Group Of Primary Care Practices Research Articles

Early Response of Primary Care Practices to COVID-19 Pandemic.

Introduction:The emergence of the COVID-19 pandemic and subsequent public health mitigation strategies resulted in rapid and significant changes to delivery of primary care. The field of primary care faced an unprecedented dual challenge of providing routine care to patients while ensuring patient and staff safety and managing patients with a highly transmissible disease. This study describes how a diverse group of primary care practices addressed these challenges at the start of the COVID-19 pandemic, in Spring 2020.Methods:A cross-sectional electronic survey of representatives from primary care practices in the WWAMI region Practice and Research Network (WPRN). Survey topics included clinical workforce, operations, and use of telemedicine in the first 3 months of the COVID-19 pandemic.Results:To safely manage patients with COVID-19 symptoms all clinics modified operations; 81.3% diverted patients with respiratory symptoms to a telemedicine evaluation, 68.8% diverted these patients to be seen in-person at another location, and 75% made in-clinic changes to maintain safety. The set of operational changes employed by clinics was diverse. To continue to provide routine patient care, all clinics employed telemedicine. Over 80% of clinics had never used telemedicine prior to March 2020.Conclusions:A diverse group of primary care clinics all rapidly implemented a variety of operational adaptations to address patient needs and maintain patient and staff safety at the onset of the COVID- 19 pandemic. Telemedicine, together with other measures, provided critical pathways for maintaining delivery of care.

Impact of Unannounced Standardized Patient Audit and Feedback on Care, Documentation, and Costs: an Experiment and Claims Analysis

BackgroundMeaningful variations in physician performance are not always discernible from the medical record.ObjectiveWe used unannounced standardized patients to measure and provide feedback on care quality and fidelity of documentation, and examined downstream effects on reimbursement claims.DesignStatic group pre-post comparison study conducted between 2017 and 2019.SettingFourteen New Jersey primary care practice groups (22 practices) enrolled in Horizon BCBS’s value-based program received the intervention. For claims analyses, we identified 14 additional comparison practice groups matched on county, practice size, and claims activity.ParticipantsFifty-nine of 64 providers volunteered to participate.InterventionUnannounced standardized patients (USPs) made 217 visits portraying patients with 1–2 focal conditions (diabetes, depression, back pain, smoking, or preventive cancer screening). After two baseline visits to a provider, we delivered feedback and conducted two follow-up visits.MeasurementsUSP-completed checklists of guideline-based provider care behaviors, visit audio recordings, and provider notes were used to measure behaviors performed and documentation errors pre- and post-feedback. We also compared changes in 3-month office-based claims by actual patients between the intervention and comparison practice groups before and after feedback.ResultsExpected clinical behaviors increased from 46% to 56% (OR = 1.53, 95% CI 1.29–1.83, p < 0.0001), with significant improvements in smoking cessation, back pain, and depression screening. Providers were less likely to document unperformed tasks after (16%) than before feedback (18%; OR = 0.74, 95% CI 0.62 to 0.90, p = 0.002). Actual claim costs increased significantly less in the study than comparison group for diabetes and depression but significantly more for smoking cessation, cancer screening, and low back pain.LimitationsSelf-selection of participating practices and lack of access to prescription claims.ConclusionDirect observation of care identifies hidden deficits in practice and documentation, and with feedback can improve both, with concomitant effects on costs.

Clinical Implications

Clinical Implications

Evaluating the Health Information Technology Regional Extension Center in South Carolina

ObjectiveTo determine the impact of the South Carolina Regional Extension Center, Center for Information Technology Implementation Assistance (CITIA-SC), on physician practices engaged in the process of electronic medical record (EMR) adoption. Data sourcesData from a cross-sectional survey distributed in March 2011 to 1310 primary care practice groups throughout South Carolina was used to determine the degree of EMR adoption throughout the state (n=452 respondents; 34.5% response rate). Participation in CITIA-SC was determined by obtaining a list of practices from CITIA-SC. Study designA posttest-only design with nonequivalent groups was used to estimate the degree of EMR implementation, plans for and perceived barriers to implementation based on CITIA-SC participation. ResultsCITIA-SC practice sites faced similar barriers to EMR implementation as non-CITIA-SC participants, including initial or recurring cost of an EMR, low staff expertise with EMRs or computers, and productivity disruption. Additionally, CITIA-SC practice sites had fewer IT personnel on staff (p=0.0358) and were considering EMR implementation without a plan (p=0.0125). Despite these barriers, more practices participating in the CITIA-SC program were preparing to invest in an EMR system within one year when compared to nonparticipants (75.9% versus 28.3%, p<0.0001). ConclusionOur results indicated that the practice sites that participate in the REC had fewer IT resources and more perceived barriers to implementation. These results suggest that REC participant practice sites intend to implement an EMR, but recognize the need for technical assistance in the preparation and implementation of an EMR system.

The science of primary health-care improvement: potential and use of community-based participatory research by practice-based research networks for translation of research into practice

There is a need for new approaches to supplement the existing methods of taking research from bench to bedside and from bedside to practice. Community-based participatory research (CBPR) is an emerging model of research that enhances ongoing clinical research by involving key stakeholders, including community members and patients. A practice-based research network (PBRN) is a group of primary care practices devoted principally not only to the primary care of patients, but also with a mission to investigate questions related to community-based practice and to improve the quality of primary care. Traditionally, PBRN research has not included patients or community members, while CBPR has excluded health providers as key stakeholders. Typical overlap topics of PBRN and CBPR research are health-care disparities, prevention, chronic disease management and mental health. The inclusion of CBPR within a PBRN has been identified as an important next step with the potential to significantly enhance the research process. This review focuses on bringing together the ideals of CBPR and PBRNs in order to tackle intractable problems such as disparities in health-care access and outcomes and translate these results into practice. Specifically, the CBPR PBRN approach can: (1) guide the research process so that studies more closely match the needs of all stakeholders (including providers, patients and community members); (2) assist in the development of the research protocol and identification of research methodologies so that the study is more amenable to participants; (3) facilitate recruitment of research participants; (4) enrich the data collection and analysis; and (5) allow rapid translation of results from the study back into clinical practice and the community. Once these mechanisms have been clearly elucidated, their widespread adoption will positively impact overall health at both a local and national level.

Improved cardiovascular prevention using best CME practices: A randomized trial

It was hypothesized that after a continuing medical education (CME) event, practice enablers and reinforcers addressing main clinical barriers to preventive care would be more effective in improving general practitioners' (GPs) adherence to cardiovascular guidelines than a CME event only. A cluster-randomized trial was conducted on a convenience sample of 122 GPs who were randomly assigned to either CME only (control group) or CME with practice enablers and reinforcers (PER group). In the PER group, nurses visited GPs' offices once a month to implement the clinical intervention on patients > or = 55 years old with a scheduled visit in the month following the nurse visit: (1) screening medical records for potentially undermanaged high-risk patients; (2) prompting physicians to reassess preventive care in these patients; (3) enclosing a checklist reporting most recent information relevant to guidelines' implementation; and (4) enclosing a summary of experts' recommendations in the form of a follow-up and treatment algorithm. A retrospective chart audit of 2344 consenting patients, potentially undermanaged at baseline, demonstrated that the PER intervention following CME significantly improved adherence to guidelines compared to CME alone (OR: 1.78, 95% CI: 1.32-2.41). The intervention was designed for self-implementation in primary care practices that have their own nursing staff. PER GPs were highly satisfied with the intervention; the majority said that they would implement it in their practice if someone trained their nurse, thus suggesting support for development of a multiprofessional CME program to disseminate this clinical approach to primary care practice groups.

Clinician- and organization-level factors in the adoption of evidence-based care for depression in primary care

Although more individuals are receiving care for depression than those in the past, they often do not receive high-quality care. Strategies to improve quality have focused on changing clinician behavior and more recently on reducing practice barriers. Both strategies hold promise but have had widely varying success either because practices have not successfully removed barriers or because removing barriers alone is not sufficient for improving care. It is unknown under which circumstances clinicians with a high propensity toward recognizing depression and providing depression care can overcome barriers. We explore organizational and clinician factors affecting patient receipt of guideline-concordant services. We use data from adult patients with major depression receiving care in a geographically diverse group of primary care practices participating in the Quality Improvement for Depression study. We estimate the effects of barriers and clinician propensity on six aspects of depression care and adequate treatment. Barriers and propensity interact in affecting depression services. In comparison with similar clinicians in practices with few barriers, high-propensity clinicians working in practices with more barriers are less likely to provide depression education and are likely to provide fewer follow-up calls and fewer follow-up visits. High-propensity clinicians are more likely to offer antidepressants in practices with more barriers. To improve the quality of care, efforts should both eliminate practice barriers and increase clinician propensity to provide care. Future research on factors associated with quality improvement can benefit from an approach which specifies how organizational and clinician factors interact to enact change.

Disease Burden in the Managed Care Population at an Academic Medical Center: The Effect of Adding Local Partners

Academic medical centers (AMCs) have traditionally cared for the most severely ill patients. AMCs' effort to meet the challenges of managed care contracts may be nullified by adverse selection unless payment mechanisms adequately consider the health risk of the AMC's managed care population. The authors compared the disease burden between the University of Michigan Health System (UMHS) and its community competitors and assessed the effect of adding local primary care partners through strategic outsourcing on these differences in disease burden. This is a population-based study from one managed care plan in Michigan. The study population was commercial members (n = 127, 892) enrolled in the plan for the entire 12 months of 2001. The authors derived several morbidity measures from age and sex, Adjusted Clinical Groups, and Aggregated Diagnosis Groups using administrative data. Compared to community groups, the UMHS consistently had a higher disease burden, while the nonacademic groups as a whole had more young members with acute conditions. After the UMHS partnered with two local primary care practice groups in their area, this AMC-local partner group had an equal or lower disease burden than the remainder of the community groups that experienced a slightly higher proportion of members with multiple medical conditions. The higher disease burden borne by AMCs is a complex phenomenon. Without local partners, the UMHS did experience higher disease burden, although the degree depends on the measurement of morbidity. Partnering with carefully selected local primary care groups may ameliorate the AMC's disproportionate disease burden.

A State-Level Application of the Chronic Illness Breakthrough Series: Results from Two Collaboratives on Diabetes in Washington State

Breakthrough Series Collaboratives addressing chronic conditions have been conducted at the national level and in single health care delivery systems but not at the state level. Two state-level collaboratives were conducted: Diabetes Collaborative I (October 1999-November 2000) included 17 clinic teams from across the state, and Diabetes Collaborative II (February 2001-March 2002) included 30 teams and 6 health plans. Both collaboratives took place in Washington State, where a diverse group of primary care practices participated, and health insurance plans partnered with the clinic teams. Teams individually tested and implement changes in their systems of care to address all components of the Chronic Care Model. All 47 teams completed the collaboratives, and all but one maintained a registry throughout the 13 months. Most teams demonstrated some amount of improvement on process and outcome measures that addressed blood sugar testing and control, blood pressure control, lipid testing and control, foot exams, dilated eye exams, and self-management goals. The benefits of holding collaboratives more locally include increased technical support and increased participation, translating into wider implementation of prevention-focused, patient-centered care.

Feasibility of incorporating computer-tailored health behaviour communications in primary care settings.

We set out to investigate the feasibility of incorporating a computer-tailored health behaviour program into routine care in a group of primary care practices in Rhode Island. Two existing computer programs (physical activity, smoking) that tailored text and graphical feedback to survey responses were combined and adapted for use in primary care directly by patients. Ten primary care practices were recruited and worked closely with project staff to develop a practice-specific plan for incorporating the program into the workflow and office routine. Feasibility was measured by the percentage of patients who used the program during the day of their visit. Only one of the ten offices was able to successfully incorporate the program into their office workflow and delivery of routine care. The main categories of barriers to incorporating the computer program into routine care included: the program was viewed overall as inconsistent with practice workflow, the staff was inexperienced with the program, technical problems with the computer and/or printer, the program placed an additional time burden on staff who already felt overworked. Suggestions for improving the program or the way that it was incorporated into routine care included: shortening the program, modifying the program's orientation to a target population (such as patients with hypertension) and incorporating decision-support feedback to help physicians manage the target condition, modifying the program to include other programs pertinent to primary care (for example, depression screening), selecting patients to use the program, rather than asking all patients to use it. After working closely with ten highly motivated primary care offices, we were unable to fully implement a point-of-care health behaviour computer system for patients and providers. Suggestions for disseminating computer-tailored health behaviour communications in primary care settings are discussed.

Improving preventive service delivery through office systems.

Rates of childhood immunizations and other preventive services are lower in many practices than national goals and providers' own estimates. Office systems have been used in adult settings to improve the delivery of preventive care, but their effectiveness in pediatric practices is unknown. This study was designed to determine whether a group of primary care practices in 1 community could implement office-based quality improvement systems that would significantly improve their delivery of childhood preventive services. The study was part of a larger community-wide intervention study reported in a preceding study. All the major providers of primary care to children in 1 community were recruited and agreed to participate (N = 8 practices). Project staff worked on-site with improvement teams in each practice to develop tailored systems to assess and improve the delivery of immunizations and screening for anemia, tuberculosis, and lead exposure. Office-based quality improvement systems typically involved some combination of chart prescreening, risk assessment forms, Post-it prompts, flow-sheets, reminder/recall systems, and patient education materials. Office systems also often involved redistributing responsibilities among office staff. All 8 participating practices created improvement teams. Project staff met with the practices 10 to 15 times over 12 months. After the period of office assistance, the overall rates for all preventive services except tuberculosis screening increased by amounts that were both clinically and statistically significant. Absolute percent improvements included: complete immunizations at 12 months, 7%; complete immunizations at 24 months, 12%; anemia screening, 30%; lead screening, 36%. The amount of improvement achieved varied considerably between practices. Office systems and the principles of quality improvement that underlie them seem to be effective in improving the delivery of childhood preventive services. Important predisposing factors may exist within practices that affect the likelihood that an individual practice will make significant improvements. prevention, immunizations, improvement, office systems, primary care.

Confessions of a behavior therapist in primary care: The odyssey and the ecstasy

As the pressures surrounding health care reform continue to mount, there has been a corresponding emphasis on re-integrating health and behavioral health services. This trend promises to provide behaviorally trained clinicians with numerous opportunities to practice in medical settings. The de facto mental health system in the United States is the primary care system; yet, there are few behavioral health practitioners practicing “on site” in primary care practice groups. This is unfortunate, because research studies and clinical experience suggest that physicians have very favorable attitudes toward behavioral procedures and use them regularly in medical practice. This article attempts to summarize key learning experiences from a 5-year primary care integration project at Group Health Cooperative, organized by three behaviorally trained psychologists. The major principles underpinning effective health and behavioral health integration will be examined. Main sources of organizational and disciplinary resistance, along with some “tried and true” strategies for countering that resistance, are highlighted. The concept of primary mental health care is introduced, as a distinctive form of behavioral health service that shares many of the philosophies of primary medical care. Changes in the structure of clinical practice are inevitable in primary care and, accordingly, moving to a consultation model is a more viable method for delivering services. The defining characteristics of the consultant, versus therapist, model will be highlighted, as will the core clinical services that are most valued in primary care settings. Finally, key practice style adjustments will be discussed to highlight how much the practice of behavior therapy must change to accommodate the demands of the primary care setting.

A strategy to define the role of the primary care physician in occupational and environmental medicine.

Although occupational medicine has its own unique knowledge, skills, and organizational base, it exists in a cultural, social, and organizational environment that is common to other institutions in our culture. It is therefore possible that the task of introducing the practice of occupational medicine into primary care can be made easier by examining the experience of those who have already attempted to introduce preventive Cardiology Academic Award provides a potential paradigm for enlisting a cadre of 10 to 25 innovative primary care physicians who would begin to develop actual practice models and disseminate their findings about the implementation of occupational medicine in primary care. Introducing preventive cardiology into primary care has required that multiple barriers be overcome; it is not unreasonable to expect that occupational medicine will face many of the same barriers. However, if these barriers can be successfully overcome at the experimental sites, the result will be a group of primary care practices that can be used as models for the expansion of occupational medicine to primary care in general.