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Objective: To describe telemedicine use patterns and understand clinic's approaches to shifting care delivery during the COVID-19 pandemic. Methods: We used electronic health record data from 203 community health centers across 13 states between 01/01/2019 and 6/31/2021 to describe trends in telemedicine visit rates over time. Qualitative data were collected from 13 of those community health centers to understand factors influencing adoption and implementation of telemedicine. Results: Most clinics in our sample were in urban areas (n = 176) and served a majority of uninsured and publicly insured patients (12.8% and 44.4%, respectively) across racial and ethnic minority groups (16.6% Black and 29.3% Hispanic). During our analysis period there was a 791% increase in telemedicine visits from before the pandemic (.06% pre- vs 47.5% during). A latent class growth analysis was used to examine differences in patterns of adoption of telemedicine across the 203 CHCs. The model resulted in 6 clusters representing various levels of telemedicine adoption. A mixed methods approach streamlined these clusters into 4 final groups. Clinics that reported rapid adoption of telemedicine attributed this change to leadership prioritization of telemedicine, robust quality improvement processes (eg, using PDSA processes), and emphasis on training and technology support. Conclusions: In response to the COVID-19 pandemic, telemedicine adoption rates varied across clinics. Our study highlight that organizational factors contributed to the clinic's ability to rapidly uptake and use telemedicine services throughout the pandemic. These approaches could inform future non-pandemic practice change and care delivery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve‐out" model to a "carve‐in" model integrating the financing of behavioral and physical health care. Data Sources/Study Setting: Medicaid claims data from Washington State, 2014–2019, supplemented with structured interviews with key stakeholders. Study Design: This mixed‐methods study used difference‐in‐differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve‐out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions. Data Collection: Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach. Principal Findings: The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%–2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness. Conclusions: Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve‐in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care. [ABSTRACT FROM AUTHOR]

Purpose: Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness.Methods: We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators.Results: Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators.Conclusions: Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes. [ABSTRACT FROM AUTHOR]

Purpose: We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care.Methods: We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes.Results: In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes.Conclusions: There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation. [ABSTRACT FROM AUTHOR]

Practice transformation, organizational change, innovation, quality improvement, professional practice, health extension, outreach, practice facilitation, primary care, burnout, health information technology, practice-based research. [Extracted from the article]

Purpose: Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations.Methods: In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score.Results: The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores.Conclusion: There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models. [ABSTRACT FROM AUTHOR]

Failed diffusion of innovations may be linked to an inability to use and apply data, information, and knowledge to change perceptions of current practice and motivate change. Using qualitative and quantitative data from three large-scale health care delivery innovations--accountable care organizations, advanced primary care practice, and EvidenceNOW--we assessed where data-driven innovation is occurring and where challenges lie. We found that implementation of some technological components of innovation (for example, electronic health records) has occurred among health care organizations, but core functions needed to use data to drive innovation are lacking. Deficits include the inability to extract and aggregate data from the records; gaps in sharing data; and challenges in adopting advanced data functions, particularly those related to timely reporting of performance data. The unexpectedly high costs and burden incurred during implementation of the innovations have limited organizations' ability to address these and other deficits. Solutions that could help speed progress in data-driven innovation include facilitating peer-to-peer technical assistance, providing tailored feedback reports to providers from data aggregators, and using practice facilitators skilled in using data technology for quality improvement to help practices transform. Policy efforts that promote these solutions may enable more rapid uptake of and successful participation in innovative delivery system reforms. [ABSTRACT FROM AUTHOR]

Background: Intervention toolkits are common products of grant-funded research in public health and primary care settings. Toolkits are designed to address the knowledge translation gap by speeding implementation and dissemination of research into practice. However, few studies describe characteristics of effective intervention toolkits and their implementation. Therefore, we conducted this study to explore what clinic and community-based users want in intervention toolkits and to identify the factors that support application in practice.Methods: In this qualitative descriptive study we conducted focus groups and interviews with a purposive sample of community health coalition members, public health experts, and primary care professionals between November 2010 and January 2012. The transdisciplinary research team used thematic analysis to identify themes and a cross-case comparative analysis to explore variation by participant role and toolkit experience.Results: Ninety six participants representing primary care (n = 54, 56%) and community settings (n = 42, 44%) participated in 18 sessions (13 focus groups, five key informant interviews). Participants ranged from those naïve through expert in toolkit development; many reported limited application of toolkits in actual practice. Participants wanted toolkits targeted at the right audience and demonstrated to be effective. Well organized toolkits, often with a quick start guide, with tools that were easy to tailor and apply were desired. Irrespective of perceived quality, participants experienced with practice change emphasized that leadership, staff buy-in, and facilitative support was essential for intervention toolkits to be translated into changes in clinic or public -health practice.Conclusions: Given the emphasis on toolkits in supporting implementation and dissemination of research and clinical guidelines, studies are warranted to determine when and how toolkits are used. Funders, policy makers, researchers, and leaders in primary care and public health are encouraged to allocate resources to foster both toolkit development and implementation. Support, through practice facilitation and organizational leadership, are critical for translating knowledge from intervention toolkits into practice. [ABSTRACT FROM AUTHOR]

Objectives. Little is known about clinicians' use of prescription drug monitoring program (PDMP) profiles in decision-making. The objective of this qualitative study was to understand how clinicians use, interpret, and integrate PDMP profiles with other information in making clinical decisions. Design. Qualitative interviews of clinician PDMP users. Setting. Oregon registrants in the state's PDMP. Subjects. Thirty-three clinicians practicing in primary care, emergency medicine, pain management, psychiatry, dentistry, and surgery. Methods. We conducted semistructured telephone interviews with PDMP users. A multidisciplinary team used a grounded theory approach to identify patterns of PDMP use and how PDMP profiles influence clinical decisions. Results. PDMP use varied from consistent monitoring to checking the PDMP only on suspicion of misuse, with inconsistent use reported particularly among short-term prescribers. Primary care clinicians reported less routine use with existing pain patients than with new patients. In response to worrisome PDMP profiles with new patients, participants reported declining to prescribe, except in the case of acute, verifiable conditions. Long-term prescribers reported sometimes continuing prescriptions for existing patients depending on perceived patient intent, honesty, and opioid misuse risk. Some long-term prescribers reported discharging patients from their practices due to worrisome PDMP profiles; others expressed strong ethical grounds for retaining patients but discontinuing controlled substances. Conclusion. Greater consistency is needed in use of PDMP in monitoring existing patients and in conformity to guidelines against discharging patients from practice. Research is needed to determine optimal approaches to interpreting PDMP profiles in relation to clinical judgment, patient screeners, and other information. [ABSTRACT FROM AUTHOR]

While an increasing number of researchers are using online discussion forums for qualitative research, few authors have documented their experiences and lessons learned to demonstrate this method’s viability and validity in health services research. We comprehensively describe our experiences, from start to finish, of designing and using an asynchronous online discussion forum for collecting and analyzing information elicited from care coordinators in Patient-Centered Medical Homes across the United States. Our lessons learned from each phase, including planning, designing, implementing, using, and ending this private online discussion forum, provide some recommendations for other health services researchers considering this method. An asynchronous online discussion forum is a feasible, efficient, and effective method to conduct a qualitative study, particularly when subjects are health professionals. [ABSTRACT FROM AUTHOR]

The article presents a study that investigates the efficacy of electronic health record (EHR) adoption in improving ambulatory care quality in the U.S. Researchers did a study on 798 diabetic patients found in 16 EHR. They found that EHR enhancement is not sure that it will boost the quality of EHR for diabetes care.

The article focuses on a team-based change management strategy in primary care through Using Learning Teams for Reflective Adaptation (ULTRA) study. It states that study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making. It states that there were improved practicewide communication in 12 of these practices.

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors. [ABSTRACT FROM AUTHOR]

PURPOSE Our objective was to identify themes that emerged from the evaluation of 17 interventions funded by the Robert Wood Johnson Foundation's Prescription for Health that aimed to enhance adherence to healthy behaviors in the primary care setting. METHODS We performed a content analysis of diary data from this 16-month initiative. Other data sources used to complement this analysis include funded grant applications and field notes from interviews with investigative teams and a limited number of site visits. Participants were 17 practice-based research networks (PBRNs) that had projects funded during Round 1 of Prescription for Health. RESULTS Five themes emerged regarding implementation of health behavior change: (1) health behavior change resources are enthusiastically received by practices and patients, and when given a choice, patients prefer methods of assistance that involve personal contact; (2) practice extenders require extensive training, as well as careful case management and support, in order to function fully and avoid burnout; (3) integrating behavior change tools into the primary care setting requires time, effort, and often specialized expertise; (4) even simple interventions require practice change, and use of a practice change model to guide implementation efforts is crucial; and (5) research philosophy and project management approaches vary across PBRNs and have implications for the potential sustainability of an intervention. CONCLUSIONS A more versatile, multifaceted solution involving new tools, technologies, and multidisciplinary care teams is needed in order to integrate health behavior change into everyday primary care routines. Even the best interventions require a model to articulate how to integrate an innovation into practices. [ABSTRACT FROM AUTHOR]

Background: Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs).Methods: This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs' EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes.Results: Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes.Conclusions: Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics' ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs.Trial Registration: ClinicalTrials.gov, NCT02325531. Registered 15 December 2014. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the editor discusses various reports published within the issue including one by Bodenheimer on his personal experience with chronic foot pain, one by Jones and Reis on mentoring, and one by Nordin on access and care continuity in patients.

Background: Primary care practices able to create linkages with community resources may be more successful at helping patients to make and sustain health behavior changes. Methods: Health behavior-change interventions in eight practice-based research networks were examined. Data were collected July 2005–October 2007. A comparative analysis of the data was conducted to identify and understand strategies used for linking primary care practices with community resources. Results: Intervention practices developed three strategies to initiate and/or implement linkages with community resources: pre-identified resource options, referral guides, and people external to the practice who offered support and connection to resources. To initiate linkages, practices required the capacity to identify patients, make referrals, and know area resources. Linkage implementation could still be defeated if resources were not available, accessible, affordable, and perceived as valuable. Linkages were facilitated by boundary-spanning strategies that compensated for the lack of infrastructure between practices and resources, and by brokering strategies that identified interested community partners and aided mutually beneficial connections with them. Linkages were stronger when they incorporated practice or resource abilities to motivate the patient, such as brief counseling or postreferral outreach. Further, data suggested that sustaining linkages requires continuous attention and ongoing communication between practices and resources. Conclusions: Creating linkages between primary care practices and community resources has the potential to benefit both patients and clinicians and to lessen the burden on the U.S. healthcare system resulting from poor health behaviors. Infrastructure support and communication systems must be developed to foster sustainable linkages between practices and local resources. [Copyright &y& Elsevier]

Introduction: Brief smoking-cessation interventions in primary care settings are effective, but delivery of these services remains low. The Centers for Medicare and Medicaid Services' Meaningful Use (MU) of Electronic Health Record (EHR) Incentive Program could increase rates of smoking assessment and cessation assistance among vulnerable populations. This study examined whether smoking status assessment, cessation assistance, and odds of being a current smoker changed after Stage 1 MU implementation.Methods: EHR data were extracted from 26 community health centers with an EHR in place by June 15, 2009. AORs were computed for each binary outcome (smoking status assessment, counseling given, smoking-cessation medications ordered/discussed, current smoking status), comparing 2010 (pre-MU), 2012 (MU preparation), and 2014 (MU fully implemented) for pregnant and non-pregnant patients.Results: Non-pregnant patients had decreased odds of current smoking over time; odds for all other outcomes increased except for medication orders from 2010 to 2012. Among pregnant patients, odds of assessment and counseling increased across all years. Odds of discussing or ordering of cessation medications increased from 2010 compared with the other 2 study years; however, medication orders alone did not change over time, and current smoking only decreased from 2010 to 2012. Compared with non-pregnant patients, a lower percentage of pregnant patients were provided counseling.Conclusions: Findings suggest that incentives for MU of EHRs increase the odds of smoking assessment and cessation assistance, which could lead to decreased smoking rates among vulnerable populations. Continued efforts for provision of cessation assistance among pregnant patients is warranted. [ABSTRACT FROM AUTHOR]

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7 percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs. [ABSTRACT FROM AUTHOR]

The article offers information on accountable care organizations (ACOs) are that aims to improve quality of care while controlling costs for populations of patients in the U.S. ACOs took conceptual shape in 2005 and with an objective to achieve the triple aim of better health, better care, and lower costs, payment and delivery systems.