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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.

Primary care is a key setting for the delivery of parent-focused behavioral interventions. Various methods of intervention show promising efficacy but fail to engage adequate parental participation. This study used a sequential-explanatory mixed-method design to understand factors underlying parents' attitudes toward the content, sources, and delivery methods of behavioral guidance in primary care. Fifteen parents who previously participated in a larger survey study participated in interviews about their experiences and attitudes toward integrated primary care. Qualitative data were analyzed and sorted by quantitative data of interest to identify demographic, child, and parental factors that shape attitudes toward integrated care. Parents emphasized a need for tailored behavioral guidance, and multiple interconnected factors (e.g., trust of providers, perceived convenience of delivery modalities, stigma associated with behavioral health services) drove parents' attitudes toward behavioral primary care. These attitudes varied based on socioeconomic status, child behavior symptoms, and reported use of corporal punishment. [ABSTRACT FROM AUTHOR]

Background: Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives.Objective: Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation.Study Design: We used an iterative mixed-methods design.Participants, Approach, and Measures: We collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation.Key Results: In the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: - 2.83, p < 0.01 for number of encounters, and - 2.04, p < 0.01 for number of months with encounters). Qualitative data showed that Health System and FQHC ownership influenced types of practices enrolled in EvidenceNOW, and suggested that in these practices lower autonomy and greater complexity compared to clinician-owned ownership influenced facilitation participation patterns.Conclusions: Practice ownership shaped how but not how much practices participated in external facilitation. This finding highlights the importance of tailoring facilitation approaches based on ownership-related characteristics in future QI initiatives. [ABSTRACT FROM AUTHOR]

Interactive online diaries are a novel approach for evaluating project implementation and provide real-time communication between evaluation staff members and those implementing a program. Evaluation teams can guide the lines of inquiry and ensure that data are captured as implementation develops. When used together with conventional evaluation strategies, interactive online diaries allow for an in depth understanding of project implementation, as well as the challenges program staff members confront and the solutions they develop. Interactive online diaries also can help evaluators address challenges such as self-reporting bias, documenting project evolution, and capturing implementers' ongoing insights as they develop. These insights might otherwise be lost to the evaluation process. The authors describe the development and use of this online approach in the evaluation of a foundation-sponsored program to improve the provision of preventive care in physicians offices. The program included 17 practice-based research networks and their participating primary care practices. [ABSTRACT FROM AUTHOR]

Background: This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts.Methods: We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force.Results: Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns.Conclusions: Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations. [ABSTRACT FROM AUTHOR]

Background: Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children's coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children's insurance assistance.Methods: We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784).Results: Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14-1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68-0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64-2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53-0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used.Conclusions: This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care.Trial Registration: ClinicalTrials.gov, NCT02298361 ; retrospectively registered on November 5, 2014. [ABSTRACT FROM AUTHOR]

The article presents a cross-sectional study on the cultural and structural features of zero-burnout primary care practices in the U.S. In the study, the practices of small-to-medium-size primary care clinics taking part in the Agency for Healthcare Research and Quality's EvidenceNOW program were analyzed. Other topics include the potential strategies to prevent burnout like promoting leadership development and fostering practice agency.

Background: Two primary care clinics implemented an opioid use disorder (OUD) treatment program that integrates behavioral health counseling with buprenorphine treatment and uses tiers. This project aimed to understand how patients moved through tiers in this program. Method: We purposively sampled 20 patients with at least 10 OUD-related treatment visits; we documented tier changes at all visits between September 1, 2016 and December 31, 2018 using a standard data collection instrument. These data were used to construct run-charts. Results: About 45% of sampled patients had at least one relapse noted and 60% of patients dropped in tier during the study. Reductions in tier often happened when the patient was navigating difficult psychosocial situations in their life, whereas increases in tier often accompanied positive life events. We also found variation in use of the tiers. Discussion: OUD treatment from two clinics by tier illustrates that recovery is an individualized process based on patient need that can fluctuate due to psychosocial triggers and significant life events. Having tiers can guide treatment and provide both clinicians and patients with information about what to expect during treatment while still allowing the flexibility to meet patients where they are. (PsycInfo Database Record (c) 2021 APA, all rights reserved). [ABSTRACT FROM AUTHOR]

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]

Introduction: A practice embarks on a radical reformulation of how care is designed and delivered when it decides to integrate medical and behavioral health care for its patients and success depends on managing complex change in a complex system. We examined the ways change is managed when integrating behavioral health and medical care.Method: Observational cross-case comparative study of 19 primary care and community mental health practices. We collected mixed methods data through practice surveys, observation, and semistructured interviews. We analyzed data using a data-driven, emergent approach.Results: The change management strategies that leadership employed to manage the changes of integrating behavioral health and medical care included: (a) advocating for a mission and vision focused on integrated care; (b) fostering collaboration, with a focus on population care and a team-based approaches; (c) attending to learning, which includes viewing the change process as continuous, and creating a culture that promoted reflection and continual improvement; (d) using data to manage change, and (e) developing approaches to finance integration.Discussion: This paper reports the change management strategies employed by practice leaders making changes to integrate care, as observed by independent investigators. We offer an empirically based set of actionable recommendations that are relevant to a range of leaders (policymakers, medical directors) and practice members who wish to effectively manage the complex changes associated with integrated primary care. (PsycINFO Database Record [ABSTRACT FROM AUTHOR]

Introduction: Buprenorphine, a medication for opioid use disorder (OUD), can be administered within primary care; however, little is known about characteristics associated with retention on buprenorphine in these settings. This study examines patient correlates of buprenorphine retention and whether an integrated, interdisciplinary treatment model (buprenorphine and behavioral health) is associated with higher odds of buprenorphine retention than a primarily medication-only treatment model.Methods: Electronic health record data from adult patients with an OUD, ≥1 buprenorphine order and ≥1 visit to either of two primary care clinics between 9/2/2014-6/27/2018 were extracted (N = 494 patients). Two research team members reviewed the medication start and stop dates for each buprenorphine order and classified as retained (≥6 months of orders) or not retained (<6 months of orders). Logistic regressions estimated the odds of retention on buprenorphine by 1) patient characteristics and 2) timing of patient's engagement in buprenorphine treatment (pre- or post-implementation of an integrated treatment model).Results: Of the study sample, 53% had ≥6 months of buprenorphine orders. Almost two times higher odds of retention were found among patients with ≥1 psychiatric comorbidity (versus none) and among those with buprenorphine orders in the post- versus pre-period.Conclusions: An integrated, interdisciplinary model of OUD treatment was associated with ≥6 months of buprenorphine orders among our study population. Continued research is needed in real-world primary care settings to understand the impact of OUD treatment models on patient outcomes. A more nuanced examination of the associations between psychiatric diagnoses and buprenorphine treatment retention is warranted. [ABSTRACT FROM AUTHOR]