Primary Care Provider Experiences Research Articles

Synchronous neurology-primary care collaboration in a medical home.

Synchronous collaboration as defined by a simultaneous encounter between primary care providers (PCPs), patients, and neurologists may improve access to neurologic expertise, care value, and satisfaction of PCPs and patients. We examined a series of synchronous collaborations and report outcomes, PCP satisfaction, downstream utilization, and illustrative case examples. Within an outpatient collaborative primary care-neurology care model, we implemented synchronous video consultations from a central hub to satellite clinics while increasing availability of synchronous telephone and face-to-face collaboration. PCP experience was assessed by a postcollaboration survey. Individual cases were summarized. Clinical and utilization outcomes were assessed by a neurologist immediately after and by follow-up chart review. A total of 58 total synchronous collaborations were performed: 30 by telephone (52%), 18 face to face (31%), and 10 by video (17%) over 27 clinic half-days. The most frequent outcomes as assessed by the neurologist were reassurance of the PCP (23/58; 40%) and patient (22/59; 38%), and the neurologist changed the treatment plan (23/58; 40%). A subsequent face-to-face consultation was completed in 15% (6/58) of patients initially assessed by telephone or video. Test utilization was avoided in 40% (23/58). Unintended utilization occurred 9% (5/58). Most PCPs were very satisfied with the ease of access, quality of care, and reported high likelihood of subsequent use. PCPs perceived similar or less time spent during synchronous vs asynchronous collaboration and neurologist usually altered the testing (87.8%) and treatment plan (95.2%). Synchronous collaboration between neurologists and PCPs may improve timely access to neurologic expertise, downstream utilization, and PCP satisfaction.

The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings

PurposeChronic disease is a global concern. While ample research has aimed to identify the epidemiology of multimorbidity and patient complexity using administrative data, little attention has been paid to the processes of care that treating complex patients entail. Consequently, the concept of patient complexity itself does not directly speak to how challenging it may be to care for a given patient. The purpose of this study was to investigate how primary care providers define, encounter, and manage complex patients, especially those with chronic pain. To our knowledge, this is the first study to move beyond general narrative descriptions of complexity towards an interrogation that is grounded in the work practices of caring for these patients.MethodsWe undertook an institutional ethnography (IE) in Ontario, Canada. IE uses people’s everyday work problems as the starting point for an exploration of the often-invisible social relations that orient experiences. Grounded in the everyday experience of primary care providers, we draw here on 51 interviews that were collected as part of our larger IE study, to interrogate the utility of definitions of patient complexity as medical multimorbidity.FindingsCare providers consider patients challenging due to their socio-economic status more so than their medical problems alone. Our data shows that patients’ issues are often bound up with poverty, trauma, and mental health concerns, and are challenging for health care providers in part because the interventions needed exceed the scope of their medical expertise, while social issues render the treatment of potentially straightforward medical problems complicated. This was especially so for patients with chronic pain.ConclusionDefining patient complexity as morbidity alone is inadequate; such models neglect syndromes and conditions that are not included in formal disease classifications. Chronic pain should be included among the chronic conditions that are considered to constitute multimorbidity. In order to provide effective patient-centered care, discussions of patient complexity must also attend to the complex social and economic circumstances in which many patients live and include broader issues of inequity and social justice. This approach would enable policies to better support primary care providers who struggle to manage their patients with complex needs across domains of physiological health, mental health, and the quality of their living conditions, and in so doing improve the care that patients receive.

Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences.

Electronic consultation (eConsult), which involves primary care provider (PCP)-to-specialist asynchronous consultation, is increasingly used in health care systems to streamline care and to improve patient access. The Association of American Medical Colleges (AAMC) formed a collaborative to support the implementation of an electronic medical record (EMR)-based, opt-in eConsult program across multiple academic medical centers (AMCs). In this model, PCPs can elect to send either an eConsult or a traditional referral. We sought to understand the PCP experience with eConsult to identify facilitators of and barriers to the successful adoption of the model. We conducted 35 semi-structured interviews and 6 focus groups with a range of primary care providers at 7 AMCs participating in the AAMC collaborative. Interviews were recorded and transcribed or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies. We identified three major themes related to the eConsult program: (1) eConsult increases the comprehensiveness of primary care and fills PCPs' knowledge gaps through case-based learning. (2) Factors that influence PCPs to order an eConsult rather than a traditional referral include patient preference, case complexity, and need for expert guidance. (3) Implementation challenges included increasing PCPs' awareness of the program, addressing PCPs' concerns about increased workload, recruiting engaged specialist consultants, and ensuring high quality eConsult responses. Implementation success relied on PCP ownership of the consultation process, mitigating unintended consequences, ongoing education about the program, and mechanisms for providing feedback to clinicians. Our findings demonstrate that an opt-in eConsult program at AMCs has the potential to increase PCP knowledge and enhance the comprehensiveness of primary care. For these benefits to be realized, program implementation requires sustained efforts to overcome barriers to use and establish norms guiding eConsult communication.

Primary Care Providers' Perspectives on Providing Care to Women Veterans with Histories of Sexual Trauma.

One in four women Veterans who use the Veterans Health Administration (VA) screen positive for military sexual trauma and may need trauma-sensitive care and coordination. VA primary care providers (PCPs), women veterans' main source of care, need to be well-versed in trauma-sensitive approaches to care. Women veterans' numerical minority in the VA can make provider exposure to female patients inconsistent, which may impede PCP experience in providing appropriate care. To inform strategies for improving trauma-sensitive primary care, we sought to better understand PCPs' current approaches to providing care to women veterans with sexual trauma histories. We conducted semistructured telephone interviews with PCPs (n=28) practicing in VA primary care clinics. Participants were asked about their experiences delivering trauma-sensitive care as well as best practices. Interviews were recorded, transcribed, and analyzed for major themes regarding barriers to and facilitators of trauma-sensitive care. Participants expressed challenges delivering care to women with sexual trauma histories, including 1) insufficient time, 2) lack of perceived proficiency and/or personal comfort (with general physical examinations as well as gender-specific care such as Pap, breast, and pelvic examinations), and 3) difficulties with fostering positive patient-provider relationships. Access to mental health resources was noted as a key facilitator of providing trauma-sensitive care. Participants also shared existing (and potential) best practices and recommendations, such as paying special attention to patient behavioral cues related to comfort. PCPs delivering care to women in VA facilities may benefit from an increased awareness of best practices to facilitate the delivery of trauma-sensitive care.

Qualitative perspectives of primary care providers who treat Medicaid managed care patients

BackgroundDeclining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis.MethodsWe conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes.ResultsProviders expressed challenges effectively meeting their patients’ needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice.ConclusionsUnderinvestment in primary care in Medicaid may detract from providers’ professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

Opinions and Experiences of Primary Healthcare Providers Regarding Violence against Women: a Systematic Review of Qualitative Studies

The aim of this systematic review of qualitative studies is to explore the opinions and experiences of primary care providers regarding violence against women. Structured searches were conducted in nine bibliographic databases (March 2016). Study identification, critical appraisal (using the CASP tool), and analyses (thematic synthesis) were conducted. 46 qualitative studies were selected. Three main themes were identified: 1) Defining violence against women and its causes; 2) Awareness of violence against women and disclosure, with subthemes: 2.1.) Barriers experienced by primary care providers; 2.2) Facilitators for providing appropriate help; 3) Actions taken by providers to help women. Violence against women was generally considered as an unacceptable act with important health consequences. Barriers to address violence against women included organizational factors, providers’ subjective feelings and perceived role, and providers’ perceptions about women facing violence against women. Facilitators included a trusting relationship with women, attentive non-judgmental listening, participate in the community, team-work and continuing education. Providing emotional support and offering information about resources were the main actions taken by primary care providers. Women-centred care, respecting women’s decision making processes and a biopsychosocial approach may provide direction to more compassionate and supportive care while strengthening primary healthcare response.

Utilization of Patient Navigators in an Urban Academic Pediatric Primary Care Practice.

Navigating health care systems can be a challenge for families. A retrospective descriptive cohort analysis was conducted assessing referrals to patient navigators (PNs) in one urban academic pediatric primary care practice. PNs tracked referral processes and a subset of PN referrals was assessed for markers of successful referrals. The most common reasons for referral were assistance overcoming barriers to care (46%), developmental concerns (38%), and adherence/care coordination concerns (14%). Significant predictors of referral were younger age, medical complexity, public insurance, male sex, and higher rates of no-show to visits in primary or subspecialist care. The majority of referrals were resolved. The referrals for process-oriented needs were significantly more successful than those for other concerns. PNs were more effective for discrete process tasks than for those that required behavior change by patients or families. Future directions include analysis of cost effectiveness of the PN program and analysis of parent and primary care provider experience.

Primary Care Provider Experience with Breast Density Legislation in Massachusetts.

Dense breasts on mammography independently increases breast cancer risk and decreases mammography sensitivity. Thirty-two states have adopted notification laws to raise awareness among women with dense breasts about supplemental screening. Little is known about these policies' impact on clinical practice among primary care providers (PCPs). This study explores PCP attitudes, knowledge, and the impact of the Massachusetts dense breast notification legislation on clinical practice after its enactment in 2015. An anonymous, online survey at two urban safety-net hospitals was administered in 2015-2016. Practicing MDs and nurse practitioners in primary care were invited to participate. All 145 PCPs in general internal medicine at the two sites were e-mailed a survey link and 80 (55%) were completed. While 64 of 80 PCPs surveyed (80%) had some familiarity with the legislation, none identified the 8 required components of notifications contained in the Massachusetts legislation. Forty-nine percent (39/80) did not feel prepared to respond to patient questions about dense breasts. Forty-one percent (33/80) correctly identified that no current guidelines recommend the use of supplemental screening tests solely based on breast density and 85% (68/80) indicated interest in further training. Female and less experienced providers were more likely to be in favor of the legislation (49% vs. 11% by gender; 76% <5 years vs. 9%> 20 years). Women practitioners (55%) who were more likely than men (17%, p = 0.01) to agree with the policy changed their discussions of mammography results with patients. PCPs feel underprepared to counsel women about breast density identified on mammography and its implications.

"Those Conversations in My Experience Don't Go Well": A Qualitative Study of Primary Care Provider Experiences Tapering Long-term Opioid Medications.

Given the risks of long-term opioid therapy, patients may benefit from tapering these medications. There is little evidence to guide providers' approach to this process. We explored primary care providers' experiences discussing and implementing opioid tapering with patients on long-term opioid therapy. Qualitative study using six semistructured, in-person focus groups. Primary care providers (N = 40). Six academically affiliated primary care clinics in university, urban safety net, and Veterans Health Administration medical centers in Colorado. Focus groups were audio-recorded, transcribed, and analyzed using a mixed inductive-deductive approach in ATLAS.ti. Emergent themes were identified through an iterative, multidisciplinary team-based process. We identified 1) strategies for identifying candidates for opioid tapering, 2) barriers to opioid tapering, and 3) facilitators of opioid tapering. Strategies for identifying candidates for opioid tapering included evidence of high-risk behavior, serious adverse events, opioid-related side effects, and patient preference. Barriers included the providers' emotional burden, inadequate resources, and a lack of trust between patient and provider. Facilitators of opioid tapering included empathizing with the patient's experience, preparing patients for opioid tapering, individualizing implementation of opioid tapering, and supportive guidelines and policies. While discussing and implementing opioid tapering present significant challenges, primary care providers described key facilitators. These findings suggest a need to develop and test the effectiveness of resources to support patient-centered opioid tapering and locally developed policies to support and standardize providers' approaches to opioid prescribing.

Primary Care Providers with More Experience and Stronger Self-Efficacy Beliefs Regarding Women Veterans Screen More Frequently for Interpersonal Violence

BackgroundMilitary sexual trauma (MST) and/or intimate partner violence (IPV) are common experiences in the growing group of women veterans using the Veterans Health Administration health care system. And even though MST screening is closely monitored at the facility level, little is known about individual primary care provider (PCP) behavior with regard to screening women for MST and IPV. ObjectivesTo understand how PCP experiences and beliefs regarding women's health care influence PCP-reported screening for MST and IPV. Research Design and ParticipantsWe administered a cross-sectional online survey from September 2014 through April 2015 (supplemented by a mailed survey between April and May 2015) to 281 PCPs in 12 Veterans Health Administration medical centers. Measures and AnalysisSurveys measured PCP-reported screening frequency for MST and IPV, experience with women veterans, self-efficacy, gender-sensitive beliefs, and perceived barriers to providing comprehensive care for women. We used multivariable ordered logistic regression analysis to identify correlates of screening, weighted for nonresponse and adjusted for clustering. ResultsNinety-four PCPs (34%) completed the survey. Being a designated women's health provider (p < .05) and stronger self-efficacy beliefs about screening women for MST (p < .001) were associated with reporting more frequent screening for MST. Being a designated women's health provider (p < .01), seeing women patients at least once per week (p < .001), and self-efficacy beliefs about screening women for IPV (p < .001) were associated with reporting more frequent screening for IPV. ConclusionsVeterans Health Administration initiatives to enhance PCP opportunities to screen women veterans for trauma and to strengthen self-efficacy beliefs about comprehensive women's health care may increase screening of women veterans for MST and IPV.

Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment.

Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic. In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice. Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments. The EHR problem list data on Advance Health Care Directives (AHCDs) and Physician Orders for Life-Sustaining Treatment (POLST) were used to calculate ACP documentation rates. Examining seriously ill patients ≥65 years with no preexisting ACP documentation seen by providers during 2013 to 2014, 88.6% (AHCD) and 91.1% (POLST) of 79 specialists had zero ACP documentations. Of 358 PCPs, 29.1% (AHCD) and 62.3% (POLST) had zero ACP documentations. Interviewed PCPs often believed ACP documentation was beneficial and accessible, while specialists more often did not. Specialists expressed more confusion about documenting ACP, whereas PCPs reported standard clinic workflows. Problems with interoperability between outpatient and inpatient EHR systems and lack of consensus about who should document ACP were sources of variations in practices. Results suggest that providers desire standardized workflows for ACP discussion and documentation. New Medicare reimbursement for ACP and an increasing number of quality metrics for ACP are incentives for health-care systems to address barriers to ACP documentation.

Acceptability and Feasibility of an Evidence-Based Requisition for Bone Mineral Density Testing in Clinical Practice.

Introduction. The purpose of this study is to understand the experience of primary care providers (PCPs) using an evidence-based requisition for bone mineral density (BMD) testing. Methods. A qualitative descriptive approach was adopted. Participants were given 3 BMD Recommended Use Requisitions (RUR) to use over a 2-month period. Twenty-six PCPs were interviewed before using the RUR. Those who had received at least one BMD report resulting from RUR use were then interviewed again. An inductive thematic analysis was performed. Results. We identified four themes in interview data: (1) positive and negative characteristics of the RUR, (2) facilitators and barriers for implementation, (3) impact of the RUR, and (4) requisition preference. Positive characteristics of the RUR related to both its content and format. Negative characteristics related to the increased amount of time needed to complete the form. Facilitators to implementation included electronic availability and organizational endorsement. Time constraints were identified as a barrier to implementation. Participants perceived that the RUR would promote appropriate referrals and the majority of participants preferred the RUR to their current requisition. Conclusions. Findings from this study provide support for the RUR as an acceptable point-of-care tool for PCPs to promote appropriate BMD testing.

Implementation of hypertension and guidelines in urban Mongolia: A Qualitative study of primary care providers

Introduction: Hypertension and diabetes are an emerging problem within Mongolia. The prevalence of high blood pressure was 28.1% and diabetes 8.2% in 2009. Cardiovascular disease (CVD) has been one of the leading causes of mortality since 2000. NCD Risk Factors Survey in Mongolia conducted in 2009 found that a large proportion of the population has never had their blood pressure (42.6%) or blood glucose (85.2%) measured. This suggests that early detection of risk factors for diabetes and CVDs is limited in Mongolia. Short description of practice change implemented: In 2011, the working group of the Ministry of Health, Mongolia in co-operation with Millennium Challenge Account-Mongolia Health Project developed and published clinical guidelines on arterial hypertension and diabetes. Primary prevention is the main focus of the guidelines. Family physicians, nurses, dieticians and podiatrists comprising the health care team are responsible for most primary diabetes and hypertension care. However, there is international evidence that guidelines are not always implemented well in practice. Aim and theory of change used if any: There has been no attempt to examine how the guidelines have been implemented and applied at the primary care level in Mongolia. This paper aims to explore the experiences, barriers, and enablers to implementation of these guidelines in primary care settings. Targeted population and stakeholders: A qualitative study with semi-structured interviews was conducted to explore the process of implementing the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the guidelines and their implementation. Twenty individual interviews and ten focus group discussions were conducted with primary care providers in urban Mongolia. Data was analysed using a thematic inductive approach. Timeline: The research was conducted from November 2013 to February 2014 in Ulaanbaatar city, Mongolia. Highlights: (innovation, Impact and outcomes) All study participants were aware of the guidelines, and were using them in daily practice. A number of study participants attended guideline training sessions to enhance their knowledge and skills associated with guideline recommendations. A 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117081– http://www.ijic.org/ wide range of resources, including screening devices, blood tests, medications and educational materials, had been supplied by the Mongolian Government. This study found that primary care providers experienced a number of challenges in implementing the guidelines including frustration caused by increased workload, and low patient health literacy. Conclusions: (comprising key findings) The supply of medical appliances and numerous training sessions contributed to the positive experiences of primary care providers in implementing the diabetes and hypertension guidelines in urban Mongolia. In this sample of practitioners there appears to have been good uptake of the guidelines, which were integrated effectively into daily practice. Primary practitioners gained new knowledge and skills in implementing the guidelines and were able to incorporate them into their primary care practices. Discussions: This study provides strong evidence that comprehensive and rigorous dissemination and implementation strategies might be a prerequisite for the successful implementation of guidelines. The study critically underlines a significance of legal background embedded in strong professional culture, employment relationship between providers and funders, funding mechanism tied with a state budget and hierarchically-built health system design. These aspects led to a widespread acceptance and broad adoption of the guidelines. Lessons learned: This study provides a key message/lesson to be carefully considered when other evidence based clinical guidelines are released into effect in Mongolia and elsewhere. There are a variety of systemic or organisational barriers to the implementing the guidelines, which include lack of time due to competing tasks, lack of necessary built environment to exercise the lifestyle interventions, increased workload due to a number of new services and clinical procedures introduced along with the guidelines and complexity of some aspects in the guidelines that must be carefully reviewed prior to launch any clinical guidelines. By not considering the variety of barriers, interventions to improve adherence are less likely to be successful. We strongly urge that the issuing of guidelines should be preceded by workload studies as well as situational analyses so that resources can be put in place before their implementation to enable evidence-based changes in medical practice that should result in reducing the long term cardiovascular consequences of hypertension and diabetes.

The experience of primary care providers with an integrated mental health care program in safety-net clinics.

Primary care providers participating in a statewide implementation of an integrated mental health care program for "safety-net" patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question "How could psychiatric consultation [in the program] be improved?" Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.

We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record.

Poor communication between hospitalists and outpatient physicians can contribute to adverse events after discharge. Electronic medical records (EMRs) shared by inpatient and outpatient clinicians offer primary care providers (PCPs) better access to information surrounding a patient's hospitalization. However, the PCP experience and subsequent expectations for discharge communication within a shared EMR are unknown. We surveyed PCPs 1 year after a shared EMR was implemented at our institution to assess PCP satisfaction with current discharge communication practices and identify areas for improvement. Seventy-five of 124 (60%) clinicians completed the survey. Although most PCPs reported receiving automated discharge notifications (71%), only 39% felt that notifications plus discharge summaries were adequate for safe transitions of care. PCPs expressed that complex hospitalizations necessitated additional communication via e-mail or telephone; only 31% reported receiving such communication. The content most important in additional communication included medication changes, follow-up actions, and active medical issues. Despite optimized access to information provided by a shared EMR, only 52% of PCPs were satisfied with current discharge communication. PCPs express a continued need for high-touch communication for safe transitions of care. Further standardization of discharge communication practices is necessary.

Primary care provider experience and social support among homeless-experienced persons with tri-morbidity

Measures Tri-morbidity was operationalized as meeting the following criteria: 1) probable mental illness or major psychiatric distress, based on reporting a diagnosis of post-traumatic stress disorder or schizophrenia, having ever taken psychiatric medication for a significant period of time, or a score of 30+ on the Colorado Symptom Index (range: 5– 70) [1]; 2) lifetime moderateor high-risk alcohol or illicit drug use, as measured using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) v. 3 [2]; and 3) reporting at least 1 of 14 physician-diagnosed chronic medical conditions. Primary care experience was measured using the Primary Care Quality-Homeless (PCQ-H) tool (range: 1–4) [3]. Social support was measured using the “strong ties” scale (range: 3–15) [4], which queries the degree to which persons are bothered by not having a close companion, enough friendships, or people to whom they feel close.

Primary care providers' experiences notifying parents of cystic fibrosis newborn screening results.

This study examines primary care provider (PCP) experiences with the initial parental disclosure of cystic fibrosis (CF) newborn screening (NBS) results in order to identify methods to improve parent-provider communication during the CF NBS process. PCPs of infants who received positive CF NBS results participated in semistructured phone interviews. Interviews were analyzed using a qualitative content analysis. PCPs acknowledged the difficulty of "breaking bad news" to parents, and emphasized minimizing parental anxiety and maximizing parental understanding. PCPs used a variety of methods to notify parents, and shared varying information about the significance of the results. Variation in the method of parental notification, information discussed, and attention to parents' emotional needs may limit successful follow-up of children with positive CF NBS results. A multifaceted intervention to improve PCP knowledge, management, and communication could improve provider confidence, optimize information transfer, and minimize parental distress during the initial disclosure of CF NBS results.

"We've not gotten even close to what we want to do": a qualitative study of early patient-centered medical home implementation.

The Veterans Health Administration (VA) Patient Aligned Care Teams (PACT) initiative is designed to deliver a medical home model of care associated with better patient outcomes, but success will depend in part on the model's acceptability and sustainability among clinic employees. We sought to identify key themes in the experience of primary care providers, nurse care managers, clerical and clinical associates, and clinic administrators implementing PACT, with the aim of informing recommendations for continued development of the model and its components. Observational qualitative study; data collection from 2010 to 2013, using role-stratified and team focus groups and semi-structured interviews. 241 of 337 (72 %) identified primary care clinic employees in PACT team or administrative roles, from 15 VA clinics in Oregon and Washington. Data coded and analyzed using conventional content analysis techniques. Overall, participants were enthusiastic about the PACT concept, but felt necessary resources for success were not yet in place. Well-functioning teams were perceived as key to successful implementation. Development of such teams depended on adequate staffing, training, and dedicated time for team development. Changes within the broader VA system were also seen as necessary, including devolving greater control to the clinic level and improving system alignment with the PACT model. PACT advocates from among clinic and institutional level leadership were identified as a final key ingredient for success. These themes were consistent despite differences in clinic settings and characteristics. PACT implementation faced significant challenges in its early years. Realizing PACT's transformative potential will require acting on the needs identified by clinic workers in this study: ensuring adequate staffing in all team roles, devoting resources to in-depth training for all employees in communication and other skills needed to maximize team success, and aligning the broader VA hospital system with PACT's decentralized, team-based approach.

Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access

ObjectiveThis evaluation assessed the opinions and experiences of primary care providers and their support staff before and after implementation of expanded on-site mental health services and related system changes in a primary care clinic. MethodIndividual semistructured interviews, which contained a combination of open-ended questions and rating scales, were used to elicit opinions about mental health services before on-site system and resource changes occurred and repeated following changes that were intended to improve access to on-site mental health care. ResultsIn the first set of interviews, prior to expanding mental health services, primary care providers and support staff were generally dissatisfied with the availability and scheduling of on-site mental health care. Patients were often referred outside the primary care clinic for mental health treatment, to the detriment of communication and coordinated care. Follow-up interviews conducted after expansion of mental health services, scheduling refinements and other system changes revealed improved provider satisfaction in treatment access and coordination of care. Providers appreciated immediate and on-site social worker availability to triage mental health needs and help access care, and on-site treatment was viewed as important for remaining informed about patient care the primary care providers are not delivering directly. ConclusionsExpanding integrated mental health services resulted in increased staff and provider satisfaction. Our evaluation identified key components of satisfaction, including on-site collaboration and assistance triaging patient needs. The sustainability of integrated models of care requires additional study.

Six-monthly diabetes monitoring of well-controlled patients: Experiences of primary care providers

AimsTo examine experiences of primary care providers with six-monthly diabetes monitoring of well-controlled patients. MethodsThis study was part of the EFFIMODI study, examining whether six-monthly monitoring of well-controlled (HbA1c ≤58mmol/mol, systolic blood pressure ≤145mmHg and total cholesterol ≤5.2mmol/l) type 2 diabetes patients results in equivalent cardiometabolic control compared to three-monthly monitoring. Primary care providers completed a questionnaire about their experiences with six-monthly diabetes monitoring, whether they want to continue six-monthly monitoring and for which type of patients six-monthly monitoring is sufficient. ResultsOf 163 questionnaires, 157 (96.3%) were completed and returned. Only 14 (8.9%) primary care providers were negative about the six-monthly monitoring and 102 (65.0%) would like to continue six-monthly monitoring. Primary care providers disagreed about patients’ ability to determine their own monitoring frequency and whether six-monthly monitoring was suitable for all well-controlled type 2 diabetes patients. Practical concerns emerged such as the inability to declare healthcare costs and the unsuitability of electronic health record systems. ConclusionsAlmost two out of three primary care providers would like to continue six-monthly monitoring of well-controlled type 2 diabetes patients. However, some diabetes care providers should be convinced and some practical concerns should be solved.