THE CHALLENGES OF FACILITATING PRACTICE CHANGE INITIATIVES TO IMPROVE GERIATRIC CARE IN RURAL PRIMARY CARE

Abstract

Background: The Carolina Geriatric Workforce Enhancement Program (CGWEP) integrated education and workflow modifications into four primary care practices in 2017 (Rural Federally Qualified Health Center, Family Medicine Clinics, and Internal Medicine Residency Program). Methods: The CGWEP partnered with practice support professionals in NC Area Health Education Centers (AHECs) to improve outcomes in falls, advanced care planning (ACP) and health literacy. Projects aligned with metrics included in the merit-based incentive payment systems and patient centered medical home criteria. Practices 1 and 2 focused on fall risk identification and reduction. Practice 1 emphasized clinic-wide education while Practice 2 reorganized workflows. Practice 3 chose to perform coaching of residents to facilitate ACP discussions. Practice 4 reorganized workflows and developed clinical competencies to improve efficiency. Results: Practices 1 and 2 - improvement in falls screening rates of 47% and 12% respectively. Intervention documentation improved by 93% and 17% respectively. Practice 3 - 3% improvement documentation of ACP education. Practice 4 -10% increase in practice productivity. Each practice experienced challenges with implementation of the PDSA plans. Through these projects the CGWEP team developed sixteen best practices to help address the challenges. Conclusions: Practice improvement resulted from innovative training of clinic staff, workflow redesign, and Plan, Do, Study, Act (PDSA) cycles. Enhancing geriatrics in primary care is most successful when projects are grounded in practice priorities aligned with existing quality metrics, provide whole team training, and develop efficiencies in practice workflow. PDSA evaluation cycles can identify new opportunities in workflow patterns and training.