Primary Care Sites Research Articles

Increasing Contraceptive Prescriptions in Adolescent Females With Documented Interest in Contraception: A Quality Improvement Project

BackgroundAdolescent pregnancy is a significant cause of morbidity and mortality among women and infants. Timely and comprehensive reproductive care in the medical home is essential in preventing unintended adolescent pregnancy. MethodsThis quality improvement (QI) project was completed within the Division of Primary Care Pediatrics at Nationwide Children’s Hospital in Columbus, a large pediatric quaternary medical center. The population included female patients 15 to 17 years old from predominantly medically underserved communities receiving well care at 14 urban primary care sites. We identified 4 key drivers: 1) electronic health record, 2) provider training, 3) patient access, and 4) provider buy-in. The outcome measure of this QI project was the percentage of female patients 15 to 17 years old who received a contraceptive prescription within 14 days of answering “yes” to interest in starting contraception at a well-care visit. ResultsFemale patients 15 to 17 years old with an interest in contraception documented increased from 20% to 76%. Etonogestrel subdermal implant placement plus referrals to the BC4Teens clinic increased from 28/month to 32/month. Females 15 to 17 years old interested in contraception who received contraception within 14 days of a visit increased from 50% to 70%. ConclusionsWith this QI project, we increased the percentage of adolescents receiving contraceptive prescriptions within 14 days of indicating they were interested in starting a contraceptive. Improvement in the outcome measure was accomplished through improvements in 2 process measures: 1) increased documentation of interest in contraception and 2) improved access to referrals for contraceptive services and etonogestrel subdermal implant placement.

Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial

Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce. We aimed to investigate the efficacy and safety of a judicious short course of an opioid analgesic for acute low back pain and neck pain. OPAL was a triple-blinded, placebo-controlled randomised trial that recruited adults (aged ≥18 years) presenting to one of 157 primary care or emergency department sites in Sydney, NSW, Australia, with 12 weeks or less of low back or neck pain (or both) of at least moderate pain severity. Participants were randomly assigned (1:1) using statistician-generated randomly permuted blocks to guideline-recommended care plus an opioid (oxycodone-naloxone, up to 20 mg oxycodone per day orally) or guideline-recommended care and an identical placebo, for up to 6 weeks. The primary outcome was pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale), analysed in all eligible participants who provided at least one post-randomisation pain score, by use of a repeated measures linear mixed model. Safety was analysed in all randomly assigned eligible participants. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000775516). Between Feb 29, 2016, and March 10, 2022, 347 participants were recruited (174 to the opioid group and 173 to the placebo group). 170 (49%) of 346 participants were female and 176 (51%) were male. 33 (19%) of 174 participants in the opioid group and 25 (15%) of 172 in the placebo group had discontinued from the trial by week 6, due to loss to follow-up and participant withdrawals. 151 participants in the opioid group and 159 in the placebo group were included in the primary analysis. Mean pain score at 6 weeks was 2·78 (SE 0·20) in the opioid group versus 2·25 (0·19) in the placebo group (adjusted mean difference 0·53, 95% CI -0·00 to 1·07, p=0·051). 61 (35%) of 174 participants in the opioid group reported at least one adverse event versus 51 (30%) of 172 in the placebo group (p=0·30), but more people in the opioid group reported opioid-related adverse events (eg, 13 [7·5%] of 174 participants in the opioid group reported constipation vs six [3·5%] of 173 in the placebo group). Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo. This finding calls for a change in the frequent use of opioids for these conditions. National Health and Medical Research Council, University of Sydney Faculty of Medicine and Health, and SafeWork SA.

Design and Implementation of a Digitally Enabled Care Pathway to Improve Management of Depression in a Large Health Care System: Protocol for the Implementation of a Patient Care Platform.

Major depressive disorder (MDD) is a serious public health concern worldwide. A treatment approach that incorporates measurement-based care (MBC) and shared decision-making between patients with MDD and their providers may foster patient engagement and improve clinical outcomes. While digital tools such as mobile apps show promise for expanding health interventions, these apps are rarely integrated into clinical practice. The primary objective of this ongoing study is to determine whether implementation of a digital tool-the Pathway Platform-in primary care improves adherence to MBC practices; here, we present the study methods. This large-scale, real-world implementation study is based on a pilot study of an earlier iteration of a mobile app (the Pathway app) that confirmed the feasibility of using the app in patients with MDD and showed a positive trend in patient engagement in the app arm. In addition, a user-centered design approach that included qualitative assessments from patients and providers was used to improve understanding of the patient journey and care team workflows. User feedback highlighted the need for enhanced features, education modules, and real-time data sharing via integration with the electronic health record. The current iteration of the Platform includes the newest version of the Pathway app, education modules for both patients and providers, and real-time patient-level data sharing with the electronic health record. The study takes place in primary care sites within the Advocate Aurora Health system in Illinois and includes adult patients with MDD who were recently prescribed monotherapy antidepressant medication (defined as a new start, medication switch, or dose change in the past 3 months). Clinical performance and selected patient outcomes will be compared before and after the implementation of the Platform. Patient recruitment was completed in July 2022, with initial results expected in mid-2023. This study will provide useful insights into real-world integration of a digital platform within a large health system. The methods presented here highlight the unique user-centric development of the Pathway Platform, which has resulted in an enhanced digital tool with the potential to foster MBC and shared decision-making, improve patient-provider communication, and ultimately lead to optimized treatment outcomes for patients with MDD. ClinicalTrials.gov NCT04891224; https://clinicaltrials.gov/ct2/show/NCT04891224. DERR1-10.2196/43788.

1692-P: Designing and Testing a Novel Weight Navigation Program to Improve Obesity Treatment in Primary Care Settings

Background: We developed and tested a novel Weight Navigation Program (WNP). The WNP aims to (1) integrate American Board of Obesity Medicine Diplomates into primary care teams, (2) deliver preference-sensitive weight management treatment, and (3) optimize patients’ achievement of ≥5% weight loss through remote weight monitoring with proactive outreach to support patients with <5% weight loss. Methods: This is a quality improvement program conducted at an academic primary care site from October 2020 to September 2021. WNP inclusion criteria are BMI ≥30 and ≥1 weight-related condition. Primary outcomes were measures of feasibility, including rates of referral to and engagement in the WNP. Secondary outcomes were mean weight loss and percentage of patients achieving ≥5% weight loss. We compared rates of referral to weight management treatment programs (i.e., nutrition counseling, meal replacement (MR), bariatric surgery) and prescribing of weight management medications (WMMs) among WNP-eligible patients at the pilot site and at a nearby clinic (control). Rates are also reported for patients with a completed WNP visit. Results: Of 1,533 eligible patients, 238 (16%) were referred to the WNP and 135 (9%) completed a WNP visit. Mean percent weight change at 12-months for WNP patients was 5% and 39% achieved ≥5% weight loss. WNP-eligible patients at the WNP site (n=1,533) were referred to WMTs and prescribed WMMs at similar rates to WNP-eligible patients at the control site (n=2,913) (nutrition counseling 4.8% v. 6.8%, MR 1.0% v. 0.6%, WMM 2.0% v. 3.2%, bariatric surgery 1.2% vs. 1.8%). Patients with a completed WNP visit (n=135) received WMTs at substantially higher rates than the pilot and control sites (nutrition counseling 26.7%, MR 13.3%, WMM 11.9%, bariatric surgery 16.3%). Discussion: A WNP is feasible and may support achievement of ≥5% weight loss. Additional work is needed to compare the efficacy of WNP vs usual care for weight loss. Disclosure D.H.Griauzde: None. A.T.Kraftson: None. C.D.Turner: None. J.Henderson: None. A.Othman: None. L.Oshman: Stock/Shareholder; Abbott, AbbVie Inc., Merck & Co., Inc., Procter & Gamble, Johnson & Johnson, Eli Lilly and Company. J.Gabison: None. E.Walford: None. P.K.Arizaca-dileo: None. D.I.Beckius: None. Funding University of Michigan Elizabeth Weiser Caswell Diabetes Institute; Michigan Center for Diabetes and Translational Research (P30DK092926-09 to D.H.G.); National Institute of Diabetes and Digestive and Kidney Diseases (K23DK123416-01A1 to D.H.G.)

Understanding collaborative implementation between community and academic partners in a complex intervention: a qualitative descriptive study

BackgroundCommunity-academic partnerships (CAPs) can improve the relevance, sustainability, and uptake of new innovations within the community. However, little is known about what topics CAPs focus on and how their discussions and decisions impact implementation at ground level. The objectives of this study were to better understand the activities and learnings from implementation of a complex health intervention by a CAP at the planner/decision-maker level, and how that compared to experiences implementing the program at local sites.MethodsThe intervention, Health TAPESTRY, was implemented by a nine-partner CAP including academic, charitable organizations, and primary care practices. Meeting minutes were analyzed using qualitative description, latent content analysis, and a member check with key implementors. An open-answer survey about the best and worst elements of the program was completed by clients and health care providers and analyzed using thematic analysis.ResultsIn total, 128 meeting minutes were analyzed, 278 providers and clients completed the survey, and six people participated in the member check. Prominent topics of discussion categories from the meeting minutes were: primary care sites, volunteer coordination, volunteer experience, internal and external connections, and sustainability and scalability. Clients liked that they learned new things and gained awareness of community programs, but did not like the volunteer visit length. Clinicians liked the regular interprofessional team meetings but found the program time-consuming.ConclusionsAn important learning was about who had “voice” at the planner/decision-maker level: many of the topics discussed in meeting minutes were not identified as issues or lasting impacts by clients or providers; this may be due to differing roles and needs, but may also identify a gap. Overall, we identified three phases that could serve as a guide for other CAPs: Phase (1) recruitment, financial support, and data ownership; Phase (2) considerations for modifications and adaptations; Phase (3) active input and reflection.

Effect of Free Medicine Distribution on Health Care Costs in Canada Over 3 Years

Few interventions are proven to reduce total health care costs, and addressing cost-related nonadherence has the potential to do so. To determine the effect of eliminating out-of-pocket medication fees on total health care costs. This secondary analysis of a multicenter randomized clinical trial using a prespecified outcome took place across 9 primary care sites in Ontario, Canada (6 in Toronto and 3 in rural areas), where health care services are generally publicly funded. Adult patients (≥18 years old) reporting cost-related nonadherence to medicines in the past 12 months were recruited between June 1, 2016, and April 28, 2017, and followed up until April 28, 2020. Data analysis was completed in 2021. Access to a comprehensive list of 128 medicines commonly prescribed in ambulatory care with no out-of-pocket costs for 3 years vs usual medicine access. Total publicly funded health care costs over 3 years, including costs of hospitalizations. Health care costs were determined using administrative data from Ontario's single-payer health care system, and all costs are reported in Canadian dollars with adjustments for inflation. A total of 747 participants from 9 primary care sites were included in the analysis (mean [SD] age, 51 [14] years; 421 [56.4%] female). Free medicine distribution was associated with a lower median total health care spending over 3 years of $1641 (95% CI, $454-$2792; P = .006). Mean total spending was $4465 (95% CI, -$944 to $9874) lower over the 3-year period. In this secondary analysis of a randomized clinical trial, eliminating out-of-pocket medication expenses for patients with cost-related nonadherence in primary care was associated with lower health care spending over 3 years. These findings suggest that eliminating out-of-pocket medication costs for patients could reduce overall costs of health care. ClinicalTrials.gov Identifier: NCT02744963.

The experiences of patients ill with COVID-19-like symptoms and the role of testing for SARS-CoV-2 in supporting them: A qualitative study in eight European countries during the first wave of the pandemic

Background Access to testing during the first wave of the COVID-19 pandemic was limited, impacting patients with COVID-19-like symptoms. Current qualitative studies have been limited to one country or were conducted outside Europe. Objectives To explore - in eight European countries - the experiences of patients consulting in primary care with COVID-19-like symptoms during the first wave of the pandemic. Methods Sixty-six semi-structured interviews, informed by a topic guide, were conducted by telephone or in person between April and July 2020. Patients with COVID-19-like symptoms were purposively recruited in primary care sites in eight countries and sampled based on age, gender, and symptom presentation. Deductive and inductive thematic analysis techniques were used to develop a framework representing data across settings. Data adequacy was attained by collecting rich data. Results Seven themes were identified, which described the experiences of patients consulting. Two themes are reported in this manuscript describing the role of COVID-19 testing in this experience. Patients described significant distress due to their symptoms, especially those at higher risk of complications from COVID-19, and those with severe symptoms. Patients wanted access to testing to identify the cause of their illness and minimise the burden of managing uncertainty. Some patients testing positive for COVID-19 assumed they would be immune from future infection. Conclusion Patients experiencing novel and severe symptoms, particularly those with comorbidities, experienced a significant emotional and psychological burden due to concerns about COVID-19. Testing provided reassurance over health status and helped patients identify which guidance to follow. Testing positive for SARS-CoV-2 led to some patients thinking they were immune from future infection, thus influencing subsequent behaviour.

Enhancing family medicine training to build capacity in Pakistan: a call for action

ABSTRACT A high-performing, integrated, primary healthcare system is essential to achieve universal health coverage (UHC) goals and improve health indicators. There is enough evidence that healthcare is cost-effective with significantly better outcomes in countries where primary care is delivered through trained family physicians. The concept of “Family Practice approach” is relatively new in developing countries like Pakistan, where majority of basic healthcare is provided by doctors without a formal postgraduate training. The intention to adopt this approach in primary care has increased in recent years in an effort to attain UHC, yet implementation requires a paradigm shift with intervention at multiple levels. There is an opportunity to learn from better developed primary care models for example in UK and Australia to develop a pragmatic and collaborative approach to develop the specialty of family medicine in primary care. This calls for academic interventions at multiple levels, such as mandating family medicine inclusion in undergraduate medical curricula, and ensuring quality of postgraduate training by investment in developing primary care sites for training, curricula, assessment, and quality assurance structures. Encouraging medical students and general practitioners to pursue a post graduate qualification in family medicine would also require promoting family medicine as a worthwhile career and developing a higher esteem for qualified family physicians than the conventional GPs in public and private sector healthcare institutions. These interventions would help evolution of locally grounded solutions to improve the quality of primary care, hence the health outcomes of the larger population of Pakistan.

Care coordination between rural primary care and telemedicine to expand medication treatment for opioid use disorder: Results from a single-arm, multisite feasibility study.

The use of telemedicine (TM) has accelerated in recent years, yet research on the implementation and effectiveness of TM-delivered medication treatment for opioid use disorder (MOUD) has been limited. This study investigated the feasibility of implementing a care coordination model involving MOUD delivered via an external TM provider for the purpose of expanding access to MOUD for patients in rural settings. The study tested a care coordination model in 6 rural primary care sites by establishing referral and coordination between the clinic and a TM company for MOUD. The intervention spanned approximately 6 months from July/August 2020 to January 2021, coinciding with the peak of the COVID-19 pandemic. Each clinic tracked patients with OUD in a registry during the intervention period. A pre-/post-intervention design (N = 6) was used to assess the clinic-level outcome as patient-days on MOUD based on patient electronic health records. All clinics implemented critical components of the intervention, with an overall TM referral rate of 11.7% among patients in the registry. Five of the 6 sites showed an increase in patient-days on MOUD during the intervention period compared to the 6-month period before the intervention (mean increase per 1,000 patients: 132 days, P = .08, Cohen's d = 0.55). The largest increases occurred in clinics that lacked MOUD capacity or had a greater number of patients initiating MOUD during the intervention period. To expand access to MOUD in rural settings, the care coordination model is most effective when implemented in clinics that have negligible or limited MOUD capacity.

Changes in clinical markers observed from pharmacist-managed cardiovascular risk reduction clinics in federally qualified health centers: A retrospective cohort study.

Reductions in hemoglobin A1c (HbA1C) have been associated with improved cardiovascular outcomes and savings in medical expenditures. One public health approach has involved pharmacists within primary care settings. The objective was to assess change in HbA1C from baseline after 3-5 months of follow up in pharmacist-managed cardiovascular risk reduction (CVRR) clinics. This retrospective cohort chart review occurred in eight pharmacist-managed CVRR federally qualified health clinics (FQHC) in Indiana, United States. Data were collected from patients seen by a CVRR pharmacist within the timeframe of January 1, 2015 through February 28, 2020. Data collected include: demographic characteristics and clinical markers between baseline and follow-up. HbA1C from baseline after 3 to 5 months was assessed with pared t-tests analysis. Other clinical variables were assessed and additional analysis were performed at 6-8 months. Additional results are reported between 9 months and 36 months of follow up. The primary outcome evaluation included 445 patients. Over 36 months of evaluation, 3,803 encounters were described. Compared to baseline, HbA1C was reduced by 1.6% (95%CI -1.8, -1.4, p<0.01) after 3-5 months of CVRR care. Reductions in HbA1C persisted at 6-8 months with a reduction of 1.8% ([95%CI -2.0, -1.5] p<0.01). The follow-up losses were 29.5% at 3-5 months and 93.2% at 33-36 months. Our study augments the existing literature by demonstrating the health improvement of pharmacist-managed CVRR clinics. The great proportion of loss to follow-up is a limitation of this study to be considered. Additional studies exploring the expansion of similar models may amplify the public health impact of pharmacist-managed CVRR services in primary care sites.

Efficacy of a Primary Care eHealth Obesity Treatment Pilot Intervention Developed for Vulnerable Pediatric Patients.

Background: Challenges to treat excess weight in primary care settings include time constraints during encounters and barriers to multiple visits for patient families, especially those from vulnerable backgrounds. Dynamo Kids! (DK), a bilingual (English/Spanish) e-health intervention, was created to address these system-level challenges. This pilot study assessed the effect of DK use on parent-reported healthy habits and child BMI. Methods: In this 3-month, quasi-experimental cohort design, DK was offered to parents with children aged 6-12 years with BMI ≥85th percentile in three public primary care sites in Dallas, Texas. DK included three educational modules, one tracking tool, recipes, and links to internet resources. Parents completed an online survey before and after 3 months. Pre-post changes in family nutrition and physical activity (FNPA) scores, clinic-measured child %BMIp95, and self-reported parent BMI were assessed using mixed-effects linear regression modeling. Results: A total of 73 families (mean child age = 9.3 years; 87% Hispanic, 12% non-Hispanic Black, and 77% Spanish-speaking families) completed the baseline survey (participants) and 46 (63%) used the DK site (users). Among users, pre-post changes (mean [standard deviation]) showed an increase in FNPA scores (3.0 [6.3], p = 0.01); decrease in child %BMIp95 (-1.03% [5.79], p = 0.22); and decrease in parent BMI (-0.69 [1.76], p = 0.04). Adjusted models showed -0.02% [95% confidence interval: -0.03 to -0.01] change in child %BMIp95 for each minute spent on the DK website. Conclusions: DK demonstrated a significant increase in parent FNPA scores and decrease in self-reported parent BMI. e-Health interventions may overcome barriers and require a lower dosage than in-person interventions.

Diagnostic Accuracy of Mobile Health-Based Audiometry for the Screening of Hearing Loss in Adults: A Systematic Review and Meta-Analysis.

Background: Hearing loss is one of the most prevalent chronic health conditions. Traditional pure tone audiometry (PTA) is the gold standard for hearing loss screening, but is not widely available outside specialized clinical centers. Mobile health (mHealth)-based audiometry could improve access and cost-effectiveness, but its diagnostic accuracy varies widely between studies. Therefore, we aimed to evaluate the diagnostic accuracy of mHealth-based audiometry for hearing loss screening in adults compared with traditional PTA. Methods: Ten English and Chinese databases were searched from inception until April 30, 2022. Two researchers independently selected studies, extracted data, and appraised methodological quality. The bivariate random-effects model was adopted to estimate the pooled sensitivity and specificity for each common threshold (i.e., the threshold to define mild or moderate hearing loss). The hierarchical summary receiver operating characteristic model was used to assess the area under the receiver operating characteristic curve (AUC) across all thresholds. Results: Twenty cohort studies were included. Only one study (n = 109) used the mHealth-based speech recognition test (SRT) as the index test. Nineteen studies (n = 1,656) used mHealth-based PTA as the index test, and all of them were included in the meta-analysis. For detecting mild hearing loss, the pooled sensitivity and specificity were 0.91 (95% confidence interval [CI] 0.80-0.96) and 0.90 (95% CI 0.82-0.94), respectively. For detecting moderate hearing loss, the pooled sensitivity and specificity were 0.94 (95% CI 0.87-0.98) and 0.87 (95% CI 0.79-0.93), respectively. For all PTA thresholds, the AUC was 0.96 (95% CI 0.40-1.00). Conclusions: mHealth-based audiometry provided good diagnostic accuracy for screening both mild and moderate hearing loss in adults. Given its high diagnostic accuracy, accessibility, convenience, and cost-effectiveness, it shows enormous potential for hearing loss screening, particularly in primary care sites, low-income regions, and settings with in-person visit limitations. Further work should evaluate the diagnostic accuracy of the mHealth-based SRT tests.

CoCM Helps Duke Primary Care Meet Standards of Care

Back to table of contents Previous article Next article ProfessionalFull AccessCoCM Helps Duke Primary Care Meet Standards of CareMark MoranMark MoranSearch for more papers by this authorPublished Online:2 Mar 2023https://doi.org/10.1176/appi.pn.2023.04.4.14aAbstractThe program at Duke is another example of how North Carolina is expanding collaborative care services.Use of the Collaborative Care Model (CoCM) at Duke University began on a pilot basis five years ago, when the University Health System awarded the Department of Psychiatry an innovation grant to establish the model at a handful of primary care sites.Today the model has been implemented throughout Duke’s primary care system.Marvin Swartz, M.D., said collaborative care offered a way for primary care practices to meet standards of depression care requiring follow-up with patients within a month after being prescribed an antidepressant.Marvin Swartz, M.D., a professor of psychiatry and behavioral health at Duke, said a selling point was that CoCM allowed primary care practices to meet standards of care for depression that require physicians to see a patient within one month of prescribing an antidepressant. As part of the pilot program, Duke had developed its own patient registry, which allows the CoCM team—which typically consists of the primary care physician, behavioral health care manager, and consulting psychiatrist—to track patients’ progress.Swartz is also director of the Duke Area Health Education Center (AHEC), which is providing training and technical support to practices implementing collaborative care.“Primary care physicians really liked the model,” he said. “When we presented it to our health system leadership after the success of the pilot, we said we thought it was the only way that primary care could meet standards of care for management of depression. We argued ‘If that’s how we achieve the standard of care, then we need to do it.’ That led to its spreading across Duke’s primary care sites.”In a state that has one of the fastest growing populations and a small number of psychiatrists who are clustered in urban areas, CoCM is a population health solution to a vast need, Swartz said. “This is a way we can address the shortage in the mental health workforce in an efficient way and be sure all primary care offices have at least this base to meet their needs and can address the large proportion of people with mild to moderate conditions.”Swartz said that measurement-based care—using scales and validated instruments to assess progress of treatment—and communication of patients’ scores is a great improvement in cross-disciplinary communication.“Everyone knows what a PHQ-9 is. Primary care physicians typically don’t have the time to weave through a narrative. What they get back from the consulting psychiatrist is an efficient response with not a lot of verbiage.“Primary care doctors can also know that every one of their patients is evaluated by the behavioral health care manager using a variety of scales,” Swartz continued. “It’s a new language in collaboration.” ■ ISSUES NewArchived

Challenges to Engaging Women Veterans in Quality Improvement From Patient Care to Policy: Women's Health Managers' Perspectives.

Patients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement. Data were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman etal.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods. When effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways-that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings-and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI. There may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement.

Collaborative Care Model Gaining Traction in North Carolina

Collaborative Care Model Gaining Traction in North Carolina

Too Many Walls and Not Enough Bridges: Care Transitions Models to Support Older Adults with Mental Illness and Cognitive Impairment

Challenges in transitions of care can lead to increased morbidity, mortality, and increased health care costs. In particular, older adults with mental illness (MI) or cognitive impairment (CI) are particularly vulnerable when transitioning from different health care settings and back to the community. For instance, almost half of older adults with cognitive impairment who are discharged home from the emergency department return within 30 days. Similarly, older adults with MI and CI admitted to a skilled nursing facility are less likely to be discharged and, if discharged, spend less time in the community. Importantly, these outcomes mediated by the presence of depression, agitation, and functional impairment, highlighting the need for interventions that provide symptom management and address frailty.Some interventions have been shown to improve transitions from acute care to post-acute care. The Institute for Health Improvement Age Friendly Health System Initiative incorporates the 4 M model of what matters most, mobility, medications, and mentation framework in order to bring to together evidenced based initiatives that improve safety and outcomes for older adults. These interventions embed comprehensive geriatric care throughout the care continuum: hospitals, transitions out of hospitals, and post-acute and long-term care facilities. Other interventions have utilized home visits upon discharge to minimize readmission and increase time at home. Less is known about initiatives which address the role of subspeciality care and community-based organizations (CBOs) in maintaining older adults with MI and CI in the community.Montefiore Einstein is a fully integrated academic health system including 11 hospitals including a rehabilitation hospital, 65 primary care sites, 18 mental health/ substance abuse treatments clinics, a care management organization, and a home health program. Montefiore's Center of Excellence for Alzheimer's Disease (CEAD) has successfully expanded the delivery of comprehensive, high-quality, cost-effective care for people with CI. The CEAD is staffed with board-certified neurologists, geriatricians, psychiatrists, neuropsychologists and social workers. Our focus on the early diagnosis of Alzheimer's disease and related dementias helps patients and their caregivers prepare for the future and better manage the cost of care, potentially avoiding costly, unnecessary emergency room visits and hospitalizations. It was also recently designated an IHI-designated Age Friendly system. Montefiore Home Care (MHC), established in 1947, is the nation's first hospital- based certified home health agency. 40% of homebound older adults have MI and CI but have limited access to appropriate evaluation and treatment. Accordingly in 2004, MHC developed a consultative geriatric program in collaboration with the Division of Geriatric Psychiatry to provide comprehensive social work and geriatric psychiatry assessments in the home after discharge from hospital. In addition to the collaboration with MHC, Montefiore Division of Geriatric Psychiatry has leveraged foundational funding to collaborate with CBOs to bring evidence-based mental health services to seniors over the past two decades.During this session, presenters will describe several ongoing and new Montefiore initiatives to address care transitions for older adults with MI and CI. Dr. Zwerling will describe how the CEAD is spearheading the transition for Montefiore Einstein to an Age Friendly system. Ms. Korenblatt will highlight how the MHC Geriatric Psychiatry Program social work team serves as a bridge between acute care and CBOs to minimize hospital readmissions. Finally, Dr. Ceïde will highlight a specific example of an evolving partnership with one specific CBO in order to maintain older adults with MI and CI in the community.

Functional imaging in asthma and COPD: design of the NOVELTY ADPro substudy.

The NOVEL observational longiTudinal studY (NOVELTY; ClinicalTrials.gov identifier NCT02760329) is a global, prospective, observational study of ∼12 000 patients with a diagnosis of asthma and/or COPD. Here, we describe the design of the Advanced Diagnostic Profiling (ADPro) substudy of NOVELTY being conducted in a subset of ∼180 patients recruited from two primary care sites in York, UK. ADPro is employing a combination of novel functional imaging and physiological and metabolic modalities to explore structural and functional changes in the lungs, and their association with different phenotypes and endotypes. Patients participating in the ADPro substudy will attend two visits at the University of Sheffield, UK, 12±2 months apart, at which they will undergo imaging and physiological lung function testing. The primary end-points are the distributions of whole lung functional and morphological measurements assessed with xenon-129 magnetic resonance imaging, including ventilation, gas transfer and airway microstructural indices. Physiological assessments of pulmonary function include spirometry, bronchodilator reversibility, static lung volumes via body plethysmography, transfer factor of the lung for carbon monoxide, multiple-breath nitrogen washout and airway oscillometry. Fractional exhaled nitric oxide will be measured as a marker of type-2 airways inflammation. Regional and global assessment of lung function using these techniques will enable more precise phenotyping of patients with physician-assigned asthma and/or COPD. These techniques will be assessed for their sensitivity to markers of early disease progression.

Evaluation of cardiovascular risk scores after implementation of digital therapeutic intervention in patients with uncontrolled primary hypertension

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Terrals Technologies Private Limited Background Cardiovascular risk scores serve as a useful tool to reinforce the importance of lifestyle modifications and treatment compliance. Yet, there remains a gap between advice by the physician and its implementation by the patient. Digital therapeutics (DTx) as a technology based approach can help bridge this gap. In this context, knowing the quantum of change in disease outcomes and long term cardiovascular risk after DTx implementation can be helpful in persuading the patients for lifestyle interventions. Purpose To evaluate the change in cardiovascular risk scores in hypertensive patients after a digital therapeutic intervention. Method We conducted a prospective, single arm, 12-week intervention trial at two primary care sites in India. A total of 125 subjects within the age group of 30-65 years with primary hypertension (≥ 140/90 mmHg) were enrolled. They were provided DTx intervention which consisted of modification in diet, physical activities, self-monitoring and health education superimposed on behavior science theories. Atherosclerotic Cardiovascular Disease (ASCVD) risk scores from Pooled Cohort Equation were calculated for all subjects before &amp; after the DTx intervention and the change in score was assessed. Results We received the data of 116 patients having a mean age of 47.66 ± 9.47 years and mean BMI of 27.20 ± 4.77 Kg/m². After DTx intervention, the change in mean systolic blood pressure, among other ASCVD equation parameters, was -26.38 mmHg (154.77 vs 128.39 mmHg, P&amp;lt;0.001). The corresponding post-intervention 10-year mean ASCVD risk score for the sample population decreased by 4.74% (11.86% vs 7.12%, P&amp;lt;0.001). The 10-year mean relative risk of ASCVD decreased by 39.95 %. Similarly ASCVD lifetime risk score decreased by 3.04% (49.54% vs 46.50%, P&amp;lt;0.001), amounting to mean relative risk reduction of 6%. Female subjects (n=60) showed higher 10-year mean ASCVD risk reduction of 5.70% (11.70% vs 6.00%, P&amp;lt;0.001), compared to male subjects (n=56) who showed 10-year mean ASCVD risk reduction of 3.76% (12.06% vs 8.30%, P&amp;lt;0.001). This amounted to a relative risk reduction of 48.69% and 30.71% for female &amp; male subjects, respectively. Patients with stage 1 hypertension (n=82) showed a reduction in 10-year mean ASCVD risk of 2.86% (9.90% vs 7.04%, P&amp;lt;0.001). Patients with stage 2 (n=30) &amp; stage 3 hypertension (n=4) achieved higher 10-year mean ASCVD risk reduction of 8.67% (16.07% vs 7.40%, P&amp;lt;0.001) &amp; 13.6% (20.88% vs 7.20%, P=.006). Conclusion Digital therapeutics enabled intervention has caused a significant decrease in 10-year &amp; lifetime ASCVD risks which can eventually lead to a decrease in cardiovascular complications, morbidity and mortality. Therefore, such intervention programs should be further explored and studied.

Examining the Primary Care Experience of Patients With Opioid Use Disorder: A Qualitative Study.

Despite substantial investment in expanding access to treatment for opioid use disorder (OUD), overdose deaths continue to increase. Primary care holds enormous potential to expand access to OUD treatment, but few patients receive medications for OUD (MOUD) in primary care. Understanding both patient and clinician experiences is critical to expanding access to patient-centered MOUD care, yet relatively little research has examined patient perspectives on primary care-based MOUD. We sought to examine the care experiences of patients with OUD receiving medication-based treatment in a primary care setting. We conducted semistructured interviews with patients receiving MOUD at a single primary care site at the University of Utah. Interviews were performed and transcribed by qualitative researchers, who used rapid qualitative analysis using a grounded theory-based approach to identify key themes pertaining to patient experiences receiving medication-based OUD treatment in primary care. Twenty-one patients were screened, and 14 completed the interview. In general, participants had numerous medical and psychiatric comorbidities. The following key themes pertaining to primary care-based OUD treatment were identified: (1) overall health improvement, (2) team-based care, (3) comparing primary care to specialty addiction treatment, (4) access to medications for OUD, and (5) discrimination and stigma. Patients reported many advantages to receiving primary care-based MOUD treatment. In particular, the flexibility and added support of team-based care along with the convenience of receiving addiction treatment alongside regular medical care were highly valued. These findings can be used to develop patient-centered initiatives aimed at expanding OUD treatment within primary care.

Coping with in-locus factors and systemic contradictions affecting antibiotic prescription and dispensing practices in primary care-A qualitative One Health study in Brazil.

Antimicrobial resistance (AMR) is an increasing threat to global health. The risks and sanitary consequences of AMR are disproportionately experienced by those living in Low- and Middle-Income Countries (LMICs). While addressing antibiotic use has largely been documented in hospital settings, the understanding of social drivers affecting antibiotic prescribing and dispensing practices in the context of human and animal health in primary care (PC) in LMICs remains extremely limited. We seek to explore how in-locus and multi-level social factors influence antibiotic prescriptions and dispensing practices in the context of human and animal health in primary care in Brazil. This is a baseline qualitative One Health study; semi-structured interviews and field observations were undertaken in primary care sites located in a socioeconomically vulnerable area in the city of São Paulo, the most populated city of Brazil. Twenty-five human and animal healthcare professionals (HP) were purposely sampled. Interview data were subject to thematic analysis. Three overlapping social drivers were identified across HPs' discourses: individual and behavioral challenges; relational and contextual factors influencing the overprescription of antibiotics (AB); and structural barriers and systemic contradictions in the health system. As a result of the interaction between multilevel in-locus and structural and contextual factors, HPs experience contextual and territorial challenges that directly influence their risk perception, diagnosis, use of laboratorial and image exams, time and decision to undergo treatment, choice of AB and strategies in coping with AB prescriptions. Additionally, in-locus factors influencing antibiotic prescriptions and dispensing practices are intertwined with individual accounts of risk management, systemic contradictions and ambivalences in the national health system. Our findings suggest interventions tackling AB use and AMR in Brazil should consider the social context, the complex health system structure and current integrated programs and services in PC.