Practice Redesign Research Articles

Evaluating access during change: A qualitative exploration of access impacts to Canadian primary care rehabilitation providers during the COVID-19 pandemic

IntroductionThe COVID-19 pandemic required substantial changes in delivery of team-based primary care, impacting both how and which patients accessed the more comprehensive services teams provide. We sought to explore changes in access to primary care rehabilitation services during the first year of the COVID-19 pandemic to identify potential new problems and improvements. MethodsIn this longitudinal study, sixteen rehabilitation professionals working on primary care teams in Manitoba and Ontario recorded audio-diaries and later participated in interviews throughout the first year of the pandemic. Qualitative analysis included data immersion, coding to identify the practice changes and associated access impacts, then applying Levesque and colleagues’ Patient-Centred Access to Healthcare framework to interpret findings. FindingsParticipants described service changes that both enhanced and reduced access, including redeployment, outreach, virtual care, discontinuation of some services and start of new ones, and new risk management strategies. Some implied equity-specific impacts. Virtual care and outreach activities created access for patient populations who previously may have been underserved, while virtual care, redeployment, and new risk management activities created new access barriers and inequities, leaving some patients completely unable to reach care. Changes to team collaboration activities could help or hinder access. ConclusionContinuing outreach activities, strengthening team collaboration, and thoughtfully integrating virtual care can improve access to comprehensive primary care. As the primary care sector works to recover from pandemic impacts and address population health needs, applying a patient-centred access framework during practice redesign offers a meaningful way to strengthen services.

Designing the Internal Organization for Circular Economy Innovation: A Knowledge Governance and Microfoundations Approach

Firms implementing circular economy principles in their innovation processes necessitates the redesign of well-established processes and practices. This redesign leverages the various knowledge and practice domains within the firm, at different levels and scales. Despite the importance of knowledge to innovation management, there is a lack of research in innovation studies examining how firms could manage different knowledge flows within the circular economy context. In most research in this area, studies tend to assume that existence of governance mechanisms to manage these knowledge flows. However, given the need for redesigning or introducing entirely new business models to incorporate circularity principles, there is also a need to understand the internal organization that facilitates such changes. In this paper, we conceptualize how organizational mechanisms governing knowledge processes influence firms' adoption of circular-oriented innovation processes. We conclude that firms go through various stages and levels in the adoption process. These levels are linked through situational, action-formation, and transformational mechanisms that govern supportive knowledge processes. We contribute the innovation management literature by linking circular innovation process adoption to knowledge governance and the underlying knowledge processes. Specifically, we highlight the microfoundations nuances of circular-oriented innovation processes adoption that are pertinent to organizing innovation activities within the firm.

Investigating social sustainability practices in global supply networks: A fuzzy-set qualitative comparative analysis

Given the paucity of research that examines the impact of Social Sustainability Practices (SSP) on performance outcomes, this study investigates the adoption and influence of these practices on firms' and suppliers’ overall performance, whilst also considering the level of complexity of operational environments of global supply networks. A Fuzzy-sets Qualitative Comparative Analysis (FsQCA) approach is adopted, based on eight primary case studies within the food, chemical and textile sectors, with data collected through semi-structured interviews conducted with representatives from each company.The research identified four key categories of SSP: informative, control, collaborative, and supply network redesign practices. The findings offer empirical support for the notion that SSP adoption yields improved performance outcomes for both the firm and its suppliers. These positive effects encompass enhanced firm profitability, increased supplier efficiency, and heightened supplier innovativeness. Nevertheless, the research uncovered that the relationship between adopting SSP and their impact on performance is not always straightforward. In certain instances, a combination of these practices may be necessary to achieve the desired performance level.In addition, a prudent consideration of the operational complexity present in global supply networks is crucial for informed decision-making pertaining to the selection and adoption of the most appropriate SSP. Driving profits in complex operational environments requires integrating both informative and collaborative practices, whilst tight control is necessary to improve supplier efficiency, regardless of the extent of complexity. Collaboration also emerged as a core factor of success in enhancing supplier innovation regarding social sustainability. Decision makers should also collaborate with external entities, particularly Non-Governmental-Organisations (NGOs) and industry associations/peers, to educate suppliers, thus creating an auspicious environment where suppliers are accountable for their own sustainability performance. This research carries significant practical implications. Managers should evaluate diverse combinations of SSP to confront global sustainability challenges through the utilization of customized strategies that can yield enhanced performance results. Expanding sustainability beyond primary suppliers can often be challenging in a global supply networks, given a firm's limited oversight, transparent knowledge and control over lower tier suppliers. Consequently, managers should seek to strengthen controls and oversight within the manageable segments of the supply network, all the while facilitating self-adaptation within the extended supply network with the adoption of informative and collaborative practices that extend reach, homogeneity, and improve overall governance.

Mitigating Contaminant-Driven Risks for the Safe Expansion of the Agricultural-Sanitation Circular Economy in an Urbanizing World.

The widespread adoption of an agricultural circular economy requires the recovery of resources such as water, organic matter, and nutrients from livestock manure and sanitation. While this approach offers many benefits, we argue this is not without potential risks to human and environmental health that largely stem from the presence of contaminants in the recycled resources (e.g., pharmaceuticals, pathogens). We discuss context specific challenges and solutions across the three themes: (1) contaminant monitoring; (2) collection transport and treatment; and (3) regulation and policy. We advocate for the redesign of sanitary and agricultural management practices to enable safe resource reuse in a proportionate and effective way. In populous urban regions with access to sanitation provision, processes can be optimized using emergent technologies to maximize removal of contaminant from excreta prior to reuse. Comparatively, in regions with limited existing capacity for conveyance of excreta to centralized treatment facilities, we suggest efforts should focus on creation of collection facilities (e.g., pit latrines) and decentralized treatment options such as composting systems. Overall, circular economy approaches to sanitation and resource management offer a potential solution to a pressing challenge; however, to ensure this is done in a safe manner, contaminant risks must be mitigated.

Computational Enzyme Redesign Enhances Tolerance to Denaturants for Peptide C-Terminal Amidation.

The escalating demand for biocatalysts in pharmaceutical and biochemical applications underscores the critical imperative to enhance enzyme activity and durability under high denaturant concentrations. Nevertheless, the development of a practical computational redesign protocol for improving enzyme tolerance to denaturants is challenging due to the limitations of relying solely on model-driven approaches to adequately capture denaturant-enzyme interactions. In this study, we introduce an enzyme redesign strategy termed GRAPE_DA, which integrates multiple data-driven and model-driven computational methods to mitigate the sampling biases inherent in a single approach and comprehensively predict beneficial mutations on both the protein surface and backbone. To illustrate the methodology's effectiveness, we applied it to engineer a peptidylamidoglycolate lyase, resulting in a variant exhibiting up to a 24-fold increase in peptide C-terminal amidation activity under 2.5 M guanidine hydrochloride. We anticipate that this integrated engineering strategy will facilitate the development of enzymatic peptide synthesis and functionalization under denaturing conditions and highlight the role of engineering surface residues in governing protein stability.

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations.

Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations. Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). Cross-sectional study using ordinary least squares regression controlling for patient and community factors. Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid. Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022. Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001). Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.

Redesigning Learning Space for Teacher Professional Development: From Traditional PD to Metaverse-based PD

To address the evolving demand for modern-day classrooms and skills, there is a need to redesign the approach used for teacher training and professional development. This proposed research project aims to explore how teachers perceive the implementation of metaverse-based professional development, using qualitative research methods. The study's findings may provide insights for the redesign of teacher professional development practices, aiming to enhance their effectiveness in the classroom.

Closing the Gaps in Care of Dyslipidemia: Revolutionizing Management with Digital Health and Innovative Care Models.

Although great progress has been made in the diagnostic and treatment options for dyslipidemias, unawareness, underdiagnosis and undertreatment of these disorders remain a significant global health concern. Growth in digital applications and newer models of care provide novel tools to improve the management of chronic conditions such as dyslipidemia. In this review, we discuss the evolving landscape of lipid management in the 21st century, current treatment gaps and possible solutions through digital health and new models of care. Our discussion begins with the history and development of value-based care and the national establishment of quality metrics for various chronic conditions. These concepts on the level of healthcare policy not only inform reimbursements but also define the standard of care. Next, we consider the advances in atherosclerotic cardiovascular disease risk score calculators as well as evolving imaging modalities. The impact and growth of digital health, ranging from telehealth visits to online platforms and mobile applications, will also be explored. We then evaluate the ways in which machine learning and artificial intelligence-driven algorithms are being utilized to address gaps in lipid management. From an organizational perspective, we trace the redesign of medical practices to incorporate a multidisciplinary team model of care, recognizing that atherosclerotic cardiovascular disease risk is multifaceted and requires a comprehensive approach. Finally, we anticipate the future of dyslipidemia management, assessing the many ways in which atherosclerotic cardiovascular disease burden can be reduced on a population-wide scale.

ChatGPT-Proofing: Redesigning Assessment Practices for E-Learning

The 21st century has ushered in a profound transformation in the realm of education, fueled by the widespread integration of e-learning, fueled by technological advancements and the pursuit of adaptable and accessible learning modalities. As the e-learning landscape continues to evolve, a pertinent question emerges: Do conventional assessment methods align effectively with the exigencies of the digital era and the competencies imperative for thriving in the knowledge economy? This systematic literature review undertakes a comprehensive exploration of this significant question. Through a meticulous synthesis and analysis of a diverse body of existing research, this review effectively brings to light compelling evidence that underscores the pressing need for the redesign of assessment practices within the context of e-learning. In probing this multifaceted subject, the review critically examines how traditional assessment approaches may fall short in capturing the intricacies of modern-day skillsets, critical thinking proficiencies, and adaptability demanded by the swiftly evolving digital landscape. In its conclusion, this study serves as a pivotal catalyst for change, illuminating the urgency and potential benefits of reimagining assessment practices for the dynamic realm of 21st-century e-learning. Based on the findings, it provides stakeholders with prudent and actionable recommendations, empowering them to embark on a purposeful journey of redesigning assessment strategies. By proactively embracing these recommendations, educators, policymakers, and institutions can engender a learner-centric ecosystem that optimally nurtures and empowers learners for a future defined by innovation and adaptability.

BIO29: A Microfluidic Model Of Extracorporeal Circuit Thrombosis

Purpose: Cardiovascular medical devices such as extracorporeal membrane oxygenation (ECMO) machines are critical for the treatment and management of cardiorespiratory illnesses. However, blood contact with medical device biomaterials causes dangerous blood clot formation (thrombosis). In ECMO, blood clots can grow large enough to occlude circuitry and fail the device, or clots may dislodge and potentiate stroke and embolism in patients. While medical device thrombosis is clinically managed with systemic anticoagulation, thrombosis and its associated complications still exist, and anticoagulation frequently worsens patient outcomes by causing severe bleeding. There remains an urgent need to understand the mechanisms of biomaterial thrombosis and develop thromboresistant biomaterials. We hereby demonstrate a novel biomaterial thrombosis on-a-chip model system for real-time, high-throughput evaluation of ECMO thrombosis. Methods: Our study combines computational fluid dynamics (CFD) and microfluidic technology to design in vitro models with customizable, clinically relevant biomaterials and flow conditions, which are two key factors influencing thrombus formation. ANSYS Fluent was used to model the flow parameters within ECMO tubing and tubing-connector junctions (TCJ). Microfluidic devices were fabricated using standard photolithography and soft lithography with unplasticized polyvinylchloride (UPVC) and polycarbonate (PC), replicating ECMO tubing and TCJ respectively. Biomaterial thrombosis was visualized in real-time via confocal microscopy, and analyzed as the total fluorescent area of platelet adhesion (CD41-FITC) and human fibrin/ogen (AF647) accumulation. Results: CFD revealed that shear rates of 500 – 5000 s-1 and decelerating flow regimes are relevant to ECMO tubing thrombosis. Microfluidic evaluation at such conditions showed that compared to the low platelet adhesion observed at continuous high shear (3000 s-1) (340 ± 266 µm2), platelet adhesion increased by 16-fold at continuous low shear (1000 s-1) (5510 ± 3631 µm2), increased 5-fold at deceleration into high shear (1703 ± 598 µm2), and increased 2.7-fold at stagnant into high shear conditions (912 ± 308 µm2). These results may be used to guide clinical practice and ECMO redesign to minimize low, decelerating shear. Conclusion: We have developed a model system capable of evaluating biomaterial thrombosis at tailorable, clinically relevant biomaterial and flow combinations. Additionally, this system may be used to test novel anti-thrombotic biomaterials or patient-specific blood-biomaterial compatibility. Ultimately, this model will improve ECMO treatment efficacy by advancing the field’s knowledge in scientific mechanisms underlying biomaterial thrombosis, inform clinicians of thrombotic flow regimes which should be minimized, and identify thrombotic biomaterial and flow combinations to guide bioengineers to design the next generation of safer ECMO.Figure 1. A microfluidic device incorporating extracorporeal circuit biomaterials is used to visualize thrombus formation under clinically relevant flow.

Care Management Processes Important for High-Quality Diabetes Care.

Identify the improvement in diabetes performance measures and population-based clinical outcomes resulting from changes in care management processes (CMP) in primary care practices over 3 years. This repeated cross-sectional study tracked clinical performance measures for all diabetes patients seen in a cohort of 330 primary care practices in 2017 and 2019. Unit of analysis was patient-year with practice-level CMP exposures. Causal inference is based on dynamic changes in individual CMPs between years by practice. We used the Bayesian method to simultaneously estimate a five-outcome model: A1c, systolic and diastolic blood pressure, guideline-based statin use, and Optimal Diabetes Care (ODC). We control for unobserved time-invariant practice characteristics and secular change. We modeled correlation of errors across outcomes. Statistical significance was identified using 99% Bayesian credible intervals (analogous to P < 0.01). Implementation of 18 of 62 CMPs was associated with statistically significant improvements in patient outcomes. Together, these resulted in 12.1% more patients meeting ODC performance measures. Different CMPs affected different outcomes. Three CMPs accounted for 47% of the total ODC improvement, 68% of A1c decrease, 21% of SBP reduction, and 55% of statin use increase: 1) systems for identifying and reminding patients due for testing, 2) after-visit follow-up by a nonclinician, and 3) guideline-based clinician reminders for preventive services during a clinic visit. Effective quality improvement in primary care focuses on practice redesign that clearly improves diabetes outcomes. Tailoring CMP adoption in primary care provides effective improvement in ODC performance through focused changes in diabetes outcomes.

Coupling of crop and livestock production can reduce the agricultural GHG emission from smallholder farms

Ensuring global food security and environmental sustainability is dependent upon the contribution of the world's hundred million smallholder farms, but the contributions of smallholder farms to global agricultural greenhouse gas (GHG) emissions have been understudied. We developed a localized agricultural life cycle assessment (LCA) database to calculate GHG emissions and made the first extensive assessment of the smallholder farms' GHG emission reduction potentials by coupling crop and livestock production (CCLP), a redesign of current practices toward sustainable agriculture in China. CCLP can reduce the GHG emission intensity by 17.67%, with its own feed and manure returning to the field as an essential path. Scenario analysis verified that greater GHG emission reduction (28.09%-41.32%) will be achieved by restructuring CCLP. Therefore, this mixed farming is a mode with broader benefits to provide sustainable agricultural practices for reducing GHG emissions fairly.

Outcomes of A Virtual Practice-Tailored Medicare Annual Wellness Visit Intervention.

Interventions are needed to promote utilization of the Medicare Annual Wellness Visit (AWV), an underused opportunity to perform screenings and plan individualized preventive health services. Using remote practice redesign and electronic health record (EHR) support, we implemented the Practice-Tailored AWV intervention in 2021 (during the COVID-19 pandemic) in 3 small community-based practices. The intervention combines EHR-based tools with practice redesign approaches and resources. Outcomes included completion of AWV and fulfillment of recommended preventive services. At baseline the 3 practices had 1,513 Medicare patients with at least 1 visit in the past 12 months. AWV utilization went from 7% at baseline to 54% 8 months postintervention implementation; advance care planning increased 10.7% (from 7.9% to 18.6%); depression screening increased 16.3% (from 51.7% to 68.0%); and alcohol misuse screening increased 17.3% (from 42.6% to 59.9%). Every individual preventive health service was received more often by patients with an AWV than those without. At the patient level, fulfillment of all eligible preventive services (of a maximum of 12 evaluated) went from 47.5% to 53.8% (P < .001). Subgroup analyses showed that patients with AWVs completed a greater percentage of their total recommended preventive health services than those without an AWV. Virtual implementation of an intervention that combined EHR-based tools with practice redesign approaches increased AWV and preventive services utilization in Medicare patients. Given the success of this intervention during the COVID-19 pandemic (when practices had many competing demands), greater consideration should be given to delivering future interventions virtually.

ACR Presidential Address: Rheumatologists-Folks You Can Trust.

ACR Presidential Address: Rheumatologists-Folks You Can Trust.

Optimizing Ride-Hailing Platforms: A Comprehensive Evaluation of Drivers' Perspectives on Application Features and Rating Systems

Transportation is a critical aspect of daily life, and governments strive to facilitate people's movement efficiently and safely. The proliferation of ride-hailing applications has introduced challenges for drivers, prompting the need for a comprehensive evaluation. This study focuses on assessing ride-hailing applications and their rating systems from the drivers' perspective. Through two conducted focus groups involving 13 participants, drivers shared insights on improving their experiences and enhancing rating systems. The analysis of their discussions revealed key themes, emphasizing the necessity of adjusting certain application features and advocating for a practical and efficient redesign of rating systems. This research contributes valuable insights to the ongoing discourse on optimizing ride-hailing platforms for both drivers and riders.

Redefining Quality Assessment in Canadian K-12 Schools With Empathy, Critical Consciousness and Metacognition

Over the past decades, educational pedagogies have been shaped by many theorists and frameworks. For the purpose of this paper, the researchers define educational pedagogy through a lens that is influenced by Paulo Freire. For instance, educational pedagogy can be defined as seeking a balance within the tension between freedom and authority, while navigating the challenging structures that shape educational institutions (Freire, 2005, 2020). These structures include the impact of lived experiences and realities, the role of curricula, and the changing interactions within society that influence the pedagogical frameworks in education (Freire, 2020). This paper begins to consider a new framework for assessment and evaluation in Ontario, Canada’s K-12 schools, where educational pedagogy, empathy, metacognition, and critical consciousness may be posited as potential components moving forward. This paper deeply examines these three key elements of effective and authentic assessment: empathy, critical consciousness and metacognition. Each of these terms is defined and situated in a 21C digital learning context, and the authors suggest that new directions in assessment and evaluation must consider these three significant as fundamental to any redesign of assessment practices. Consideration may be given to the perspectives and experiences of educational leaders, educators, students, and their communities, and how these perspectives can shape the values and how we meet the challenges in education. Pedagogy in practice can often reflect the strategies and beliefs that influence educators’ values and choices, and the resulting impact on learning. Part of these pedagogical considerations may include the development of empathy, critical consciousness and metacognition throughout the assessment and evaluation process. Using a Canadian context, the authors argue that post-pandemic learners require a different set of tools to learn, and post-pandemic teachers need to reconfigure the ways in which that learning is measured, assessed and evaluated.&#x0D; , ,,,

Outcomes of a Data-Driven Physician Practice Redesign.

This study evaluated a practice redesign to improve access into a specialty practice. The secondary goal was to improve financial performance, while avoiding an increase in physician burnout. Historical demand was utilized to calculate capacity. Next, data-driven schedules were developed for this practice. We also transitioned schedules from five 8-hour to four 10-hour workdays. Access was improved for news (100% increase), consultations (16% increase), and procedures (70% increase). Gross revenue increased by 10.62% and physician burnout reduced by 25%. This project offers insights into improving the efficiency of a resource-constrained practice, while improving financial performance and reducing burnout.

It Started with a Blog: How International Connections were Made and Sustained in a Global Pandemic

In a desperate 2020 Covid-inspired pivot, the early childhood team at Victoria University, Melbourne, introduced remote placements for their early childhood teacher students. This was represented through RPEC @ VU (Remote Placements in Early Childhood at Victoria University), and when an online blog post about RPEC@VU reached Ireland, the VU team were contacted by the early childhood team at Dublin City University, who were similarly introducing remote placement for their students. On opposite sides of the world, each team working in isolation in their own country, these educators connected to share ideas, insights and inspiration. From the redesign of thinking and practice in response to the pandemic, unforeseen opportunities were generated. This paper presents a case study exploring the shared values that brought the early childhood teams from these two institutions together and that continue to sustain the partnership. A vibrant international collaboration continues to be built across the two institutions.

Working Framework for Appropriate Use of Virtual Care in Primary Care.

Given the absence of guidelines for use of virtual visits for primary care delivery, a framework is needed to inform the most appropriate use of virtual visits. We conducted in-depth, structured interviews of 18 patients, primary care clinicians, and other select informants. They were asked to discuss optimal, acceptable, and suboptimal uses of telemedicine for delivering care relative to in-person care delivery. The concepts expressed informed our development of a framework about appropriate use of virtual visits. The 103 concepts supported 5 main themes that emerged as a framework: clinical situations which are optimal for in-person care; situations optimal for virtual visits; situations that might be exchangeable between sites; contextual factors favoring in-person care; and contextual factors favoring virtual visits. After further validation, we expect that this framework may guide future research and practice: it may be valuable for clinical practice redesign, for designing evaluations of the outcomes of virtual visits, for outcomes research, for patient education, for triage, and possibly for reimbursement considerations.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.