be an avenue for delivering a psychological intervention for chronic pain. The purpose of this study was to optimize a psychological intervention for patients with chronic pain to be delivered in primary care, utilizing the perspectives of providers and patients. Method: Psychologists (n = 9), primary care providers (n = 9), and patients with chronic pain (n = 9) participated in separate focus groups. Participants reviewed the proposed 4-session intervention, provided feedback prompted by a set of open-ended questions, and completed a survey. Results: Statements from focus groups were transcribed and coded into 2 thematic categories: (a) content of the intervention and (b) logistics and design. Participants believed that offering a brief, behavioral intervention for chronic pain in a primary care clinic was feasible and useful. All providers (100%) agreed or strongly agreed that they would refer a patient to this intervention, and 100% of patients agreed or strongly agreed that they would participate. Discussion: Feedback solicited from the focus groups led to alterations to the treatment manual, such as adding a fifth session, using different psychological strategies, and logistical changes in delivery (i.e., meeting biweekly and intervisit contacts). The modified version of this intervention will be evaluated with a pilot randomized controlled clinical trial. Keywords: chronic pain, primary care, behavioral intervention, psychology, Approximately 100 million Americans suffer from chronic pain (American Academy of Pain Medicine, 2011). The biopsychosocial model, which posits that pain is affected by social and psychological components, suggests that [...]

Extant research provides equivocal conclusions if the combined presentation of health anxiety with severe somatic symptoms confers risk for greater future primary care usage. The present study further examined the combination of health anxiety and somatic symptoms as a predictor of healthcare usage in primary care. Using a prospective longitudinal design, a large sample (N = 530) of patients presenting for treatment at a community health center completed self-report measures assessing health anxiety and somatic symptom severity. A medical record review at the time of questionnaire administration and 1 year following that administration was completed to assess the frequency of medical visits during the preceding and subsequent year. As expected, the interactive effect between health anxiety and somatic symptom severity predicted greater subsequent year medical visits. Covariates included preceding year medical visits, sociodemographic variables, body mass index, smoking status, and depressive symptom severity. Simple effects indicated that health anxiety predicted greater subsequent year medical visits when coupled with relatively severe, but not mild, somatic symptoms. Assessing health anxiety and somatic symptom severity in primary care settings could be important for identifying individuals at risk for future frequent healthcare visits and who may benefit from intervention., Author(s): Thomas A. Fergus [sup.1] , Lance P. Kelley [sup.2] , Jackson O. Griggs [sup.2] Author Affiliations: (Aff1) 0000 0001 2111 2894, grid.252890.4, Department of Psychology and Neuroscience, Baylor University, [...]

Background There is a rising prevalence of multimorbidity, particularly in older patients, and a need for evidence-based medicines management interventions for this population. The Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care (SPPiRE) trial aimed to investigate the effect of a general practitioner (GP)-delivered, individualised medication review in reducing polypharmacy and potentially inappropriate prescriptions (PIPs) in community-dwelling older patients with multimorbidity in primary care. Methods and findings We conducted a cluster randomised controlled trial (RCT) set in 51 GP practices throughout the Republic of Ireland. A total of 404 patients, aged [greater than or equal to]65 years with complex multimorbidity, defined as being prescribed [greater than or equal to]15 regular medicines, were recruited from April 2017 and followed up until October 2020. Furthermore, 26 intervention GP practices received access to the SPPiRE website where they completed an educational module and used a template for an individualised patient medication review that identified PIP, opportunities for deprescribing, and patient priorities for care. A total of 25 control GP practices delivered usual care. An independent blinded pharmacist assessed primary outcome measures that were the number of medicines and the proportion of patients with any PIP (from a predefined list of 34 indicators based predominantly on the STOPP/START version 2 criteria). We performed an intention-to-treat analysis using multilevel modelling. Recruited participants had substantial disease and treatment burden at baseline with a mean of 17.37 (standard deviation [SD] 3.50) medicines. At 6-month follow-up, both intervention and control groups had reductions in the numbers of medicines with a small but significantly greater reduction in the intervention group (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI]: 0.899 to 0.999, p = 0.045). There was no significant effect on the odds of having at least 1 PIP in the intervention versus control group (odds ratio [OR] 0.39, 95% CI: 0.140 to 1.064, p = 0.066). Adverse events recorded included mortality, emergency department (ED) presentations, and adverse drug withdrawal events (ADWEs), and there was no evidence of harm. Less than 2% of drug withdrawals in the intervention group led to a reported ADWE. Due to the inability to electronically extract data, primary outcomes were measured at just 2 time points, and this is the main limitation of this work. Conclusions The SPPiRE intervention resulted in a small but significant reduction in the number of medicines but no evidence of a clear effect on PIP. This reduction in significant polypharmacy may have more of an impact at a population rather than individual patient level. Trial registration ISRCTN Registry ISRCTN12752680., Author(s): Caroline McCarthy 1,*, Barbara Clyne 1, Fiona Boland 1,2, Frank Moriarty 1,3, Michelle Flood 3, Emma Wallace 1, Susan M. Smith 1, for the SPPiRE Study team Introduction Advances [...]

Primary care is in a bad place. Physicians feel undervalued. Cumbersome technology, administrative burdens and payer hassles mean physicians are unable to spend the time they want with their patients. [...]

Introduction: Service users' involvement as cofacilitators of mental health trainings is a nascent endeavor in low- and middle-income countries, and the role of families on service user participation in trainings has received limited attention. This study examined how caregivers perceive and facilitate service user's involvement in an antistigma program that was added to mental health Gap Action Program (mhGAP) trainings for primary care workers in Nepal. Method: Service users were trained as cofacilitators for antistigma and mhGAP trainings delivered to primary care workers through the REducing Stigma among HealthcAre ProvidErs (RESHAPE) program. Key informant interviews (n = 17) were conducted with caregivers and service users in RESHAPE. Results: Five themes emerged: (a) Caregivers' perceived benefits of service user involvement included reduced caregiver burden, learning new skills, and opportunities to develop support groups. (b) Caregivers' fear of worsening stigma impeded RESHAPE participation. (c) Lack of trust between caregivers and service users jeopardized participation, but it could be mitigated through family engagement with health workers. (d) Orientation provided to caregivers regarding RESHAPE needed greater attention, and when information was provided, it contributed to stigma reduction in families. (e) Time management impacted caregivers' ability to facilitate service user participation. Discussion: Engagement with families allows for greater identification of motivational factors and barriers impacting optimal program performance. Caregiver involvement in all program elements should be considered best practice for service user-facilitated antistigma initiatives, and service users reluctant to include caregivers should be provided with health staff support to address barriers to including family. Keywords: mental health, caregivers, service users, family, stigma, In global mental health, the participation of mental health service users and their family members in advocacy, training, service, and research has been identified as a strategy to improve the [...]

As healthcare continues its slow but steady shift to a value-based landscape, good care coordination is becoming crucial for physician practices to thrive and for patients to get the best [...]

The AAFP has released a new position paper (https:// www.aafp.org/about/policies/all/visionprinciples-qualitymeasurement.html) aimed at helping steer the future development and use of quality measures in initiatives related to practice improvement and physician [...]

Before entering medicine, I was inspired by community organizing as a model for driving social change and improving public health. As a clinician, I remain inspired by this approach; however, I find that it has been more challenging to integrate into my day-to-day work than I expected. In this essay, I describe my journey from community organizer to primary care clinician and reflect on the lessons I've learned about the value of community organizing and ways that it can be incorporated into clinical practice. Ultimately, I propose a model for how clinicians and health centers can proactively partner with community organizing groups and facilitate referrals to help patients directly engage in transforming the root causes of their health challenges. This model shifts the focus from the patient as an individual agent of change to the community, and offers important lessons to clinicians interested in community health equity. Key words: community participation; social change; emigrants and immigrants; health equity; social determinants of health; community health services, I was elbow-deep in my Step One boards review book when I received the call. 'The state senate just added a bunch of anti-immigrant amendments to the budget,' Roberto told [...]

ON PAPER, care coordination looks simple: primary care physicians and specialists collaborating to provide the best treatment for patients. Virtually all primary care physicians engage in coordinated care to some [...]

Objective To evaluate the implementation of a programme to provide primary care physicians for remote and deprived populations in Brazil. Methods The Mais Medicos (More Doctors) programme was launched In July 2013 with public calls to recruit physicians for priority areas. Other strategies were to increase primary care infrastructure investments and to provide more places at medical schools. We conducted a quasi-experimental, before-and-after evaluation of the implementation of the programme in 1708 municipalities with populations living in extreme poverty and in remote border areas. We compared physician density, primary care coverage and avoidable hospitalizations in municipalities enrolled (n=1450) and not enrolled (n=258) in the programme. Data extracted from health information systems and Ministry of Health publications were analysed. Findings By September 2015,4917 physicians had been added to the 16 524 physicians already In place In municipalities with remote and deprived populations. The number of municipalities with [greater than or equal to] 1.0 physician per 1000 inhabitants doubled from 163 in 2013 to 348 in 2015. Primary care coverage in enrolled municipalities (based on 3000 inhabitants per primary care team) increased from 77.9% in 2012 to 86.3% in 2015. Avoidable hospitalizations in enrolled municipalities decreased from 44.9% in 2012 to 41.2% in 2015, but remained unchanged in control municipalities. We also documented higher infrastructure investments in enrolled municipalities and an increase in the number of medical school places over the study period. Conclusion Other countries having shortages of physicians could benefit from the lessons of Brazil's programme towards achieving universal right to health. Objectif Evaluer la mise en oeuvred'un programme destine a renforcer la presence de medecins generalistes aupres des populations isolees et defavorisees du Bresil. Methodes Dans le cadre du programme Mais Medicos (plus de medecins), qui a debute en juillet 2013, des appels publics ont ete lances afin de recruter des medecins dans les zones prioritaires. D'autres strategies ont consiste a augmenter les investissements dans les infrastructures de soins primaires et a ouvrir plus de places dans les ecoles de medecine. Nous avons realise une evaluation quasi-experimentale, avant-apres, de la mise en oeuvre du programme dans 1708 municipalites dont certaines populations vivaient en situation d'extreme pauvrete ainsi que dans des zones frontalieres reculees. Nous avons compare la densite de praticiens, la couverture desoins primaires et le nombre d'hospitalisations evitables dans les municipalites qui participaient au programme (n=1450) et celles qui n'y participaient pas (n=258). Des donnees extraites de systemes d'information sanitaire et de publications du ministere de la Sante ont ete analysees. Resultats Au mois de septembre 2015,4917 medecins etaient venus s'ajouter aux 15 524 praticiens deja en place dans des municipalites ou vivaient des populations isolees ou defavorisees. Le nombre de municipalites comptant [greater than or equal to] 1,0 medecin pour 1000 habitants avait double, passant de 163 en 2013 a 348 en 2015. La couverture de soins primaires dans les municipalites participantes (sur la base de 3000 habitants par equipe de soins primaires) etait passee de 77,9% en 2012 a 86,3% en 2015. Le nombre d'hospitalisations evitables dans les municipalites participantes etait passe de 44,9% en 2012 a 41,2% en 2015, mais etait reste identique dans les municipalites temoins. Sur la periode etudiee, nous avons egalement observe une hausse des investissements dans les infrastructures dans les municipalites participantes ainsi qu'une augmentation du nombre de places dans les ecoles de medecine. Conclusion D'autres pays qui souffrent d'une penurie de medecins pourraient s'inspirer des lecons du programme bresilien pour garantir le droit de tous a la sante. Objetivo Evaluar la implementacion de un programa que ofrezca medicos de atencion primaria para poblaciones remotasy desfavorecidas de Brasil. Metodos En julio de 2013 se lanzo el programa Mais Medicos (Mas Medicos), el cual hizo un llamamiento publico para contratar medicos para zonas prioritarias. Otras estrategias fueron aumentar las inversiones en infraestructuras de atencion primarla y proporcionar mas plazas en las escuelas de medicina. Se realizo una evaluacion cuasiexperimental antes y despues de la implementacion del programa en 1 708 municipios con una poblacion en extrema pobreza, asi como en zonas fronterizas remotas. Se comparo la densidad de medicos, la cobertura de atencion primaria y las hospitalizaciones evitables en los municipios inscritos [n = 1 450) y no inscritos (n=258) en el programa. Se analizaron los datos recopilados de los sistemas de informacion sanitaria y de publicaciones del Ministerio de Sanidad. Resultados En septiembre de 2015, se sumaron 4 917 medicos a los 16 524 que ya se encontraban en municipios con poblaciones remotas y desfavorecidas. El numero de municipios con [greater than or equal to] 1,0 medico por cada 1 000 habitantes se duplico, de 163 en 2013 a 348 en 2015. La cobertura de atencion primaria en municipios inscritos (basada en 3 000 habitantes por equipo de atencion primaria) aumento de un 77,9% en 2012 a un 86,3% en 2015. Las hospitalizaciones evitables en municipios Inscritos se redujeron de un 44,9% en 2012 a un 41,2% en 2015, pero permanecieron sin cambios en los municipios de control.Tambien se documentaron mayores inversiones en infraestructuras en los municipios inscritos y un aumento en el numero de plazas de las escuelas de medicina durante el periodo de estudio. Conclusion Otros paises con escasez de medicos podrian beneficiarse de las lecciones del programa brasileno para conseguir un derecho universal a la sanidad., Introduction Brazil's large territory, partially covered by dense forests, is a challenge for efforts to achieve universal health access and coverage for the population. After the re-establishment of democracy and [...]

Introduction: We developed the Practice Integration Profile (PIP) to measure the degree of behavioral health integration in clinical practices with a focus on primary care (PC). Its 30 items, completed [...]

Objectives We sought to determine rates and correlates of accessing health care in the 2 years following delivery among women at an urban academic medical center. Methods We used electronic medical records, discharge, and billing data to determine the occurrence of primary care, other non-primary outpatient care, emergency department visits, and inpatient admissions among women delivering at a single medical center who had a known primary care affiliation to that medical center over a 5 year period. We explored sociodemographic, clinical, and health care-related factors as correlates of care, using bivariate and multivariable modeling. Results Of 6216 women studied, most (91 %) had had at least one health care visit in the window between 2 months and 2 years postpartum (the 'late postpartum period'). The majority (81 %) had had a primary care visit. Factors associated with use of health care in this period included a chronic medical condition diagnosed prior to pregnancy (adjusted odds ratio (AOR) 1.42, 95 % CI [1.19, 1.71]), prenatal care received in an urban community health center (AOR 1.35 [1.06, 1.73]), having received obstetric (AOR 1.90 [1.51, 2.37]), primary (AOR 2.30 [1.68, 3.23]), or other non-primary outpatient care (AOR 2.35 [1.72, 3.39]) in the first 2 months postpartum, and living closer to the hospital [AOR for residence >17.8 miles from the medical center (AOR 0.74 [0.61, 0.90])]. Having had an obstetrical complication did not increase the likelihood of receipt of care during this window. Conclusions for Practice Among women already enrolled in a primary care practice at our medical center, health care utilization in the late postpartum period is high, but not universal. Understanding the characteristics of women who return for health care during this window, and where they are seen, can improve transitions of care across the life course and can provide opportunities for important and consistent interconception and well-woman messaging., Author(s): Allison Bryant[sup.1] , Tiffany Blake-Lamb[sup.1] , Ida Hatoum[sup.2] , Milton Kotelchuck[sup.1] [sup.3] Author Affiliations: (1) Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, 02114, Boston, [...]

HIGHLIGHTS * One reason for the mounting interest in direct primary care among physicians is the growing complexity of managing a practice in the current environment. * Some physicians are [...]

Primary care has always been central to a high-functioning healthcare system. But as the industry moves from fee for service (FFS) to value-based care, the role of primary care has [...]

Colorectal cancer is the third most commonly diagnosed cancer and the fourth leading cause of death in the world. There are few published studies that have used theory-based interventions designed to increase colorectal cancer screening in community lay health organizations. The present study was guided by the theoretical concepts of the preventive health model. Twelve health clubs of a municipal district in Tehran were randomized to two study groups with equal ratio. The control group received usual services throughout the study while the intervention group also received a theory-based educational program on colorectal cancer screening plus a reminder call. Screening behavior, the main outcome, was assessed 4 months after randomization. A total of 360 members aged 50 and older from 12 health clubs completed a baseline survey. Participants in the intervention group reported increased knowledge of colorectal cancer and screening tests at 4 months follow-up (p's < .001). Moreover, exposure to the theory-based intervention significantly improved self-efficacy, perceived susceptibility, efficacy of screening, social support, and intention to be screened for colorectal cancer, from baseline to 4 months follow-up (p's < .001). The screening rate for colorectal cancer was significantly higher in the intervention group compared to the control group (odds ratio = 15.93, 95 % Cl = 5.57, 45.53). Our theory-based intervention was found to have a significant effect on colorectal cancer screening use as measured by self-report. The findings could have implications for colorectal cancer screening program development and implementation in primary health care settings and through other community organizations. Keywords Cancer early detection * Health education * Patient education * Standards, Introduction Colorectal cancer is the third most commonly diagnosed cancer and the fourth leading cause of death in the world (Ferlay et al., 2010; Jemal et al., 2009). Colorectal cancer [...]

In many ways, women are ideal patients. After all, they're more likely than men to have a primary care doctor and to comply with preventive care recommendations. But there's a [...]

Ask a primary care physician (PCP) to name the most common health challenges adult male patients face, and chances are that he or she will tick off a familiar list, [...]

New hepatitis C treatments, along with recommendations that all Baby Boomers be screened for the disease, are expected to fill up the schedules for physicians who specialize in treating this [...]

As the healthcare landscape moves to patient-centered models, it is imperative that whole-person care, which includes creating strategies for large populations of patients, be an integral part of behavioral healthcare. [...]

The future and success of primary care may rest on its ability to engage patients in entirely new ways. Driven by cost containment, adoption of technology, the need for patient [...]

Problem The Brazilian population lacks equitable access to specialized health care and diagnostic tests, especially in remote municipalities, where health professionals often feel isolated and staff turnover is high. Telehealth has the potential to improve patients' access to specialized health care, but little is known about it in terms of cost-effectiveness, access to services or user satisfaction. Approach In 2005, the State Government of Minas Gerais, Brazil, funded the establishment of the Telehealth Network, intended to connect university hospitals with the state's remote municipal health departments; support professionals in providing tele-assistance; and perform tele-electrocardiography and teleconsultations. The network uses low-cost equipment and has employed various strategies to overcome the barriers to telehealth use. Local setting The Telehealth Network connects specialists in state university hospitals with primary health-care professionals in 608 municipalities of the large state of Minas Gerais, many of them in remote areas. Relevant changes From June 2006 to October 2011, 782 773 electrocardiograms and 30 883 teleconsultations were performed through the network, and 6000 health professionals were trained in its use. Most of these professionals (97%) were satisfied with the system, which was cost-effective, economically viable and averted 81% of potential case referrals to distant centres. Lessons learnt To succeed, a telehealth service must be part of a collaborative network, meet the real needs of local health professionals, use simple technology and have at least some face-to-face components. If applied to health problems for which care is in high demand, this type of service can be economically viable and can help to improve patient access to specialized health care. Probleme La population bresilienne manque d'un acces equitable aux soins de sante specialises et aux tests de diagnostic, surtout dans les communes reculees, ou les professionnels de sante se sentent souvent isoles et ou la rotation du personnel est elevee. La telesante peut ameliorer l'acces des patients aux soins de sante specialises, mais on sait peu de choses de son rapport cout-efficacite, de l'acces aux services ou de la satisfaction des utilisateurs. Approche En 2005, le gouvernement de l'Etat de Minas Gerais, au Bresil, a finance la creation d'un reseau de telesante, visant a relier les hopitaux universitaires aux services de sante municipaux recules de l'Etat, a soutenir les professionnels dans la teleassistance et a effectuer des tele-electrocardiographies et teleconsultations. Le reseau utilise un equipement a faible cout et a recouru a diverses strategies pour surmonter les obstacles relatifs a l'utilisation de la telesante. Environnement local Le reseau de telesante relie les specialistes des hopitaux universitaires de l'Etat aux professionnels des services de sante primaires de 608 communes du grand Etat de Minas Gerais, beaucoup d'entre eux se trouvant dans des zones reculees. Changements significatifs De juin 2006 a octobre 2011, 782 773 electrocardiogrammes et 30 883 teleconsultations ont ete effectues par l'intermediaire du reseau, et 6 000 professionnels de sante ont ete formes a son utilisation. La plupart de ces professionnels (97%) se sont montres satisfaits du systeme qui offrait un bon rapport cout-efficacite, etait economiquement viable et evitait 81% des renvois potentiels de cas vers des centres eloignes. Lecons tirees Pour etre un succes, un service de telesante doit faire partie d'un reseau collaboratif, satisfaire les besoins reels des professionnels de sante locaux, utiliser une technologie simple et disposer d'au moins quelques elements en face a face. En cas d'application a des problemes sanitaires pour lesquels la demande de soins est elevee, ce type de service peut etre economiquement viable et aider a ameliorer l'acces des patients aux soins de sante specialises. Situacion La falta de igualdad en el acceso de la poblacion brasilena a la asistencia sanitaria especializada y a las pruebas diagnosticas, en especial, en municipios remotos, en los que los profesionales sanitarios suelen sentirse aislados y la rotacion de personal es alta. La telesalud tiene el potencial de mejorar el acceso de los pacientes a la asistencia sanitaria especializada, pero se dispone de poca informacion en cuanto a la eficacia en relacion a los costes, al acceso a los servicios o a la satisfaccion del usuario. Enfoque En el ano 2005, el gobierno del estado de Minas Gerais, Brasil, financio el establecimiento de la Red de telesalud con la intencion de conectar los hospitales universitarios con los departamentos sanitarios de municipios remotos del estado, asi como para ayudar a los profesionales a que pudieran proporcionar asistencia y realizar electrocardiografias y consultas a distancia. La red utiliza equipos de bajo coste y ha empleado varias estrategias para superar las barreras del uso de la telesalud. Marco regional La red de telesalud conecta a los especialistas de los hospitales universitarios estatales con los profesionales de asistencia sanitaria primaria en 608 municipios del extenso estado de Minas Gerais, muchos de ellos en areas remotas. Cambios importantes Desde junio de 2006 hasta octubre de 2011, se realizaron 782 773 electrocardiogramas y 30.883 consultas a distancia a traves de la red y se formo a 6.000 profesionales sanitarios en su uso. La mayor parte de estos profesionales (97%) estaban satisfechos con el sistema, que ofrece una buena eficacia en relacion a los costes, es economicamente viable y evito el 81% de las referencias de casos potenciales a centros distantes. Lecciones aprendidas Para conseguir resultados, un servicio de telesalud debe formar parte de una red colaborativa, cubrir las necesidades reales de los profesionales sanitarios locales, utilizar tecnologias simples y tener al menos algunos componentes cara a cara. Si se aplica a los problemas sanitarios para los que existe una alta demanda de asistencia, este tipo de servicio puede ser economicamente viable y ayudar a mejorar el acceso del paciente a la asistencia sanitaria especializada., Introduction Brazil is a vast country of marked cultural, economic, geographic and infrastructural contrasts. It is composed of 27 federative units: 26 states and one federal district that contains the [...]

Summary Being involved in creative activity can have a powerful effect on people's physical, mental and emotional wellbeing. For people affected by long-term conditions, creative activities could form just as [...]

Objective: A strong primary care sector is widely acknowledged as a fundamental component of a well functioning health system and thus has been the focus of strategic reforms in a number of countries. This paper provides an economic analysis of primary healthcare reform, with the aim of identifying the key structural elements that are necessary to support enhanced models of primary health in the Australian context. Approach: This paper utilises economic theory, and draws upon empirical evidence and international experience to analyse primary healthcare reform to identify the structural elements necessary for an enhanced primary care sector. The aim of which is to improve health system performance. These structural elements are then critically examined in the Australian health system setting. Conclusion: For enhanced models of primary healthcare to promote efficiency, they must incorporate a number of key structural elements; notably: governance and purchasing responsibilities for primary care devolved to a meso-level organisational structure through capitated single fundholding arrangements; blended payment methods for reimbursing providers; the establishment of a national quality and performance framework; and the development of primary care infrastructure. Implications: As the Federal government attempts to address recommendations of the National Health and Hospital Reform Commission, a window of opportunity now exists to pursue long overdue structural reforms to deal with the challenges facing the Australian health system. The paper advances the important structural features to primary healthcare that need to be embraced as the government attempts to pursue its health reform agenda. Key words: primary healthcare, health reform, single funding, Australia. doi: 10.1111/j.1753-6405.2010.00622.x

Objective: To describe a multidisciplinary primary healthcare clinic for newly arrived humanitarian entrants in regional New South Wales and report health problems and issues encountered during the initial period of operation. Methods: A quality assurance study of the Coffs Harbour Refugee Health Clinic (a collaboration between the Area Health Service and general practitioners) was undertaken from February to December 2006. Results: Seventy-six patients received a comprehensive health assessment: 69 of these within 12 months of arrival. The median time from arrival in Australia to the first clinic visit was five days. Problems detected were categorised according to their management options. GP clinic providers expressed concern about referring patients to GPs in the community for ongoing care. Conclusions: The Coffs Harbour Refugee Health Clinic represents a successful collaboration between relevant stakeholders. It was well utilised by the target community. Implications: The service delivery model used in the clinic could be replicated in other areas in regional Australia, provided financial and human resources are available. Key words: refugee, primary healthcare, health assessment, screening. doi: 10.1111/j.1753-6405.2010.00535.x

Summary Healthcare professionals in primary care are gatekeepers to specialist services and are important in terms of ensuring access to community support and appropriate referral for the sizable number of [...]

Introduction: In 2004, Mozambique, supported by large increases in international disease‐specific funding, initiated a national rapid scale‐up of antiretroviral treatment (ART) and HIV care through a vertical “Day Hospital” approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public‐sector PHC services. Case Description: In 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district‐level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow‐up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non‐HIV aspects of primary health care. Conclusion: The integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss‐to‐follow‐up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems., Introduction The rapid scale up of antiretroviral treatment (ART) and HIV care across Africa over the past five years has provoked an important and lively debate about the impact of [...]

Introduction: Lesotho has the third highest HIV prevalence in the world (an adult prevalence of 23.2%). Despite a lack of resources for health, the country has implemented state‐of‐the‐art antiretroviral treatment guidelines, including early initiation of treatment ( Programme approach: We describe two‐year outcomes of a decentralized HIV/AIDS care programme run by Doctors Without Borders/Médecins Sans Frontières, the Ministry of Health and Social Welfare, and the Christian Health Association of Lesotho in Scott catchment area, a rural health zone covering 14 clinics and one district hospital. Outcome data are described through a retrospective cohort analysis of adults and children initiated on ART between 2006 and 2008. Discussion and Evaluation: Overall, 13,243 people have been enrolled in HIV care (5% children), and 5376 initiated on ART (6.5% children), 80% at primary care level. Between 2006 and 2008, annual enrolment more than doubled for adults and children, with no major external increase in human resources. The proportion of adults arriving sick (CD4 Conclusion: Despite major resource constraints, Lesotho is comparing favourably with its better resourced neighbour, using the latest international ART recommendations. The successful two‐year outcomes are further evidence that HIV/AIDS care and treatment can be provided effectively at the primary care level. The programme highlights how improving HIV care strengthened the primary health care system, and validates several critical areas for task shifting that are being considered by other countries in the region, including nurse‐driven ART for adults and children, and lay counsellor‐supported testing and counselling, adherence and case management., Introduction Lesotho has the third highest HIV prevalence in the world (after Swaziland and Botswana), at 23.2% among adults aged 15 to 49 [1], and is the poorest of the [...]

Byline: Shankar. Acharya The authors have documented the profile of pediatric thoracolumbar (TL) fractures presenting to their center from 2002 to 2014. Being a retrospective study, the paper only documents [...]

Introduction: Implementation of safer conception services for HIV-affected couples within primary healthcare clinics in resource-limited settings remains limited. We review service utilization and safer conception strategy uptake during the first three years of Sakh'umndeni, which is a safer conception clinic in South Africa. Methods: Sakh'umndeni is located at Witkoppen Health and Welfare Centre, a high-volume primary healthcare clinic in northern Johannesburg. Men and women desiring to conceive in less than or equal to six months and in relationships in which one or both partners are living with HIV are eligible for safer conception services. Clients receive a baseline health assessment and counselling around peri-conceptiona HIV risk reduction strategies and choose which strategies they plan to use. Clients are followed-up monthly. We describe client service utilization and uptake and continuation of safer conception methods. Factors associated with male partner attendance are assessed using robust Poisson regression. Results: Overall 440 individuals utilized the service including 157 couples in which both partners attended (55%) and 126 unaccompanied female partners. Over half of the couples (55%) represented were in serodiscordant/unknown status relationships. Higher economic status and HIV-negative status of the women increased male partner involvement, while HIV-negative status of the men decreased male involvement. Regarding safer conception strategies, uptake of antiretroviral therapy initiation (90%), vaginal self-insemination among partnerships with HIV-negative men (75%) and timed condomless intercourse strategies (48%) were variable, but generally high. Overall uptake of pre-exposure prophylaxis (PrEP) was 23% and was lower among HIV-negative men than women (7% vs. 44%, p < 0.001). Male medical circumcision (MMC) was used by 28% of HIV-negative men. Over 80% of clients took up at least one recommended safer conception strategy. Continuation of selected strategies over attempted conception attempts was >60%. Conclusions: Safer conception strategies are generally used by clients per recommendations. High uptake of strategies suggests that the proposed combination prevention methods are acceptable to clients and appropriate for scale-up; however, low uptake of PrEP and MMC among HIV-negative men needs improvement. Targeted community-based efforts to reach men unlinked to safer conception services are needed, alongside streamlined approaches for service scale-up within existing HIV and non-HIV service delivery platforms. Keywords: HIV prevention; safer conception; serodiscordance; pre-exposure prophylaxis; self-insemination; timed condomless sex; implementation; sub-Saharan Africa, Introduction Efforts to conceptualize frameworks for safer conception care have increased in recent years in response to the realization that many individuals and couples living with or affected by HIV [...]

Acore problem with primary care today is a schedule that does not allow the physician to be effective. The primary care physician lacks the time to heal. The work of [...]

Primary care physicians say they find their practices increasingly beset by outside interference that gets in the way of effective patient treatment. When asked about the main problem facing primary [...]