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PURPOSE Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients. METHODS The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative. RESULTS At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers. CONCLUSIONS Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis. Key words: quality improvement; pregnancy, high risk; maternal health; postpartum period; primary health care; medical record linkage; registries; continuity of patient care; preventive medicine, INTRODUCTION Maternal mortality rates have continued to rise nationally, with non-Hispanic Black birthing people being disproportionately affected--in 2020, they were almost 3 times more likely to die than non-Hispanic White [...]

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 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. Key words: practice facilitation; quality improvement; large-scale initiative; capacity building; implementation facilitation; organizational change; organizational innovation, INTRODUCTION Practice facilitators are trained individuals who build medical practices' capacity to make meaningful operational changes aligned with current evidence. (1,2) Facilitators provide education, motivation, accountability, and guidance on organizational [...]

The World Organization of Family Doctors (WONCA) developed the third edition of the International Classification of Primary Care (ICPC-3) to support the shift from a medical perspective to a person-centered perspective in primary health care. The previous editions (ICPC-1 and ICPC-2) allowed description of 3 important elements of health care encounters: the reason for the encounter, the diagnosis and/or health problem, and the process of care. The ICPC-3 adds function-related information as a fourth element, thereby capturing most parts of the encounter in a single practical and concise classification. ICPC-3 thus has the potential to give more insight on patients' activities and functioning, supporting physicians in shifting from a strict medical/disease-based approach to care to a more person-centered approach. The ICPC-3 is also expanded with a new chapter for visits pertaining to immunizations and for coding of special screening examinations and public health promotion; in addition, it contains classes for programs related to reported conditions (eg, a cardiovascular program, a heart failure program) and can accommodate relevant national or regional classes. Classes are selected based on what is truly and frequently occurring in daily practice. Each class has its own codes. Less frequently used concepts pertaining to morbidity are captured as inclusions within the main classes. Implementation of the ICPC-3 in an electronic health record allows provision of meaningful feedback to primary care, and supports the exchange of information within teams and between primary and secondary care. It also gives policy makers and funders insight into what is happening in primary care and thus has the potential to improve provision of care. Key words: ICPC-3; classification; primary care; health data; patient-centered care; functioning; prevention; health programs; medical informatics; population health, INTRODUCTION For a long time, family physicians have been recording routine clinical data in health records. Use of these primary care data for clinical decision support, quality assessment, research, and [...]

PURPOSE We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease. METHODS A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs--appropriate aspirin use, blood pressure (BP) control ( RESULTS Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P CONCLUSIONS Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months. Key words: practice facilitation; high-leverage change; quality improvement; cardiovascular disease; risk factors; preventive medicine; evidence-based practice; clinical quality measure; Healthy Hearts Northwest study; EvidenceNOW; AHRQ; organizational innovation, INTRODUCTION Primary care practices in the United States are in a period of transition, with considerable pressure from payers and policy makers to improve quality of care and reduce costs. [...]

Introduction: : Tuberculosis (TB) remains the most common cause of death among people living with HIV Integrating HIV and TB services reduces mortality but is sub-optimally implemented. Quality improvement (QI) methods offer a low-cost and easily implementable approach to strengthening healthcare delivery systems. This trial assessed a QI intervention on key process indicators for delivering integrated HIV-TB care in rural South African primary healthcare (PHC) clinics. Methods: Sixteen nurse supervisors, (each with a cluster of clinics) overseeing 40 PHC clinics, were randomized 1:1 to the intervention or the standard of care (SOC) groups. The QI intervention comprised three key components: clinical and QI skills training, on-site mentorship of nurse supervisors and clinic staff, and data quality improvement activities to enhance accuracy and completeness of routine clinic data. The SOC comprised monthly supervision and data feedback meetings. From 01 December 2016 to 31 December 2018, data were collected monthly by a team of study-appointed data capturers from all study clinics. This study's outcomes were HIV testing services (HTS), TB screening, antiretroviral therapy (ART) initiation, isoniazid preventive therapy (IPT) initiation and viral load (VL) testing. Results: The QI group (eight clusters) comprised 244 clinic staff who attended to 13,347 patients during the trial compared to the SOC group (eight clusters) with 217 clinic staff who attended to 8141 patients. QI mentors completed 85% (510/600) of expected QI mentorship visits to QI clinics. HTS was 19% higher [94.5% vs. 79.6%; relative risk (RR)=1.19; 95% CI: 1.02-1.38; p=0.029] and IPT initiation was 66% higher (61.2 vs. 36.8; RR=1.66; 95% CI: 1.02-2.72; p=0.044), in the QI group compared to SOC group. The percentage of patients screened for TB (83.4% vs. 79.3%; RR=1.05; p=0.448), initiated on ART (91.7 vs. 95.5; RR=0.96; p=0.172) and VL testing (72.2% vs. 72.8%; RR=0.99; p=0.879) was similar in both groups. Conclusions: QI improved HIV testing and IPT initiation compared to SOC. TB screening, ART initiation and VL testing remained similar. Incorporating QI methods into routine supervision and support activities may strengthen integrated HIV-TB service delivery and increase the success of future QI scale-up activities. Keywords: cluster-randomized; collaboratives; HIV-TB services; integration; primary healthcare clinics; quality improvement, 1 | INTRODUCTION In South Africa (SA), the convergence of the HIV and tuberculosis (TB) epidemics created one of the largest HIV-TB co-epidemics in the world [1]. In 2016, an [...]

Context: Inter-professional team-based care remains a focus of primary care transformation in Canada. Quality improvement aimed at optimizing team-based primary care requires health indicators that can be consistently measured and provide meaningful information on patient outcomes. The International Classification of Functioning, Disability, and Health, provides a conceptual model to measure health in primary care. Little is known about patients' and providers' understanding of function and its utility as a health indicator for all adult patients in primary care. Objectives: From the perspectives of patients and primary care teams, explore the: 1) understanding of the concept of function, and 2) utility of measuring function as a health indicator for adult patients in primary care. Design: A qualitative description study; part of a larger mixed methods study examining how function can be used in the performance measurement of primary care teams. Setting: Primary Care Networks (PCNs) in the Interior Health Region of British Columbia, Canada. Population Studied: 6 patient participants with experience in primary care transformation and 18 providers across 7 disciplines from two PCNs. Intervention: 24 semi-structured interviews. Outcome Measures: Description of study participants. A rich description of identified themes identified through an inductive qualitative thematic analysis. Results: Relating to the understanding of concept of function, four themes were identified: 1) Function is a bigger picture of health and the ability to live your best life, 2) Patient's beliefs about their function are key, 3) Function is rarely talked about in primary care, and 4) Patient function is personal and influenced by many things. Relating to the utility of measuring function as a health indicator in primary care, five themes were identified: 1) Optimizing function is the whole point of primary care, 2) Measuring function will lead to more patient-centred care, 3) Bringing people to the table-- team-based care, 4) Function is hard to integrate into care, and 5) Function supports quality improvement. Conclusions: Overall, the results of this study suggest there is value for patients and primary care teams to measure function as a health indicator of primary care for adult patients, however, the measurement and reporting of function should reflect the complex and high-paced environment of primary care., Presenters Gregory Cutforth, BSc, DSc (candidate), Jordan Miller, Catherine Donnelly, [...]

* Context.--Since 2008, the Northern Territory Point-ofCare Testing Program has improved patient access to pathology testing for acute and chronic disease management for remote health services. Objective.--To evaluate the analytical quality, service delivery, and clinical utility of an expanding remote point-of-care testing network. Design.--Four years (2016-2019) of data on analytical quality, test numbers, and training statistics and 6 months of clinical point-of-care testing data from Abbott i-STATs at remote health services throughout the Northern Territory were analyzed to assess analytical performance, program growth, and clinical utility. Results.--From 2016 to 2019, point-of-care test numbers increased, with chemistry and blood gas testing more than doubling to 8500 and 6000 tests, respectively, troponin I testing almost doubling (to 6000), and international normalized ratio testing plateauing at 8000 tests. Participation in quality control and proficiency testing was high, with quality comparable to laboratory-based analytical goals. A shift toward flexible training and communication modes was noted. An audit of point-of-care test results demonstrated elevated creatinine, associated with chronic kidney disease management, as the most common clinically actionable patient result. Conclusions.--The Northern Territory Point-of-Care Testing Program provides high quality point-of-care testing within remote primary health services for acute and chronic patient management and care. Clinical need, sound analytical performance, flexibility in training provision, and effective support services have facilitated the sustainability of this expanding point-of-care testing model in the remote Northern Territory during the past 11 years. doi: 10.5858/arpa.2020-0107-OA, The vast geographical area and cultural landscape of Australia's Northern Territory pose unique complexities in effective health care delivery. The Northern Territory occupies the northern central part of Australia and [...]

PURPOSE Despite evidence on the benefits of case management for the care of patients with complex needs in primary care, implementing the program-necessary to achieve its benefits-has been challenging worldwide. Evidence on factors affecting implementation remains disparate. Accordingly, the objective of this systematic review was to identify barriers to and facilitators of case management, from the perspectives of health care professionals, in primary care settings around the world. METHODS We conducted a systematic review and thematic synthesis of qualitative findings. In collaboration with 2 librarians, we searched 3 electronic databases (MEDLINE, CINAHL, EMBASE) for studies related to factors affecting case management function in primary care. Two researchers screened titles, abstracts, and full texts for inclusion, then assessed included studies for quality. Results from included studies were synthesized by thematic synthesis, and a framework was developed. RESULTS Of 1,640 unique records identified, 22 studies, originating from 6 countries, met the inclusion criteria. We identified 9 barriers and facilitators: family context; policy and available resources; physician buy-in and understanding of the case manager role; relationship building; team communication practices; autonomy of case managers; training in technology; relationships with patients; and time pressure and workload. We describe these factors, then present a framework demonstrating the relationships among them. CONCLUSIONS Our study's findings show that multiple factors influence case management implementation. These findings have implications for researchers, clinicians, and policy makers who strive to implement or reform case management programs in local or larger primary care settings. Key words: case management; patients with complex needs; chronic disease; vulnerable populations; comorbidity; health plan implementation; health services misuse; delivery of health care, integrated https://doi.org/10.1370/afm.2555., INTRODUCTION In response to an aging global population and the corresponding increase in chronic illness, case management has emerged as a powerful innovation to better care for patients with complex [...]

PURPOSE We compared the transformation experience of 2 family medicine practices that implemented the Primary Care Redesign (PCR) team-based model to improve access, quality, and experience without increasing cost. The University of Colorado's A.F. Williams Family Medicine clinic (pilot practice) implemented the model in February 2015, and a smaller, community-based practice (wave 2 practice) did so 2 years later, in February 2017. METHODS The PCR model increased the ratio of medical assistants to clinicians from about 1:2 to 2.5:1 while expanding the role of the medical assistants, through enhanced rooming procedures, in-room support (eg, scribing), post-clinician wrap-up, and in-basket assistance. We assessed access, clinical quality metrics, staffing costs, and clinician and staff experience and burnout for at least 7 months before and 42 months after the intervention. RESULTS In the pilot practice, compared with preimplementation, there were improvements in total appointments and rates of hypertension control, colorectal cancer screening, and most diabetic quality metrics. In the wave 2 practice, total appointments increased slightly when clinicians were added pre-PCR and then increased substantially after implementation; initially variable hypertension control improved rapidly after implementation. The wave 2 practice's colorectal cancer screening improved gradually, then accelerated postimplementation, while diabetic metrics initially remained stable or declined, then improved postimplementation. New patient appointments began to increase for both practices in late 2015, but grew faster in the pilot practice under PCR. Over time, all experiential domains improved for clinicians; most remained stable for staff. Clinician burnout was reduced by at least one-half in both practices except during low staffing periods, which also adversely affected staff. After a ramp-up period, the number of staff hours per visit remained stable. CONCLUSIONS The PCR model is associated with simultaneous improvements in quality, access, and clinician experience, as well as reductions in burnout, while maintaining staffing costs. Key words: professional practice; team-based care; quality improvement; health care delivery; primary care; organizational change; health information technology; practice-based research, INTRODUCTION The quadruple aim--improved patient experience, population health, care team well-being, and cost--is recognized as a strategy for improving the US health care system. (1) Tackling one element in isolation, [...]

Primary care teams are underpowered. Teams do not maximally redistribute team functions when clinicians are diverted from activities where they add the most value. This commentary describes 'advanced team care with in-room support' as a way to 'power-up' primary care teams. In this core team model, each clinician is paired with 2 or 3 highly trained medical assistants or nurses-- care team coordinators (CTCs).Early evidence suggests that this model is more satisfying to clinicians, staff, and patients and is financially sustainable. Yet its spread has been hobbled by several misguided beliefs, such as that the physician can and should do most tasks, that technology replaces people, that health care is a transactional endeavor more than a therapeutic relationship, that regulation is the main lever by which to advance quality, and that the principal way to increase net revenue is to reduce overhead. A shift in mindset is needed to energize primary care., Primary care teams are underpowered. They are underpowered because they do not maximally redistribute team functions. Clinicians (physicians and advanced practice providers) are often diverted from activities where they add [...]

PURPOSE To develop and evaluate a concise measure of primary care that is grounded in the experience of patients, clinicians, and health care payers. METHODS We asked crowd-sourced samples of 412 patients, 525 primary care clinicians, and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts in a 21/2 day international conference to provide additional insights. A multidisciplinary team conducted a qualitative analysis of the combined data to develop a parsimonious set of patient-reported items. We evaluated items using factor analysis, Rasch modeling, and association analyses among 2 online samples and 4 clinical samples from diverse patient populations. RESULTS The resulting person-centered primary care measure parsimoniously represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, advocacy, community context, comprehensiveness, continuity, coordination, family context, goal-oriented care, health promotion, integration, and relationship. Principal axes factor analysis identified a single factor. Factor loadings and corrected item-total correlations were >0.6 in online samples (n = 2,229) and >0.5 in clinical samples (n = 323). Factor scores were fairly normally distributed in online patient samples, and skewed toward higher ratings in point-of-care patient samples. Rasch models showed a broad spread of person and item scores, acceptable item-fit statistics, and little item redundancy. Preliminary concurrent validity analyses supported hypothesized associations. CONCLUSIONS The person-centered primary care measure reliably, comprehensively, and parsimoniously assesses the aspects of care thought to represent high-value primary care by patients, clinicians, and payers. The measure is ready for further validation and outcome analyses, and for use in focusing attention on what matters about primary care, while reducing measurement burden., INTRODUCTION Measures matter because they focus the precious commodity of attention. (1) Increasingly, measures also are used to concentrate material resources and infrastructure, and even to influence the right to [...]

The electronic health record (EHR) system is now an integral part of primary care practice and is an important facilitator of high-quality health care. (1,2) We highlight 4 papers in [...]

Background We evaluated the impact of the pharmacist-led Safety Medication dASHboard (SMASH) intervention on medication safety in primary care. Methods and findings SMASH comprised (1) training of clinical pharmacists to deliver the intervention; (2) a web-based dashboard providing actionable, patient-level feedback; and (3) pharmacists reviewing individual at-risk patients, and initiating remedial actions or advising general practitioners on doing so. It was implemented in 43 general practices covering a population of 235,595 people in Salford (Greater Manchester), UK. All practices started receiving the intervention between 18 April 2016 and 26 September 2017. We used an interrupted time series analysis of rates (prevalence) of potentially hazardous prescribing and inadequate blood-test monitoring, comparing observed rates post-intervention to extrapolations from a 24-month pre-intervention trend. The number of people registered to participating practices and having 1 or more risk factors for being exposed to hazardous prescribing or inadequate blood-test monitoring at the start of the intervention was 47,413 (males: 23,073 [48.7%]; mean age: 60 years [standard deviation: 21]). At baseline, 95% of practices had rates of potentially hazardous prescribing (composite of 10 indicators) between 0.88% and 6.19%. The prevalence of potentially hazardous prescribing reduced by 27.9% (95% CI 20.3% to 36.8%, p < 0.001) at 24 weeks and by 40.7% (95% CI 29.1% to 54.2%, p < 0.001) at 12 months after introduction of SMASH. The rate of inadequate blood-test monitoring (composite of 2 indicators) reduced by 22.0% (95% CI 0.2% to 50.7%, p = 0.046) at 24 weeks; the change at 12 months (23.5%) was no longer significant (95% CI -4.5% to 61.6%, p = 0.127). After 12 months, 95% of practices had rates of potentially hazardous prescribing between 0.74% and 3.02%. Study limitations include the fact that practices were not randomised, and therefore unmeasured confounding may have influenced our findings. Conclusions The SMASH intervention was associated with reduced rates of potentially hazardous prescribing and inadequate blood-test monitoring in general practices. This reduction was sustained over 12 months after the start of the intervention for prescribing but not for monitoring of medication. There was a marked reduction in the variation in rates of hazardous prescribing between practices., Author(s): Niels Peek 1,2,3,*, Wouter T. Gude 4, Richard N. Keers 1,5,6, Richard Williams 1,3, Evangelos Kontopantelis 7, Mark Jeffries 1,5, Denham L. Phipps 1,5, Benjamin Brown 1,3,8, Anthony J. [...]

Before the COVID-19 pandemic hit in 2020, the Association of Departments of Family Medicine concluded work in partnership with the Family Medicine for America's Health (FMAHealth) initiative regarding the addition [...]

Over the past 5 decades, existing disparities between the health of rural and urban Americans has grown across a range of outcomes. According to the Centers for Disease Control and [...]

THE INNOVATION A Model Programme in primary care group practices (GP clusters) was implemented in 2013 in solo practices in Hungary. (1) The practices employed--among others--nonprofessional community workers called 'health [...]

The article discusses the increasing support that the patient-centered medical homes (PCMH) model has received in recent times. The PCMH combines the tradition concepts of primary care such as a personal physician providing first-contact care with newer responsibilities to systematically improve the health of patients in such homes through information technology, chronic disease registries and new communication options.

THE INNOVATION Mounting nonclinical burdens, declining staff ratios, and rotating staff in large medical groups increase burnout and hamper the joy of primary care practice. (1) Some systems invest heavily [...]

Background: In 2004, Afghanistan pioneered a balanced scorecard (BSC) performance system to manage the delivery of primary health care services. This study examines the trends of 29 key performance indicators over a 5-year period between 2004 and 2008. Methods and Findings: Independent evaluations of performance in six domains were conducted annually through 5,500 patient observations and exit interviews and 1,500 provider interviews in >600 facilities selected by stratified random sampling in each province. Generalized estimating equation (GEE) models were used to assess trends in BSC parameters. There was a progressive improvement in the national median scores scaled from 0-100 between 2004 and 2008 in all six domains: patient and community satisfaction of services (65.3-84.5, p Conclusions: The BSC has been successfully employed to assess and improve health service capacity and service delivery using performance benchmarking during the 5-year period. However, scorecard reconfigurations are needed to integrate effectiveness and efficiency measures and accommodate changes in health systems policy and strategy architecture to ensure its continued relevance and effectiveness as a comprehensive health system performance measure. The process of BSC design and implementation can serve as a valuable prototype for health policy planners managing performance in similar health care contexts. Please see later in the article for the Editors' Summary., Introduction Emerging from decades of conflict, in 2002, Afghanistan had some of the worst health indicators in the world, with more than 30% of its population living below the poverty [...]

Background: In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. Methods and Findings: We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. Conclusions: Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases. Please see later in the article for the Editors' Summary., Introduction The private sector is the main provider of primary health care for the poor in many low and middle income countries (LMICs). For example, in South Asia about three [...]

Physicians don't always document the care they provide to patients with diabetes in a way that benefits them under a value-based or risk-adjusted payment model, says Brian Boyce, CPC, chief [...]