Independent Primary Care Practices Research Articles

Quality of Cardiovascular Disease Care in Small Urban Practices.

We wanted to describe small, independent primary care practices' performance in meeting the Million Hearts ABCSs (aspirin use, blood pressure control, cholesterol management, and smoking screening and counseling), as well as on a composite measure that captured the extent to which multiple clinical targets are achieved for patients with a history of arteriosclerotic cardiovascular disease (ASCVD). We also explored relationships between practice characteristics and ABCS measures. We conducted a cross-sectional, bivariate analysis using baseline data from 134 practices in New York City. ABCS data were extracted from practices' electronic health records and aggregated to the site level. Practice characteristics were obtained from surveys of clinicians and staff at each practice. The proportion of at-risk patients meeting clinical goals for each of the ABCS measures was 73.0% for aspirin use, 69.6% for blood pressure, 66.7% for cholesterol management, and 74.2% screened for smoking and counseled. For patients with a history of ASCVD, only 49% were meeting all ABC (aspirin use, blood pressure control, cholesterol management) targets (ie, composite measure). Solo practices were more likely to meet clinical guidelines for aspirin (risk ratio [RR] =1.17, P =.007) and composite (RR=1.29, P = .011) than practices with multiple clinicians. Achieving targets for ABCS measures varied considerably across practices; however, small practices were meeting or exceeding Million Hearts goals (ie, 70% or greater). Practices were less likely to meet consistently clinical targets that apply to patients with a history of ASCVD risk factors. Greater emphasis is needed on providing support for small practices to address the complexity of managing patients with multiple risk factors for primary and secondary ASCVD.

IUD services among primary care practices in New York City

ObjectiveIntrauterine devices (IUDs) are one of the most effective forms of reversible contraception and can reduce unintended pregnancy rates. We explored practice characteristics associated with IUD services across a network of primary care practices in New York City during 2010–2013. Study DesignData were extracted from electronic health records (EHRs) for 253 primary care practices participating in an EHR quality improvement program in New York City. We used diagnostic and procedure codes to count IUD insertions and removals among females aged 10–49 years during 2010–2013. Logistic regression models predicted the likelihood of IUD insertion, removal or no activity for 2013, based on practice characteristics. We stratified trends in IUD services over time by practice type and specialty. ResultsFrom 2010 to 2013, the proportion of practices that inserted IUDs increased slightly from 4.7% to 6.3% (p=0.17), and the proportion removing IUDs increased from 8.3% to 12.3% (p<0.01). More than 60% of obstetricians/gynecologists and midwives performed insertions or removals each year; fewer than 10% of internal medicine and pediatric providers did so. Community health centers had higher odds of performing removals than independent practices (adjusted odds ratio=10.24, 95% confidence interval: 3.37–31.17). Practices seeing >66% female patients had higher odds of performing both insertions and removals. ConclusionsFrom 2010 to 2013, IUD services increased but remained low among primary care practices in this network. Provider training and system readiness programs should include independent primary care practices, which rarely provide IUDs, to ensure that women can receive IUDs or IUD service referrals in the primary care setting. ImplicationsMuch of primary care in the United States takes place in independent practices with one or two providers. Our study of a major urban area found that these types of practices are much less likely to offer IUD services than community health centers. Ensuring that small practices know where to refer women for IUD insertion and removal services is warranted to ensure women's access to IUDs.

Total Direct Medical Expenses and Characteristics of Privately Insured Adolescents Who Incur High Costs.

Accountable care payment models aim to reduce total direct medical expenses for high-cost patients through improved quality of care and preventive health services. Little is known about health care expenditures of privately insured adolescents, especially those who incur high costs. To assess health care expenditures for high-cost adolescents and to describe the patient characteristics associated with high medical costs. A retrospective cohort analysis was conducted of data from January 1 to December 31, 2012, of 13,103 privately insured adolescents aged 13 to 21 years (mean [SD] age, 16.3 [2.4] years; 6764 [51.6%] males) at 82 independent pediatric primary care practices in Massachusetts. Analysis was conducted from April 1, 2014, to April 1, 2015. We compared demographic (age, sex, median income by zip code) and clinical (obesity, behavioral health problem, complex chronic condition) characteristics between high-cost (top 1%) and non-high-cost adolescents. We assigned high-cost adolescents to clinical categories using software from the Agency for Healthcare Research and Quality to describe clinically relevant patterns of spending. Total direct medical expenses were $41.2 million for the entire cohort and a median $1167 per patient. A total of 132 (1.0%) patients with the highest costs accounted for 23.6% of expenses of the cohort, with a median $52,577 per patient. Mental health disorders were the most common diagnosis in high-cost patients; 78 (59.1%) of these patients had at least 1 behavioral health diagnosis. Pharmacy costs accounted for 28.4% of total direct medical expenses of high-cost patients; primary care accounted for 1.0%. Characteristics associated with being a high-cost patient included having 1 complex chronic condition (relative risk [RR], 6.5; 95% CI, 4.7-9.0), having 2 or more complex chronic conditions (RR, 23.5; 95% CI, 14.2-39.1), having any behavioral health diagnosis (RR, 3.6; 95% CI, 2.6-5.1), and obesity (RR, 2.0; 95% CI, 1.3-3.0). Total direct medical expenses for privately insured high-cost adolescents are associated with medical complexity, mental health conditions, and obesity. Cost reduction strategies in similar populations should be tailored to these cost drivers.

Training community-based primary care physicians in the screening and management of mental health disorders among Latino primary care patients.

To evaluate a quality improvement intervention to improve the screening and management (e.g., referral to psychiatric care) of common mental disorders in small independent Latino primary care practices serving patient populations of predominantly low-income Latino immigrants. In seven practices, academic detailing and consultation/liaison psychiatry were first implemented (Stage 1) and then supplemented with appointment scheduling and reminders to primary care physicians (PCPs) by clinic staff (Stage 2). Acceptability and feasibility were assessed with independent patient samples during each stage. Participating PCP found the interventions acceptable and noted that referrals to language-matched specialty care and case-by-case consultation on medication management were particularly beneficial. The academic detailing and consultation/liaison intervention (Stage 1) did not significantly affect PCP screening, management or patient satisfaction with care. When support for appointment scheduling and reminders (Stage 2) was added, however, PCP referral to psychiatric services increased (P=.04), and referred patients were significantly more likely to follow through and have more visits to mental health professionals (P=.04). Improving the quality of mental health care in low-resourced primary care settings may require academic detailing and consultation/liaison psychiatric intervention supplemented with staff outreach to achieve meaningful improvement in the processes of care.

Differences in residents' self-reported confidence and case experience between two post-graduate rotation curricula: results of a nationwide survey in Japan.

BackgroundIn Japan, all trainee physicians must begin clinical practice in a standardized, mandatory junior residency program, which encompasses the first two years of post-graduate medical training (PGY1 – PGY2). Implemented in 2004 to foster primary care skills, the comprehensive rotation program (CRP) requires junior residents to spend 14 months rotating through a comprehensive array of clinical departments including internal medicine, surgery, anesthesiology, obstetrics-gynecology (OBGYN), pediatrics, psychiatry, and rural medicine. In 2010, Japan’s health ministry relaxed this curricular requirement, allowing training programs to offer a limited rotation program (LRP), in which core departments constitute 10 months of training, with electives geared towards residents’ choice of career specialty comprising the remaining 14 months. The effectiveness of primary care skill acquisition during early training warrants evaluation. This study assesses self-reported confidence with clinical competencies, as well as case experience, between residents in CRP versus LRP curricula.MethodsA nation-wide cross-sectional study of all PGY2 physicians in Japan was conducted in March 2011. Primary outcomes were self-report confidence for 98 clinical competency items, and number of cases experienced for 85 common diseases. We compared confidence scores and case experience between residents in CRP and LRP programs, adjusting for parameters relevant to training.ResultsAmong 7506 PGY2 residents, 5052 replied to the survey (67.3%). Of 98 clinical competency items, CRP residents reported higher confidence in 12 items compared to those in an LRP curriculum, 10 of which remained significantly higher after adjustment. CRP trainees reported lower confidence scores in none of the items. Out of 85 diseases, LRP residents reported less experience with 11 diseases. CRP trainees reported lower case experience with one disease, though this did not remain significant on adjusted analysis. Confidence and case experience with OBGYN- and pediatrics-related items were particularly low among LRP trainees.ConclusionsResidents in the specialty-oriented LRP curriculum showed less confidence and less case experience compared to peers training in the broader CRP residency curriculum. In order to foster competence in independent primary care practice, junior residency programs requiring experience in a breadth of core departments should continue to be mandated to ensure adequate primary care skills.

Resource document on risk management and liability issues in integrated care models.

In the wake of the implementation of the Affordable Care Act, more than 30 million previously uninsured Americans will gain access to health care. Some of these individuals may never have interfaced with the behavioral health system. In response to an increasing need for behavioral health services, improved outcomes, and cost containment, there is a growing shift from independent behavioral health and primary care practices to collaborative care practice models. These new models have psychiatrists working with primary care providers (PCPs) and behavioral health providers (BHPs, typically social workers or psychologists) using a systematic approach to concurrently treat behavioral health and physical health conditions. By following this approach it allows the extension of psychiatric expertise to more patients. From early studies in the 1990’s to improve the detection and treatment of depression in elderly patients in primary care settings, to more recent work on outcomes in the management of depression in patients with multiple chronic conditions, a vast body of research has demonstrated the benefit of collaborative care models. However, as with any new treatment modality, psychiatrists may approach collaborative care models with a degree of uncertainty about liability risks. While there are several documents as well as case law addressing the potential malpractice risk of consultation in other medical specialties, a review of the literature revealed few publications offering guidelines for psychiatric consultations. Previous publications have been limited in scope by focusing on interactions between psychiatrists with non-physician treatment providers and have not addressed the potential liability exposure in the overlapping roles of the psychiatrist within an integrated care setting. However, these authors likely could not have anticipated the change in scope of practice of psychiatry in recent years. This resource document provides background information on medical malpractice cases, defines the doctor-patient relationship, and distinguishes the different forms of “split treatment” and how this applies to psychiatric consultation offered to PCPs and BHPs in primary care settings. In addition, it describes the duty of the psychiatrist across the spectrum of roles on an integrated care team and makes recommendations to reduce the risk of medical malpractice issues. Close proximity can foster a culture of cooperation and mutual education between PCPs and psychiatrists. This approach, often referred to as “co-location,” has several benefits for patients. The PCP may or may not choose to communicate with the psychiatrist about the behavioral health of patients or make referrals, but the contiguity may increase the chances of successful referral. Limitations in this model have given rise to new treatment paradigms for improving care. In integrated care settings, behavioral health specialists are incorporated into the primary care practice with the psychiatrist providing consultation to the PCP and BHP for management of a patient’s behavioral health conditions. These recommendations may be based upon an informal or “curbside” consultation request by the PCP or BHP, a review of the medical record or registry, and, less frequently, by formal evaluation of the patient in person or by televideo. There are a number of integrated care models including the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) model and Massachusetts Child Psychiatry Access Project (MCPAP). In these models of care, the psychiatry consultant’s role may include key aspects of both formal and informal consultation and varying aspects of “split treatment” (including what have traditionally been referred to as supervisory, consultative or collaborative roles for non-physicians). This resource document provides a framework for some of the issues to consider when working in practices offering integrated care, and provides practical points to consider in managing liability concerns. Keep in mind that issues regarding liability may not always be clear, particularly in specialty areas that are rapidly evolving. Where indicated, the psychiatrist should clarify the extent of their involvement clinically and the level of interaction with the patient and care team. Whether there is liability for malpractice depends upon specific circumstances surrounding each case and each state has different laws, regulations and caselaw. Finally, consulting an attorney or risk manager for guidance on specific issues is strongly encouraged.

A typology of electronic health record workarounds in small-to-medium size primary care practices

Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features. Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff. We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds. This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Effect of a Multipayer Patient-Centered Medical Home on Health Care Utilization and Quality

The patient-centered medical home is advocated to reduce health care costs and improve the quality of care. To evaluate the effects of the pilot program of a multipayer patient-centered medical home on health care utilization and quality. An interrupted time series design with propensity score-matched comparison practices, including multipayer claims data from 2 years before (October 1, 2006-September 30, 2008) and 2 years after (October 1, 2008-September 30, 2010) the launch of the pilot program. Uptake of the intervention was measured with audit data from the National Committee for Quality Assurance patient-centered medical home recognition process. SETTING Five independent primary care practices and 3 private insurers in the Rhode Island Chronic Care Sustainability Initiative. Patients in 5 pilot and 34 comparison practices. Financial support, care managers, and technical assistance for quality improvement and practice transformation. Hospital admissions, emergency department visits, and 6 process measures of quality of care (3 for diabetes mellitus and 3 for colon, breast, and cervical cancer screening). The mean National Committee for Quality Assurance recognition scores of the pilot practices increased from 42 to 90 points of a possible 100 points. The pilot and comparison practices had statistically indistinguishable baseline patient characteristics and practice patterns, except for higher numbers of attributed member months per year in the pilot practices (31,130 per practice vs 14,779, P = .01) and lower rates of cervical cancer screening in the comparison practices. Although estimates of the emergency department visits and inpatient admissions of patients in the pilot practices trended toward lower utilization, the only significant difference was a lower rate of ambulatory care sensitive emergency department visits in the pilot practices. The Chronic Care Sustainability Initiative pilot program was associated with a reduction in ambulatory care-sensitive emergency department visits of approximately 0.8 per 1000 member months or approximately 11.6% compared with the baseline rate of 6.9 for emergency department visits per 1000 member months (P = .002). No significant improvements were found in any of the quality measures. After 2 years, a pilot program of a patient-centered medical home was associated with substantial improvements in medical home recognition scores and a significant reduction in ambulatory care sensitive emergency department visits. Although not achieving significance, there were downward trends in emergency department visits and inpatient admissions.

Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems.

IntroductionStudies showing sustained improvements in the delivery of clinical preventive services are limited. Fewer studies demonstrate sustained improvements among independent practices that are not affiliated with hospitals or integrated health systems. This study examines the continued improvement in clinical quality measures for a group of independent primary care practices using electronic health records (EHRs) and receiving technical support from a local public health agency.MethodsWe analyzed clinical quality measure performance data from a cohort of primary care practices that implemented an EHR at least 3 months before October 2009, the study baseline. We assessed trends for 4 key quality measures: antithrombotic therapy, blood pressure control, smoking cessation intervention, and hemoglobin A1c (HbA1c) testing based on monthly summary data transmitted by the practices.ResultsOf the 151 practices, 140 were small practices and 11 were community health centers; average time using an EHR was 13.7 months at baseline. From October 2009 through October 2011, average rates increased for antithrombotic therapy (from 58.4% to 74.8%), blood pressure control (from 55.3% to 64.1%), HbA1c testing (from 46.4% to 57.7%), and smoking cessation intervention (from 29.3% to 46.2%). All improvements were significant.ConclusionDuring 2 years, practices showed significant improvement in the delivery of several key clinical preventive services after implementing EHRs and receiving support services from a public health agency.

Transforming Physician Practices To Patient-Centered Medical Homes: Lessons From The National Demonstration Project

Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country's first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance. Additionally, transforming primary care requires synchronizing practice redesign with development of the health care "neighborhood," which is made up of a broad range of health and health care resources available to patients. It also requires payment reform that supports practice development and a policy environment that sets reasonable expectations and time frames for the adoption of appropriate innovations.

It Takes Two: Using Coleaders to Champion Improvements in Small Primary Care Practices

Making the kind of improvement changes necessary to move toward a patient-centered medical home will continue to challenge small, independent primary care practices. Here we describe further analysis of a successful program to understand the roles of coleaders of a change management process. Through an improvement collaborative we trained 2 coleaders (a physician and a non-physician) from 16 small primary care practices to institute depression care improvements. These coleaders participated in 3 learning sessions that provided depression care content as well as skills to implement a change management strategy. Qualitative data were collected by observation during the learning sessions and through in-depth interviews conducted at baseline, between each learning session, at the end of the project, 6 months after the project ended, and, finally, 26 months after the project's end. Interview results with the coleaders affirmed that a team approach is a viable strategy for practice improvement. The 2 coleaders used their complementary skills, relationships, and credibility among the practice staff to implement and sustain practice improvements. In their differing roles, they varied in how they perceived barriers to change and how they assessed their team's progress. Involving both a physician and a non-physician as coleaders enables improvement teams in small primary care practices to make progress both in the clinical content of their work and in the critical change management activities involved with creating a team, managing meetings, and coordinating work between meetings. Using a coleader structure enriches the improvement process, broadens participation in the change process, and helps to sustain these efforts over time.

Practice-Based Research Networks

persistently high percentage of Americans 50 years of age or older who have not been screened for colorectal cancer (CRC) despite convincing evidence that screening can reduce CRC-associated morbidity and mortality brings into sharp focus both the need for, and challenge of, translating research into practice. The gap between research and practice, although not unique to the delivery of CRC screening services, has been attributed to a number of interacting factors including limited time and resources of practitioners1 and inadequate systems to support evidence-based practices.2 Another reason offered for the slow and incomplete translation of research findings into practice is the lack of well-designed effectiveness research demonstrating how interventions aimed at improving service delivery can be best implemented under real-world conditions.3 All too often, the evaluation of an intervention aimed at improving the uptake of evidence-based care takes the form of a traditional clinical efficacy trial conducted on a highly selected cohort of patients and clinicians, and most often in an academic medical center where less than 1% of Americans visiting physicians receive their health care.4 Such studies typically exclude individuals whose care is most challenging, such as patients with multiple medical conditions or those least likely to be adherent with recommended treatment or preventive measures. They also tend to examine patient and clinician behavior under controlled situations thus precluding any systematic consideration of the patient's everyday environment or the demanding schedules and economic and other pressures faced increasingly by practices. According to Glasgow, success in translating research into practice requires that interventions be investigated in multiple settings representative of those for which the intervention is intended, and that more attention be paid to issues of external validity, including moderating factors that potentially limit the robustness of the intervention. Since the 1990s, both the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ) have offered systematic support for establishing or facilitating the growth and development of practice-based research networks (PBRNs). A major purpose of this support is to move the research enterprise beyond academic medical centers and into a variety of community-based practices, where everyday care takes place. In addition to serving as laboratories for studying the care of common conditions, these networks are ideal sites for the type of translation-related effectiveness studies Glasgow recommends. This article will focus on 2 types of PBRNs currently active in the United States those composed mostly of smaller independent primary care practices and those composed of large integrated health systems and will consider the types of research questions related to CRC screening that have been, or could be, addressed in the networks, as well as the research approaches the networks have taken to evaluate methods of improving CRC screening practices across the United States.

Outcomes and Predictors of Late-Life Depression Trajectories in Older Primary Care Patients

The naturalistic outcomes of depression in older primary care patients have been poorly characterized. The authors sought to identify depressive trajectories over 2 years and to examine specified outcome predictors. Two-year observational cohort study. University-based and independent practice primary care practices in greater Rochester. All patients aged >65 years presenting for care on selected recruitment days were eligible to participate. Of 392 subjects enrolled, 316 (80.6%) completed study measures over a 2-year follow-up. Depression trajectories were derived by applying longitudinal cluster analysis to weekly depression status from the Longitudinal Interval Follow-up Evaluation. The authors identified six distinct trajectory clusters that followed clinically intuitive patterns. Although subjects initially nondepressed or in the subsyndromal to minor depression range had a range of possible outcomes over 2 years, the cluster initially near the major depression level remained at that level over time. Consistent predictors of depression trajectory were baseline depressive symptom severity, medical burden, and psychiatric functional status; for some clusters, previous history of depression and perceived social support also had prognostic significance. The "real-world" outcomes of patients with more severe depressive symptoms are strikingly poor. Given the diverse outcomes of those with subsyndromal to mild forms of minor depression, clinicians might focus treatments on those at highest risk of poor outcome, i.e., those with greater depressive symptoms and medical burden and lower psychiatric functioning and social support. Preventive interventions research might focus on developing treatments to mitigate potentially modifiable risks such as deficits in social support.

Outcomes and Predictors of Late-Life Depression Trajectories in Older Primary Care Patients

The naturalistic outcomes of depression in older primary care patients have been poorly characterized. The authors sought to identify depressive trajectories over 2 years and to examine specified outcome predictors.Two-year observational cohort study.University-based and independent practice primary care practices in greater Rochester.All patients aged >65 years presenting for care on selected recruitment days were eligible to participate. Of 392 subjects enrolled, 316 (80.6%) completed study measures over a 2-year follow-up.Depression trajectories were derived by applying longitudinal cluster analysis to weekly depression status from the Longitudinal Interval Follow-up Evaluation.The authors identified six distinct trajectory clusters that followed clinically intuitive patterns. Although subjects initially nondepressed or in the subsyndromal to minor depression range had a range of possible outcomes over 2 years, the cluster initially near the major depression level remained at that level over time. Consistent predictors of depression trajectory were baseline depressive symptom severity, medical burden, and psychiatric functional status; for some clusters, previous history of depression and perceived social support also had prognostic significance.The "real-world" outcomes of patients with more severe depressive symptoms are strikingly poor. Given the diverse outcomes of those with subsyndromal to mild forms of minor depression, clinicians might focus treatments on those at highest risk of poor outcome, i.e., those with greater depressive symptoms and medical burden and lower psychiatric functioning and social support. Preventive interventions research might focus on developing treatments to mitigate potentially modifiable risks such as deficits in social support.

Use of Chronic Care Model Elements Is Associated With Higher-Quality Care for Diabetes

In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients' hemoglobin A(1c) (HbA(1c)) and lipid levels and self-reported receipt of care. Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician's assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA(1c); foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA(1c) values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data. Clinician-reported use of elements of CCM was significantly associated with lower HbA(1c) values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from "rarely" to "occasionally"), there was an associated 0.30% reduction in HbA(1c) value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07). Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

Independent Primary Care Practice by Nurse Practitioners

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal

Independent Primary Care Practice: A Dying Species?

Independent Primary Care Practice: A Dying Species?