Affiliated Primary Care Practices Research Articles

A Faith Community Nursing Intervention for Informal Caregiver-Older Adult Dyads.

The purpose of this study was to test the impact of embedding trained Faith Community Nurse (FCN) interventionists in a Catholic Health System affiliated primary care practice as liaisons of care in the homes of older adult clients (OACs) and their informal caregiver (IC). Specific aims were to examine if a FCN intervention improved IC and OAC health, well-being, knowledge and understanding of chronic disease management, self-advocacy, and self-care. A non-random quasi-experimental design was used. Most ICs were spouses or adult children (M age = 66) who lived with the older adult (M age = 79). The ICs' scores significantly increased after the intervention on the Preparedness for Caregiving Scale (p = .002), Spirituality as Life, Meaning, and purpose (p = .026), and Rosenberg Self Esteem Scale (p = .005). Future research is needed examining the FCN intervention with larger sample sizes in more diverse communities and acute care settings.

Implementation of a Telemedicine Student Clinical Experience.

Background: As part of a curricular change, an academic medical center implemented a medical student telemedicine clinical experience for first-year medical students in October 2020. This research is a process evaluation of the implementation of a preclerkship medical student telemedicine clinical experience. Methods: Patients with two or more chronic diseases were recruited from affiliated primary care practices. We monitored the recruitment and retainment of patients throughout the curriculum. We used surveys to evaluate patient, student, and primary care overall experience with the program. We tracked referrals to higher levels of care and assessed skills students' felt they practice with each encounter. We followed progression of notes through chart review as the year progressed. Results: Of the 408 patients contacted, 150 agreed to participate in this program (36%). Of 1,053 scheduled visits, 686 (65%) were successfully completed. Seventy-five percent of patients were seen two or more times. Nearly 70% of surveyed patients felt that the clinical experience enhanced their communication with their primary care provider, and nearly 90% stated that students were "somewhat" or "extremely" professional. The majority (97%) of students reported an "excellent" or "good" view of the medical student telemedicine clinical experience. Qualitative measures of student performance, such as note writing, showed improvement over the course of the curriculum. Conclusions: Our data suggest that patients, students, and primary care providers were widely accepting of the curriculum, patients were successfully recruited and retained, and students successfully practiced key clinical skills on a telemedicine platform.

Protocol of a multiphase study on telemedicine for older adults in primary care

IntroductionTelemedicine (TM) has been adopted by many health authorities to limit unnecessary exposure during COVID-19. Prior to the pandemic, TM was associated with improvement of quality of life of older...

188 Implementation of a Telemedicine Student Clinic

As part of a curricular change, an academic medical center implemented a medical student telemedicine education clinic for first-year medical students in October 2020. By augmenting current AAMC and LCME compliant educational standards with a telemedicine clinic experience, preclinical medical students learned versatile patient-care skills that will be effective in both in-person and virtual clinic settings. This research describes the initial successes and challenges of implementing a pre-clerkship medical student telemedicine education clinic. This research is a process evaluation of the implementation of a pre-clerkship medical student telemedicine education clinic. Patients with two or more chronic diseases were recruited from affiliated primary care practices. Students worked in pairs to perform each of the curricular goals and objectives including: reviewing the patient’s electronic medical record (EMR) and care plan, interviewing patients via a telemedicine platform, and documenting patient interactions (including an assessment and plan) in the EMR. These patient encounters were not directly supervised by faculty. Immediately after the visit, students gave an oral presentation to on-site faculty, and provided a written note to the on-site faculty and the patient’s primary care physician. If a patient visit could not be completed, a standardized patient was utilized for the telemedicine visit. In order to evaluate the program, the following data were collected: number of patient contacts, visit outcomes (including completion/non-completion of the visit, successful/unsuccessful telemedicine utilization, adequacy or need for other types of connection, need/no need for intervention by the on-site faculty for an emergent or urgent medical issue), student surveys, and patient surveys. A total of 382 patients were contacted and 122 agreed to participate in a visit (32%). Since program initiation, 15 patients have been removed by their request or for more than two visit cancellations (13.4%), and two due to death (1.6%). In the first seven months of the clinic, students scheduled 573 visits of which 373 (65%) were successfully completed. The other 200 visits (35%) were cancelled by the patient or the patient did not connect for the visit. On-site faculty intervened in 14.3% of encounters for the following reasons: send to the emergency department 1.3%, urgent consult for specialty care 5%, 24-hour follow up with PCP 8%. Visit lengths varied as follows: 0-10 minutes 6.2%, 10-20 minutes 65%, 20-30 minutes 23.2%, >30 minutes 5.6%. Patient surveys demonstrate that 67.9% felt the student clinic would enhance communication with their primary care physician “a lot” to “a great deal.” Patients rated the student as “somewhat” to “extremely professional” for 87.5% of the visits. Students evaluated the experience as follows: Excellent 71%, Good 26%, Average 3%, Poor 0%. Student skill completion is listed in Table 1. This research demonstrates that the implementation of a preclinical telemedicine curriculum is possible (patients are willing to participate), provides an opportunity for skill development, and was viewed favorably by both patients and students. Preliminary data on patient retention and student satisfaction suggest that this is a sustainable model for developing telemedicine competencies in preclinical medical students.

Advanced EMR functionalities and Frontline Staff’s Perception of Clinical Proces Integration

Electronic Medical Records (EMR) is considered to facilitate care integration, as EMRs can enable information flow and care coordination. Yet, evidence also suggests negative consequences such as increased provider burden. Research has yet to identify whether and in what way EMRs can promote care integration. This research studied the association between EMR functionalities, designed to enhance the alignment and exchange of clinical information across health care facilities, and clinical process integration within and outside health systems as perceived by staff of health system affiliated primary care practices. Using survey methods, we collected data from 700 primary care staff members in 48 practice sites within 18 physician organizations affiliated with 13 health systems. To examine associations between EMR functionalities and perceived care integration, we used multi-level linear regression models, weighting staff survey data for differences in response rate by discipline. Among distinguishing EMR functionalities, clinical decision support (?=0.23, p=0.02), medication management (?=0.22, p=0.04), and electronic messaging (?=0.32, p<0.01) were significantly associated with higher levels of perceived clinical process integration within health system, but not outside the system. Our findings provide guidance to health systems in efforts to improve clinical process integration.

Did the 2015 USPSTF Abnormal Blood Glucose Recommendations Change Clinician Attitudes or Behaviors? A Mixed-Method Assessment.

In 2015, the US Preventive Services Task Force (USPSTF) revised clinical recommendations to more broadly recommend abnormal blood glucose screening and more clearly recommend referral to behavioral interventions for adults with prediabetes. To assess the effects of the 2015 USPSTF recommendation changes on abnormal blood glucose screening and referral to behavioral interventions, and to examine physicians' perceptions of the revised recommendation. We utilized a sequential, dependent mixed-methods triangulation design. A total of 33,444 patients meeting USPSTF abnormal blood glucose screening criteria within 15 health system-affiliated primary care practices and 20 primary care physicians in North Carolina. We assessed monthly abnormal blood glucose screening rate and monthly referral rate to behavioral interventions. To estimate trend changes in outcomes, we used segmented linear regression analysis of interrupted time-series data. We gathered physicians' perspectives on the 2015 USPSTF abnormal blood glucose recommendation including awareness of, agreement with, adoption of, and adherence to the recommendation. To analyze qualitative data, we used directed content analysis. There was a slight significant change in trend in abnormal blood glucose screening rates post-recommendation. There was a slight, statistically significant decrease in referral rates to behavioral interventions post-recommendation. Physicians were generally unaware of the revisions to the 2015 USPSTF abnormal blood glucose recommendation; however, once the recommendations were described, physicians agreed with the screening recommendation but felt that the behavioral intervention referral recommendation was hard to implement. The 2015 USPSTF abnormal blood glucose guideline had little to no effect on abnormal blood glucose screening or referral to behavioral interventions in North Carolina practices. Potential interventions to improve these rates could include clinical decision tools embedded in the electronic health record and better referral systems for community-based diabetes prevention programs.

Developing a regional transmural care database: A roadmap

IntroductionIn primary care health care systems, primary care physicians (PCPs) provide most basic care services, and if necessary, refer to secondary care for specialized work-up and treatment. If hospital care is required, agreement between PCPs and secondary care physicians (SCPs) on the conditions for patient referral and back-referral are considered crucial to providing high quality patient care. The regional healthcare network of Utrecht, a region in the Netherlands, developed a set of collaborative patient care agreements (CPCAs) for specific chronic conditions. Even though these CPCA are endorsed by all relevant regional health care organisations, the adoption of these agreements in practice remains substandard. In this project, through linkage of routine care data, as registered in daily practice by PCPs and SCPs, a regional transmural care database (RTD) was developed for monitoring the use of the CPCAs. Its data was transformed into’ mirror data’ used to support PCPs and SCPs in discussing and improving current practice and to support a learning healthcare system within the region. MethodsThe development of the RTD is part of a larger action research project on joint care, called ZOUT (an acronym which is translated as “The right care at the right place in the Utrecht region”). The RTD includes data from three regional hospitals, and about 70 affiliated primary care practices which are united in the Julius General Practitioners Network (JGPN). These data were extracted, linked and presented in the form of mirror data, following simple methods to allow replication of our approach. CPCAs addressing transmural care for three chronic conditions were selected. Data from the primary care practices and the hospitals were linked by an independent trusted third party. This enabled relevant hospital data to be added to the primary care dataset, thereby providing transmural routine care data for individual patients. ResultsDuring the development of the RTD, a roadmap was created including a detailed step-by-step checklist of the organizational, administrative, technical and legal arrangements which needed to be made. Legal and administrative challenges proved most challenging. Also, incompleteness of data and the impossibility to translate several agreements into extractable data limited the potential for providing a comprehensive overview of the extent to which agreements in the CPCA were adhered to in daily care. DiscussionWe present a systematic, comprehensive (technical as well as practical) and reproducible roadmap to developing a regional transmural care database suitable for generating mirror data on joint transmural care between PCPs and SCPs. This approach includes all technical steps in data selection and linkage, as well as the substantive steps that need to be taken in the analysis and application of the results. The mirror data, which reflects the follow-up of agreements formulated in the CPCAs, enabled shared reflection and discussion between PCPs and SCPs. This supports the search for bottlenecks and potentialities for improving daily collaborative care, thereby showing great potential to serve a learning regional healthcare system.

The Experience of Working With a Faith Community Nurse Liaison of Care in a Primary Care Practice Among Older Adult Clients and Their Informal Caregiver.

Informal caregivers of older adults aging in place are at risk for adverse health and financial consequences. This descriptive qualitative study explored the experience of working with a faith community nurse (FCN) liaison of care in a Catholic health care system affiliated primary care practice among older adult clients and their informal caregiver. Semistructured face-to-face interviews were conducted with nine older adult client-informal caregiver dyads, three clients, and one caregiver (n = 22). Interviews were audio recorded, transcribed, and analyzed using Braun and Clarke's reflexive thematic analysis method. The analysis generated one overarching theme, I'm Sorry the Study and FCN Visits Are Coming to an End, and two key themes, The FCN Was Always There to Help Us (older adult clients) and The FCN Took the Pressure Off of Caregiving for Awhile (informal caregivers). Participants viewed the FCN as an instrumental member of their health care team and considered prayer and spiritual support offered by the FCN an essential element of care.

Promoting Pediatric Preventive Visits Through Quality Improvement Initiatives in the Primary Care Setting

To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake. Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits. Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P<.001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P=.233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P=.215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups. Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.

Fostering Quality Improvement Capacity in a Network of Primary Care Practices Affiliated With a Pediatric Accountable Care Organization

Quality improvement (QI) methodologies are not widely implemented in primary care practices. As an accountable care organization serving pediatric Medicaid recipients in Ohio, Partners For Kids (PFK) sought to build QI capacity in affiliated primary care practices to improve organizational performance on key quality measures. A team of QI specialists developed a comprehensive training program focused on pediatric QI initiatives. From 2014 to 2017, community-based, primary care practices affiliated with PFK were recruited to participate in QI. The primary outcome, assessed yearly, was the proportion of eligible PFK patients accessing care at a practice with ≥1 active QI project. The proportion of QI projects that demonstrated moderate improvement, defined as the implementation of ≥1 intervention and observed improvement in process measures, within 12 months of initiation was also calculated for 2017. Over the study period, the PFK QI team supported 72 projects in 33 primary care practices throughout central and southeast Ohio. In 2017, 26 practices were engaged in ≥1 active QI project, reaching 26% of all eligible PFK patients. Of the 21 projects active as of January 2017, 11 (52%) showed moderate improvement within 12 months. The PFK QI team successfully supported QI capacity building in primary care practices throughout Ohio using a systematic approach to recruitment, training, and QI resource support. New, multilevel interventions are needed to promote the uptake of preventive services among patients.

Capacity for Cancer Care Delivery Research in National Cancer Institute Community Oncology Research Program Community Practices: Availability of Radiology and Primary Care Research Partners

PurposeCancer care spans the spectrum from screening and diagnosis through therapy and into survivorship. Delivering appropriate care requires patient transitions across multiple specialties, such as primary care, radiology, and oncology. From the program’s inception, the National Cancer Institute Community Oncology Research Program (NCORP) sites were tasked with conducting cancer care delivery research (CCDR) that evaluates structural, organizational, and social factors, including care transitions that determine patient outcomes. The aim of this study is to describe the capacity of the NCORP to conduct multidisciplinary CCDR that includes radiology and primary care practices. MethodsThe NCORP includes 34 community and 12 minority and underserved community sites. The Landscape Capacity Assessment was conducted in 2015 across these 46 sites, composed of the 401 components and subcomponents designated to conduct CCDR. Each respondent had the opportunity to designate an operational practice group, defined as a group of components and subcomponents with common care practices and resources. The primary outcomes were the proportion of adult oncology practice groups with affiliated radiology and primary care practices. The secondary outcomes were the proportion of those affiliated radiology and primary care groups that participate in research. ResultsEighty-seven percent of components and subcomponents responded to at least some portion of the assessment, representing 230 practice groups. Analyzing the 201 adult oncology practice groups, 85% had affiliated radiologists, 69% of whom participate in research. Seventy-nine percent had affiliated primary care practitioners, 31% of whom participate in research. Institutional size, multidisciplinary group practice, and ownership by large regional or multistate health systems was associated with research participation by affiliated radiology and primary care groups. Research participation by these affiliated specialists was not significantly different between the community and the minority and underserved community sites. ConclusionsResearch relationships exist between the majority of community oncology sites and affiliated radiology practices. Research relationships with affiliated primary care practices lagged. NCORP as a whole has the opportunity to encourage continued and expanded engagement where relationships exist. Where no relationship exists, the NCORP can encourage recruitment, particularly of primary care practices as partners.

The Potential Role for Smartphones Among Older Adults with Chronic Noncancer Pain: A Qualitative Study.

To determine the role that smartphones may play in supporting older adults with chronic noncancer pain (CNCP) in order to improve pain management in this expanding population. Qualitative study. One academically affiliated primary care practice serving older adults with CNCP in New York City. Thirteen older adults (age 65-85 years) with CNCP on chronic opioid therapy, that is, continuous use of opioids for at least six months. One researcher conducted one-on-one telephone interviews with participants, and two researchers analyzed the transcribed data using descriptive analysis. A nurse and a physician researcher iteratively critiqued and approved the results. Participants provided opinions as to the effects that smartphones may have on medication management and communications with their providers. Smartphones can benefit older adults by supporting interactions with the health care system such as more effective scheduling and coordinating prescribing practices with local pharmacies. Participants expressed difficulties with isolation due to CNCP and posited that smartphones could provide a means for social support. Specifically, smartphones should support older adult needs to effectively communicate pain experiences with personal contacts and caregivers, as well as health care providers. Based on these results, we provide suggestions that can inform future smartphone interventions for older adults with CNCP. Smartphones that focus on supporting medication management, enhancing communication with providers, and facilitating connectedness within social networks to reduce feelings of isolation may help to improve CNCP outcomes in older adults.

Integration of geriatric mental health screening into a primary care practice: a patient satisfaction survey.

Colocation of mental health screening, assessment, and treatment in primary care reduces stigma, improves access, and increases coordination of care between mental health and primary care providers. However, little information exists regarding older adults' attitudes about screening for mental health problems in primary care. The objective of this study was to evaluate older primary care patients' acceptance of and satisfaction with screening for depression and anxiety. The study was conducted at an urban, academically affiliated primary care practice serving older adults. Study patients (N = 107) were screened for depression/anxiety and underwent a post-screening survey/interview to assess their reactions to the screening experience. Most patients (88.6%) found the length of the screening to be "just right." A majority found the screening questions somewhat or very acceptable (73.4%) and not at all difficult (81.9%). Most participants did not find the questions stressful (84.9%) or intrusive (91.5%); and a majority were not at all embarrassed (93.4%), upset (93.4%), or uncomfortable (88.8%) during the screening process. When asked about frequency of screening, most patients (72.4%) desired screening for depression/anxiety yearly or more. Of the 79 patients who had spoken with their physicians about mental health during the visit, 89.8% reported that it was easy or very easy to talk with their physicians about depression/anxiety. Multivariate results showed that patients with higher anxiety had a lower positive reaction to the screen when controlling for gender, age, and patient-physician communication. These results demonstrate strong patient support for depression and anxiety screening in primary care.

Novel Telemedicine Technologies in Geriatric Chronic Non-Cancer Pain: Primary Care Providers’ Perspectives

We sought to identify primary care providers' interest in, as well as perceived barriers and facilitators to, using novel telemedicine technologies (e.g., smartphones) for managing chronic non-cancer pain (CNCP) in older adults. Six focus groups were conducted with 25 primary care providers. Two academically affiliated primary care practices serving older adults with CNCP in New York City. The investigators used content analysis to analyze transcribed focus group data and identify specific themes. While most providers reported limited use of telemedicine, they expressed substantial interest in trying devices such as smartphones in the management of older patients with CNCP. Perceived barriers to implementation of telemedicine tools included information overload, lack of mobile device usability among patients and clinicians, liability issues, and cost. To overcome these barriers, participants suggested implementing electronic or human-based pre-analysis of data (e.g., a computer or a person that triages patient data), creating a low-cost and user-friendly mobile device design, and targeting appropriate user populations. Primary care providers are interested in applying telemedicine when caring for older adults with CNCP. Although they perceived multiple barriers to device implementation, they offered innovative solutions to address these barriers. Providers felt that novel telemedicine technologies may improve the management of CNCP but wanted evidence that the devices were both cost- and time-efficient, and led to improved patient outcomes before adopting their use in practice.

The impact of a primary care-based weight loss intervention on the quality of life

This study investigated changes in the quality of life of men and women who participated in a primary care-based weight loss intervention program. Participants were enrolled in a 2-year randomized clinical trial (POWER-UP) conducted at the University of Pennsylvania and in six affiliated primary care practices. Inclusion criteria included the presence of obesity (body mass index of 30-50 kg m(-2)) and at least two components of the metabolic syndrome. Quality of life was assessed by three measures: the Short Form Health Survey (SF-12); the Impact of Weight on Quality of Life-Lite; and the EuroQol-5D. Six months after the onset of treatment, and with a mean weight loss of 3.9 ± 0.3 kg, participants reported significant improvements on all measures of interest with the exception of the Mental Component Score of the SF-12. These changes remained significantly improved from baseline to month 24, with the exception of the EuroQol-5D. Many of these improvements were correlated with the magnitude of weight loss and, for the most part, were consistent across gender and ethnic group. Individuals with obesity and components of the metabolic syndrome reported significant improvements in most domains of the quality of life with a modest weight loss of 3.7% of initial weight, which was achieved within the first 6 months of treatment. The majority of these improvements were maintained at month 24, when participants had lost 3.0% of their weight.

Primary care practice organization influences colorectal cancer screening performance.

To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors. Primary care director survey (1999-2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001). Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors. Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease. After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p<.03), and smaller size (p<.001). Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.