Independent Primary Care Practices Research Articles

Which pediatric practices use substance use consultation services?

Substance use disorders (SUD) are common in adolescents and young adults, though few youth with SUD receive treatment, and rates of medication for substance use disorder treatment are much lower in youth compared to adults. Pediatric primary care could present an opportunity for youth with SUD to access medication, though pediatric providers may need support. Massachusetts has provided a substance use consultation line for pediatric providers since 2018. One large network of independent primary care practices within the state has been further supported by access to resources provided through a grant from the Substance Abuse and Mental Health Services Administration. In this paper, we describe the services provided in Massachusetts and examine whether additional resources are associated with increased use of the consultation line as a marker of provider engagement in SUD treatment.

Virtual quality improvement collaborative with primary care practices during COVID-19: a case study within a clinically integrated network

IntroductionQuality improvement collaboratives (QICs) are a common approach to facilitate practice change and improve care delivery. Attention to QIC implementation processes and outcomes can inform best practices for designing and...

Practice facilitation for scale up of clinical decision support for hypertension management: study protocol for a cluster randomized control trial

BackgroundOnly half of patients with hypertension have adequately controlled blood pressure. Clinical decision support (CDS) has the potential to overcome barriers to delivering guideline-recommended care and improve hypertension management. However, optimal strategies for scaling CDS have not been well established, particularly in small, independent primary care practices which often lack the resources to effectively change practice routines. Practice facilitation is an implementation strategy that has been shown to support process changes. Our objective is to evaluate whether practice facilitation provided with hypertension-focused CDS can lead to improvements in blood pressure control for patients seen in small primary care practices. Methods/designWe will conduct a cluster randomized control trial to compare the effect of hypertension-focused CDS plus practice facilitation on BP control, as compared to CDS alone. The practice facilitation intervention will include an initial training in the CDS and a review of current guidelines along with follow-up for coaching and integration support. We will randomize 46 small primary care practices in New York City who use the same electronic health record vendor to intervention or control. All patients with hypertension seen at these practices will be included in the evaluation. We will also assess implementation of CDS in all practices and practice facilitation in the intervention group. DiscussionThe results of this study will inform optimal implementation of CDS into small primary care practices, where much of care delivery occurs in the U.S. Additionally, our assessment of barriers and facilitators to implementation will support future scaling of the intervention.ClinicalTrials.gov Identifier: NCT05588466

Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings.

Established models of reproductive health service delivery were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This study examines rapid innovation of remote abortion service operations across health care settings and describes the use of telehealth consultations with medications delivered directly to patients. We conducted semi-structured interviews with 21 clinical staff from 4 practice settings: family planning clinics, online medical services, and primary care practices-independent or within multispecialty health systems. Clinicians and administrators described their telehealth abortion services. Interviews were recorded, transcribed, and analyzed. Staff roles, policies, and procedures were compared across practice settings. Across all practice settings, telehealth abortion services consisted of 5 operational steps: patient engagement, care consultations, payment, medication dispensing, and follow-up communication. Online services and independent primary care practices used asynchronous methods to determine eligibility and complete consultations, resulting in more efficient services (2-5 minutes), while family planning and health system clinics used synchronous video encounters requiring 10-30 minutes of clinician time. Family planning and health system primary care clinics mailed medications from clinic stock or internal pharmacies, while independent primary care practices and online services often used mail-order pharmacies. Online services offered patients asynchronous follow-up; other practice settings scheduled synchronous appointments. Rapid innovations implemented in response to disrupted in-person reproductive health care included remote medication abortion services with telehealth assessment/follow-up and mailed medications. Though consistent operational steps were identified across health care settings, variation allowed for adaptation of services to individual sites. Understanding remote abortion service operations may facilitate dissemination of a range of patient-centered reproductive health services.Annals "Online First" article.

Leveraging Accountable Care Organization infrastructure for rapid pandemic response in independent primary care practices

BackgroundPopulation risk segmentation and technology-enabled preventive care workflows are core competencies for Accountable Care Organizations (ACOs) that may also have relevance for public health emergencies. MethodsDuring the early weeks of the COVID-19 pandemic, we aimed to leverage existing ACO capabilities to support 467 primary care practices across 27 states with pandemic response. We used Medicare claims and electronic health records to identify patients with increased COVID-19 vulnerability, for proactive outreach and guidance for “Staying Well at Home.” Results302,125 patients met intervention criteria; 45% were reached within the first 6 weeks. Engagement in the initiative was uneven among ACO-participating practices. ACO staff identified prior practice engagement in core ACO workflows as a major facilitator of success and staffing shortages as a major barrier. Small practice size, non-metropolitan location, penetration of value-based payment models in the practice, and pre-pandemic Annual Wellness Visit completion rates were independently associated with successful outreach to COVID-vulnerable patients. ConclusionsRapid adaptation of ACO infrastructure assisted independent practices across the country to reach vulnerable patients with proactive guidance for staying well at home. The initiative was most successful in smaller, non-metropolitan practices and those with greater engagement in core ACO initiatives pre-pandemic. ImplicationsOur experience suggests that primary care participation in accountable care models can contribute to preparedness for future public health crises.

Extending collaborative care to independent primary care practices: A chronic care model.

Extending collaborative care to independent primary care practices: A chronic care model.

Coordination Without Consolidation? Options for ACOs

Findings published in this issue add to the growing literature showing that multiple types of accountable care organizations (ACOs) can be successful, whether they are confederations of smaller, independent primary care practices or larger, integrated systems.

Place Matters: Closing the Gap on Rural Primary Care Quality Improvement Capacity-the Healthy Hearts Northwest Study.

To compare rural independent and health system primary care practices with urban practices to external practice facilitation support in terms of recruitment, readiness, engagement, retention, and change in quality improvement (QI) capacity and quality metric performance. The setting consisted of 135 small or medium-sized primary care practices participating in the Healthy Hearts Northwest quality improvement initiative. The practices were stratified by geography, rural or urban, and by ownership (independent [physician-owned] or system-owned [health/hospital system]). The quality improvement capacity assessment (QICA) survey tool was used to measure QI at baseline and after 12 months of practice facilitation. Changes in 3 clinical quality measures (CQMs)-appropriate aspirin use, blood pressure (BP) control, and tobacco use screening and cessation-were measured at baseline in 2015 and follow-up in 2017. Rural practices were more likely to enroll in the study, with 1 out of 3.5 rural recruited practices enrolled, compared with 1 out of 7 urban practices enrolled. Rural independent practices had the lowest QI capacity at baseline, making the largest gain in establishing a regular QI process involving cross-functional teams. Rural independent practices made the greatest improvement in meeting the BP control CQM, from 55.5% to 66.1% (P ≤ .001) and the smoking cessation metric, from 72.3% to 86.7% (P ≤ .001). Investing practice facilitation and sustained QI strategies in rural independent practices, where the need is high and resources are low, will yield benefits that outweigh centrally prescribed models.

Soft Consolidation In Medicare ACOs: Potential For Higher Prices Without Mergers Or Acquisitions.

Antitrust guidance specifies that participation in Medicare accountable care organizations (ACOs) is sufficient to meet clinical integration standards for separately owned providers to jointly negotiate with insurers. Accordingly, ACO participation may facilitate price increases through a less conventional, "softer" consolidation that would not be categorically challenged as price fixing. Using commercial claims and data on health system membership and ACO participation, we found some abrupt, large price increases for independent primary care practices that joined health system-led ACOs but were not acquired by systems. These price jumps were rare, however, increasing prices by just 4percent, on average, among all independent practices in system-led ACOs. Additional analyses suggested minimal increases in health systems' primary care prices or market shares from ACO contracting. Thus, the price jumps were more consistent with an extension of existing pricing power from systems to some independent practices than with a major expansion of system market power. Nevertheless, the potential for growth of these arrangements through ACOs argues for closer monitoring and evaluation.

Factors associated with successful implementation of telehealth abortion in 4 United States clinical practice settings

ObjectiveTo overcome obstacles to delivering medication abortion services during the COVID-19 pandemic, clinics and providers implemented new medication abortion service models not requiring in-person care. This study identifies organizational factors that promoted successful implementation of telehealth and adoption of “no test” medication abortion protocols. Study designWe conducted 21 semi-structured, in-depth interviews with health care providers and clinic administrators implementing clinician-supported telehealth abortion during the COVID pandemic. We selected 15 clinical sites to represent 4 different practice settings: independent primary care practices, online medical services, specialty family planning clinics, and primary care clinics within multispecialty health systems. The Consolidated Framework for Implementation Research guided our thematic analysis. ResultsSuccessful implementation of telehealth abortion included access to formal and informal inter-organizational networks, including professional organizations and informal mentorship relationships with innovators in the field; organizational readiness for implementation, such as having clinic resources available for telehealth services like functional electronic health records and options for easy-to-use virtual patient-provider interactions; and motivated and effective clinic champions. ConclusionsIn response to the need to offer remote clinical services, 4 different practice settings types leveraged key operational factors to facilitate successful implementation of telehealth abortion. Information from this study can inform implementation strategies to support the dissemination and adoption of this model. ImplicationsExamples of successfully implemented telehealth medication abortion services provide a framework that can be used to inform and implement similar patient-centered telehealth models in diverse practice settings.

A Harm Reduction Approach to Treating Opioid Use Disorder in an Independent Primary Care Practice: a Qualitative Study.

BackgroundStigma is a barrier to the uptake of buprenorphine to treat opioid use disorder. Harm reduction treatment models intend to minimize this stigma by organizing care around non-judgmental interactions with people who use drugs. There are few examples of implementing buprenorphine treatment using a harm reduction approach in a primary care setting in the USA.MethodsWe conducted a qualitative study by interviewing leadership, staff, and external stakeholders at Respectful, Equitable Access to Compassionate Healthcare (REACH) Medical in Ithaca, NY. REACH is a freestanding medical practice that provides buprenorphine treatment for opioid use disorder since 2018. We conducted semi-structured interviews with 17 participants with the objective of describing REACH’s model of care. We selected participants based on their position at REACH or in the community. Interviews were recorded, transcribed, and analyzed for themes using content analysis, guided by the CDC Evaluation Framework.ResultsREACH provided buprenorphine, primary care, and mental health services in a low-threshold model. We identified three themes related to delivery of buprenorphine treatment. First, an organizational mission to provide equitable and low-stigma healthcare, which was a key to organizational identity. Second, a low-threshold buprenorphine treatment approach that was critical, but caused concern about over-prescribing and presented logistical challenges. Third, creation and retention of a harm reduction-oriented workforce by offering value-based work and by removing administrative barriers providers may face elsewhere to providing buprenorphine treatment.ConclusionsA harm reduction primary care model can help reduce stigma for people who use drugs and engage in buprenorphine treatment. Further research is needed to evaluate whether this model leads to improved patient outcomes, can overcome community stakeholder concerns, and is sustainable.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06409-6.

Supplemental Material for Extending Collaborative Care to Independent Primary Care Practices: A Chronic Care Model

Supplemental Material for Extending Collaborative Care to Independent Primary Care Practices: A Chronic Care Model

Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation

Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention. The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019. A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves. The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines. The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002). Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context. This study is registered at www.clinicaltrials.gov NCT02646488.

Barriers and Facilitators in the Recruitment and Retention of More Than 250 Small Independent Primary Care Practices for EvidenceNOW.

Few studies have examined factors that facilitate recruitment of small independent practices (SIPs) (<5 full-time clinicians) to participate in research and methods for optimizing retention. The authors analyzed qualitative data (eg, recruiter's field notes and diary entries, provider interviews) to identify barriers and facilitators encountered in recruiting and retaining 257 practices in HealthyHearts New York City (NYC). This study was a stepped-wedge randomized controlled trial that took place 2015 through 2018 across 5 boroughs in NYC. Three main factors facilitated rapid recruitment: (1) a prior well-established relationship with the local health department, (2) alignment of project goals with practice priorities, and (3) providing appropriate monetary incentives. Retention was facilitated through similar mechanisms and an ongoing multifaceted communication strategy. This article identifies specific strategies that enhance recruitment of SIPs and fills gaps in knowledge about factors that influence retention in the context of a design that requires waiting to receive the intervention.

Direct primary care-Where does integrated behavioral health fit?

Primary care is increasingly viewed as key to growing health system market share in value-based purchasing strategies for both public- and private-sector programs. Yet not all primary care physicians are interested in becoming part of large multispecialty practices or working in employed arrangements. Instead, a growing number of physicians are launching independent direct primary care (DPC) practices in order to maintain professional autonomy, mitigate burnout, and ensure long-term meaningful engagement with patients and families. Given that the typical size of a DPC care team is small, what does this mean for integrating behavioral health? As primary care evolves under various payment and delivery models, the integration of behavioral health services will require adaptability based on practice size, scope of practice, patient acuity, and payment model. Indeed, advocates of integrated behavioral health can "skate to where the puck is going to be"1 by familiarizing themselves with innovations in primary care, such as the DPC model. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Medicaid Transformation From the Independent Practice Perspective: Opportunities and Obstacles.

The importance of independent primary care practices as North Carolina approaches Medicaid transformation cannot be overstated. Forty-four percent of the state's pediatricians remain in independent practice and more than a quarter of family physicians maintain an equity stake in their practice, with

Clinician Perspectives on the Benefits of Practice Facilitation for Small Primary Care Practices.

Small independent primary care practices (SIPs) often lack the resources to implement system changes. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality, studied the effectiveness of practice facilitation to improve cardiovascular disease- related care in 257 SIPs. We sought to understand SIP clinicians' perspectives on the benefits of practice facilitation. We conducted in-depth interviews with 19 SIP clinicians enrolled in HealthyHearts NYC. Interviews were transcribed and coded using deductive and inductive approaches. To understand whether the perceived benefits of practice facilitation differ based on the availability of internal staff for quality improvement (QI), we compared themes pertaining to benefits between practices with 3 or fewer office staff vs more than 3 office staff. Clinicians perceived 2 main benefits of practice facilitation. First, facilitators served as a connection to the external health care environment for SIPs, often through teaching and information sharing. Second, facilitators provided electronic health record (EHR)/data expertise, often by teaching functionality and completing technical assistance and tasks. SIPs with more than 3 office staff felt that facilitators provided benefits primarily through teaching, whereas SIPs with 3 or fewer staff felt that facilitators also provided hands-on support. At the intersections of these benefits, there emerged 3 central practice facilitation benefits: (1) creating awareness of quality gaps, (2) connecting practices to information, resources, and strategies, and (3) optimizing the EHR for QI goals. SIP clinicians perceived practice facilitation to be an important resource for connecting their practice to the external health care environment and resources, and helping their practice build QI capacity through teaching, hands-on support, and EHR-driven solutions.

One Size Does Not Fit All: Balancing Individual and System Needs in Primary Care and Beyond.

In this issue, Dewan and Norcini invite readers to reconsider the basic minimum standards for independent primary care practice. Their willingness to push boundaries, question turf wars, and suggest innovative ways forward is laudable. Although their piece is timely and provocative, it does not fully consider the interplay between individual and system factors that influence people to pursue different kinds of degrees and practice in this context. In this Invited Commentary, the authors discuss imperatives that are underacknowledged by Dewan and Norcini: the importance of diversity in health system planning; status, power, and privilege; the extension of their argument beyond primary care; the conflation of time in training with competence; and important issues of distribution of health care resources. Ultimately, the authors argue that there may be strength in diversity, one that should not be obscured by attempts to normalize training time.

Correlates of Burnout in Small Independent Primary Care Practices in an Urban Setting.

Little is known about the prevalence and correlates of burnout among providers who work in small independent primary care practices (<5 providers). We conducted a cross-sectional analysis by using data collected from 235 providers practicing in 174 small independent primary care practices in New York City. The rate of provider-reported burnout was 13.5%. Using bivariate logistic regression, we found higher adaptive reserve scores were associated with lower odds of burnout (odds ratio, 0.12; 95% CI, 0.02-0.85; P = .034). The burnout rate was relatively low among our sample of providers compared with previous surveys that focused primarily on larger practices. The independence and autonomy providers have in these small practices may provide some protection against symptoms of burnout. In addition, the relationship between adaptive reserve and lower rates of burnout point toward potential interventions for reducing burnout that include strengthening primary care practices' learning and development capacity.

Barriers and facilitators to HPV vaccination in primary care practices: a mixed methods study using the Consolidated Framework for Implementation Research

BackgroundIn the United States, the effective, safe huma papilloma virus (HPV) vaccine is underused and opportunities to prevent cancer continue to be missed. National guidelines recommend completing the 2–3 dose HPV vaccine series by age 13, well before exposure to the sexually transmitted virus. Accurate characterization of the facilitators and barriers to full implementation of HPV vaccine recommendations in the primary care setting could inform effective implementation strategies.MethodsWe used the Consolidated Framework for Implementation Research (CFIR) to systematically investigate and characterize factors that influence HPV vaccine use in 10 primary care practices (16 providers) using a concurrent mixed methods design. The CFIR was used to guide collection and analysis of qualitative data collected through in-person semi-structured interviews with the primary care providers. We analyzed HPV vaccine use with data abstracted from medical charts. Constructs that most strongly influenced vaccine use were identified by integrating the qualitative and quantitative data.ResultsOf the 72 CFIR constructs assessed, seven strongly distinguished and seven weakly distinguished between providers with higher versus lower HPV vaccine coverage. The majority of strongly distinguishing constructs were facilitators and were related to characteristics of the providers (knowledge and beliefs; self-efficacy; readiness for change), their perception of the intervention (relative advantage of vaccinating younger vs. older adolescents), and their process to deliver the vaccine (executing). Additional weakly distinguishing constructs that were facilitators were from outer setting (peer pressure; financial incentives), inner setting (networks and communications and readiness for implementation) and process (planning; engaging, and reflecting and evaluating). Two strongly distinguishing constructs were barriers to use, one from the intervention (adaptability of the age of initiation) and the other from outer setting (patient needs and resources).ConclusionsUsing CFIR to systematically examine the use of this vaccine in independent primary care practices enabled us to identify facilitators and barriers at the provider, interpersonal and practice level that need to be addressed in future efforts to increase vaccine use in such settings. Our findings suggest that implementation strategies that target the provider and help them to address multi-level barriers to HPV vaccine use merit further investigation.